Sample completed data extraction sheet - believe that the desire to please you does

But I believe that the desire to please you does

Appendix 3. Sample completed data extraction sheet

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Author Ladany, N., Hill, C., Thompson, B., O’Brien, K.

Title Therapists perspectives of using silence in therapy: a qualitative study Source Counselling & Psychotherapy Research, 4, 1, pp. 80-89

Country USA

Year 2004

Discipline Psychotherapy

Description Comments

Document type Report of qualitative research Methodology/

Theory/ Model/tool

Consensual qualitative approach

Design/ Sample 12 experience therapists

2 case examples (neither silence as care)

Context Psychotherapy

Focus of paper Therapists’ use of silence; why therapists use silence

Findings/ proposition

“The sole general client-focussed reason [for using silence] was that therapists believed they use silence to convey empathy, respect, support (e.g. to give the client space; to honour

something the client said, to hold, to nurture or give the client permission to be themselves)”; “to demonstrate understanding and provide

therapist conditions that would facilitate the therapeutic work”1; “to facilitate client reflection; to challenge the client to take responsibility and control (by creating a little distance)”.

Does this make for patient centred care or ‘therapeutic work’ centred care?

Conclusions “Therapists typically perceive themselves as using silence to convey empathy, facilitate reflection, challenge the client to take

responsibility, facilitate expression of feelings or take time for themselves to think what to say.” “A sound therapeutic alliance is needed; therapists often educate the client about their use of silence; silence would not be used with patients who are psychotic, highly anxious or angry.

“No specific recommendation can be made in terms of when to use silence”.

Conceptualisation of silence

Silence as “a pause in the dialogue”; “silence is a multifunctional intervention. Similar-looking silences could be motivated by a variety of different reasons” by the therapist; “silence

cannot be conceptualised as a single entity in therapy with a single therapist intention and a single client perception”;

Specific words/ phrases that describe silence

“from cruel inhumanity to tender concern” (Gill 1984)

Perceived +ve aspects to patient care (caregiving)

Facilitative: “can allow clients to reflect on their own thoughts and feelings”; “convey respect and empathy”

Perceived –ve aspects to patient care (not

caregiving)

“raise anxiety, exert pressure to communicate”; Could lead to negative consequences in

therapeutic work; “some clients may experience silence as insulting, withholding or critical”; “reflecting therapist anger, stressful or heightening their fear of abandonment” Potential cause of

misunderstanding

Silence used in early sessions; where client experienced it a withholding; where client came from a family that used silence destructively. “Even though therapists may have benevolent intentions for using silence, clients may perceive silences to be anything from benevolent to intimidating.”

Demands upon/ qualities of caregiver

“Therapists typically believed they learned how to use silence from their own experience as a client and from supervision”2; “when anxious some therapists used silence less whereas others used it more”; silence was used when they “did not know what to do” and when “distracted”. “All therapists observed (without staring) what was happening with clients in relation to therapy; “looked at the client’s body language indirectly and made occasional eye contact”; “looked slightly away from clients but always attending to clients non-verbals”.

What therapists do in the silence: “thought about what was going on in the therapy; “very busy”; “daydreaming”; “metaphorically held clients”; “actively engaged”.

Silence was rarely formally taught as an

intervention. Experience of silence comes largely from their own clinical experience and

supervision.

suggests that it is not so much a taught skill as an experiential skill

General Comments

What is novel The perspective of “why use of silence?” This is the only qualitative study of therapists’ experience of silence.

Specific Experience(s) of silence:

Case 1: therapist uses silence to challenge the client which made the client “very uncomfortable”. However, “the therapist’s use of silence seemed to help the client confront his problem.”

alliance, fragile client + early in treatment). “Although the therapist reported initially feeling fine about the silence, the therapist ended up breaking the silence when she observed the client sitting rigidly and glaring at her”. The client “felt attacked and unsupported by the silence”. Described as “misapplied silence” which led to “negative therapeutic consequences”.

Review Question: How do people in professional care-giving roles describe their experiences of silence in inter-personal relationships with those in their care?

Brief description of paper

Ladany seeks to understand why therapists use silence in therapy. He suggests that it is an infrequent intervention (Hill 1986) and stresses the multifunctional quality of silence as an intervention with potentially beneficial and negative impact on the therapy. 12 experienced therapists are interviewed, their general conclusion is that they use silence for the benefit of the therapy i.e. “to convey empathy, facilitate reflection, challenge the client to take responsibility, facilitate expression of feelings or take time for themselves to think what to say.” Ladany cites one example of where silence is used [albeit in a risky way] successfully and one where the intervention failed and resulted in the end of the therapy. A strong therapeutic alliance is a prerequisite. Therapists suggest that comfort with the use of silence comes with experience.

Relevance to my study

The fact that this study focuses so strongly on the use of silence and specifically why therapists use silence reduces its relevance to my research. Neither of the case examples is relevant, because neither case demonstrates silence as care (the most caring action is the breaking of the uncomfortable silence in case 2.)

However the research gives a picture of how therapists perceive their use of silence, and how ‘at odds’ this can be with the client experience and I think this offers a salient warning to spiritual caregivers who may believe that in ‘using’ silence they are providing benevolent care. Concerns The paper seems to prioritise success of the therapy over care of the

patient. This may be an accurate portrayal of the objective of

psychotherapeutic treatment but highlights the gap between therapy and care (specifically spiritual care).

Quality of paper: Rigour, value, credibility

Evidence Assessment Tool (Hawker et al 2002:1295)

Title and Abs: Fair, Intro and Aims: Good, Method and data: Fair,

Sampling: Fair, Data analysis: Good, Ethics and Bias: Very poor, Findings, conclusion: Good, Transferability: Fair, Implications and Usefulness: Good. Total score: 300.

Other material in this paper not relevant to review question

“As therapists none of us wanted to use silence in a withholding manner or as a way to increase the client’s overall level of anxiety”