3 Results of the sub-studies
4.5 Concluding remarks
To conclude the discussion, I would like to consider the clinical implications of my findings. First, there seems to be local, interactional evidence that formulations lexically designed to display understanding of the client’s feelings and show prosodic continuity with the client’s talk are oriented to by the client as utterances expressing empathy. This orientation is manifested in the clients’ following turns of talk, where they agree with the formulation and allow themselves to remain in the emotional state expressed, for instance, by crying. In contrast, when the formulation is conveyed with prosodic disjuncture, the clients in our data often only partially agreed, or even disagreed, with the formulation, indicating their orientation towards something more problematic: a challenging rather than validating stance. From a clinical perspective, this finding emphasizes the meaning of prosodic communication in the therapeutic process. However, the difficulty of prosody is that unlike verbal actions, which can be referred to using widely-shared concepts (like questions, agreements, invitations and so on), our common sense understanding does not offer us concepts to describe what we do with prosody (Szczepek Reed 2011:12). The detailed description of prosodic continuity and prosodic disjuncture provided in this dissertation conceptualizes the prosodic features of therapists’ empathic and challenging communication, specifying the clinical theories that underlie this communication and providing tools for clinical training and supervision.
The second clinically interesting finding is practices related to disagreements and the resolution of relational stress. Safran and Muran (2006) have argued that better understanding of how relational stress is negotiated is of primary interest in clinical psychotherapy. My findings concerning supportive and unsupportive disagreement provide one description of how this negotiation is conducted at the level of actual interactional practices. If, in the case of a client’s withdrawal, therapists worked at finding congruence between their perspective and that of the client, validated the client’s emotional experience and respected the client’s epistemic primacy, the therapist succeeded in re-engaging the client in the exploration of his or her experience. However, unsupportive disagreements are also clinically interesting: these sequences prompted the clients’ aggravation and withdrawal, leading eventually to the topicalization of the therapeutic relationship. Safran and colleagues (2001) have observed that moments where the therapist tropicalizes the client’s resistance and moves to a ‘metadiscursive’ talk on the therapeutic relationship are clinically important for resolving relational stress.
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Thirdly, the findings of this dissertation emphasize the importance of recognizing and respecting the client’s epistemic primacy. Strong epistemic claims in disagreement sequences were an interactional move which invoked aggravation in clients. Furthermore, in therapists’ interpretative interventions, epistemic work was crucial. Failure to demonstrate that the intervention was based on the client’s previous talk provided the client an opportunity to focus on epistemics as a means of resisting the intervention.
Questions of epistemics are also clinically important because they seem to involve clinicians’ tacit knowledge, which is discussed in clinical theories at a rather abstract level. Thus, the findings of this dissertation provide a fresh perspective on how epistemic relations are managed in on-going interaction between the therapist and client.
All these findings indicate that clinicians’ specific interactional moves can produce strong effects on local interactional outcomes; i.e. they have sequential consequences for how clients interpret the therapist’s turns of talk and how they act in their following turns (Heritage & Maynard 2006:365). In this dissertation, these local outcomes were not linked to the global measures of the therapeutic relationship or to the efficiency of the overall therapeutic process. How these local outcomes combine to affect outcome in the longer term is an interesting question for further research.
Last, it is my hope that the detailed descriptions of therapists’ verbal, prosodic and other communicative practices offered in this dissertation will provide clinicians with a useful perspective on their relationships with clients in terms of the dynamic dialogical processes occurring in and through interaction.
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