Therapists’ continuations following I dont know—responses of adolescents in psychotherapy

https://doi.org/10.1016/j.pec.2016.05.016Get rights and content

Highlights

  • I dont know—responses by clients lead to varying continuations by therapists.

  • Therapists treat IDK-responses not just as non-cooperative behavior.

  • IDK-responses are also used as a therapeutic starting point.

  • The continuation strategies could be embedded in training of therapists.

Abstract

Objective

In psychotherapy clients’ I dont know—responses (IDK-responses) to therapists’ questions are typically considered to be non-cooperating behaviors. How therapists actually handle these behaviors remains unclear. This study therefore aims to assess client-therapist interactions following IDK-responses.

Methods

Data were collected in a Dutch child and adolescent mental healthcare service by observing Dialectical Behavior Therapy aimed at adolescents with severe emotional distress. Eighteen individual psychotherapy sessions involving two therapists with six clients were video-recorded and transcribed. Stand-alone IDK-responses were selected (n = 77) and analyzed using conversation analysis.

Results

Adolescents' IDK-responses led to varying actions of therapists. We identified five categories of continuations after IDK-responses: no IDK-related continuation; redoing of the question; proposing a candidate answer; employing therapy-specific techniques; and meta-talk on the problematic nature of the IDK-response.

Conclusions

Therapists treat IDK-responses not just as non-cooperative behavior on the part of the client; IDK-responses are also used as a starting point to collaboratively enhance clients’ insights in their own thoughts, emotions, and behaviors.

Practice implications

After IDK-responses therapists can use a variety of continuation strategies with varying therapeutic functions. These strategies can be embedded in training of therapists to deal with potentially non-cooperative behavior.

Introduction

During psychotherapy and counseling clients may be considered as non-cooperative or even resistant when responding to questions with ‘I don’t know’ [1], [2]. This behavior is then associated with unwillingness of the client to engage in therapy, and is believed to be a potential threat to the achievement of successful treatment. To achieve therapeutic goals therapists and clients should both endorse and be committed to the main principles of therapy [3]. I dont know—responses (IDK-responses) are considered a risk for the desired active participation of the client and the progress of the therapeutic conversation. For this reason psychotherapeutic handbooks suggest reducing this type of behavior in order to increase the likelihood of successful therapy [2], [4], [5].

Research on IDK-responses in therapeutic and counseling settings has focused on the non-cooperativeness of this behavior. Stivers and Robinson [6] refer to IDK-responses to questions as ‘non-answers’ because they only satisfy the ‘technical part' of responding to a question, while failing to promote the action sequence initiated by the question. This type of response seems to block the relevant course of action [7], [8]. For example, in the context of a courtroom rape trial, the defendant used claims of not knowing and not remembering to portray a particular event as being unimportant because the details of it could not be recalled [8]. In child counseling, the repeated use of IDK-responses was described as strategic and non-cooperative behavior on the child’s part [1].

Other studies show that not all IDK-responses are treated as a resistance strategy on the part of the client [9], [10]. Iversen [9] studied interviews with children aged 6–13 years about their (step)fathers' abuse, and concluded that questions related to children’s ideas on their (step)fathers' thoughts or motives could be difficult for them because it concerned knowing someone else’s thoughts. Furthermore, data from semi-structured interviews with 8–12 year olds on child trauma showed that IDK-responses may even provide possibilities that serve the progress of the interview [10]. In these studies IDK-responses were followed by ‘inability accounts’ through which the speaker seemed to demonstrate that he or she was not unwilling to comply with what had been asked, but unable to do so [11].

For therapists, IDK-responses that are not followed by further utterances of the client, i.e. stand-alone IDKs, may be challenging. However, how they actually handle these behaviors in practice remains unclear. The aim of this study was therefore to assess client-therapist interactions following stand-alone IDK-responses to gain more insight into how therapists deal with these potentially non-cooperative behaviors.

Section snippets

Study design

This study was conducted by observing Dialectical Behavior Therapy (DBT) in a Dutch child and adolescent mental healthcare organization. DBT is a well-established intervention first developed for adult patients with borderline personality disorders (BPD) [2], recently adjusted for adolescents who suffer from severe emotional distress and display symptoms of BPD1, and/or conduct into

Participant characteristics and distribution of IDK-responses

Table 1 shows client characteristics and the distribution of IDK-responses. Some clients rarely displayed this behavior (clients 3–6), while others did so repeatedly (clients 1 and 2). The data-driven analysis resulted in five categories of continuations following IDK-responses: no IDK-related continuation; redoing of the question; proposing a candidate answer; guiding the client into producing an answer using previously learned skills; and meta-talk on the problematic nature of the

Discussion

Our study shows that in order to deal with clients’ IDK-responses therapists use a wide range of interactional strategies. We identified five categories of continuations after IDK-responses: no IDK-related continuation; redoing of the question; proposing a candidate answer; employing therapy-specific techniques; and meta-talk on the problematic nature of the IDK-response.

These five types of continuations seem to fulfill different interactional and therapeutic functions. We have found empirical

Acknowledgements

This study has received grants from the Netherlands Organization for Health Research and Development (ZonMw), the Province of Groningen, the University Medical Center Groningen, the University of Groningen, health insurance company Menzis, and child and youth care providers Accare and Elker.

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