But What Should I Say Next? 5 Tips for Social Workers
by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field
It is usually around this time of year, when supervising both new interns and clinicians, that a familiar strain of questions starts to arise in my work with them. At the heart of the questions is a frequent anxiety that takes the shape of: But what should I say next? This question, which typically arises after the formal paperwork of intakes and goal setting has been completed, can feel terrorizing to some, because it gets at the heart of what we do, which is basically to try to say the next right thing at all times.
The answer to the question as to what to say next, to a client, is actually both simple and complex. At face value, the question can simply be answered by asking ourselves: What will it take to keep this person talking? That’s the goal, right - to talk more, to say what hasn’t been said, to demonstrate our curiosity, and to learn more about our clients’ internal worlds? Yes, that is all true. But underneath the simple goal of trying to keep our clients talking is a set of assessment principles and dynamics around pacing, managing symptoms, and beliefs that inform our decision-making processes.
Here are some thoughts on how to decide what to say next.
1. Relationship Building
What you say next should be in the interest of building the relationship and the attachment. This means that the next thing you say might be funny, empathic, somewhat self-disclosing, soft, and tender. The hope, after goal setting and formal assessment has been completed, is to keep the client coming. This means that we don’t always go for intense and deep questions or interpretations. Instead, we try to figure out how to build a sense of competence in our clients, a mastery over telling their story, a sense of control over how quickly their story gets told.
2. Meaning Making
What you say next should be in the interest of making meaning of symptoms. A lot of clients come in talking about symptoms of anxiety, depression, dissociation, addiction, suicidality. While it is, of course, important to stem the tide of intense symptomology, this really can’t happen until we start to understand why the symptoms are there in the first place. For example, a client might come in saying, "I'm having a hard time getting out of bed every morning." Although there is an immediate pressure to fix and relieve a symptom, to problem solve, our clients are not coming to us with new symptoms, and simple solutions are not going to provide relief. So, there is a temptation to talk about setting an alarm to wake up earlier. But we next must move our clients into a deeper understanding of their patterns and behaviors. Let’s really talk about everything about the staying in bed, instead. How long has it been going on, does it produce feelings of shame, who do they feel most judged by for it, what does it keep them safe from? In the early stages of treatment, it is unbelievably seductive to try to provide remedy, but we have to remember that the next thing to say has to be about letting our client be heard, not just fixed.
3. Be Trauma-Informed
When I start working with someone new, for probably the first several months of our work together, I assume that there is importance in working in a trauma-informed manner. This means several different things for me. First, I simply stay away from asking my clients: Why? Let’s say that you have a client who has been wanting to break up with their partner for years but hasn’t been able to. The first and most obvious question to ask is: Why? However, this is simply not a therapeutic question or intervention. Our intention in making the decision about what to say next ought to be informed by our wish to not make our clients feel inept or incompetent. When we ask why, we are suggesting that there is a simple answer to an almost always complex set of defenses and choices that inform our clients’ lives. The other reason to not ask why is that the question “Why?” is extremely anxiety provoking and often induces a level of panic that our evolving attachment to our client is not yet ready to support. Just think of the last time you were late for a bill and the bill collector asked you, “Why were you late this month?” The question immediately elicits defensiveness, shame, and a wish to come up with an answer that we really don’t have. The fact is that sometimes we are just late because of a set of unconscious factors that we don’t yet understand or because we have actually run out of money. Either way, the question doesn’t bolster esteem and can feel triggering.
Second, when trying to construct the next thing to say to a client (while maintaining a trauma-informed lens), I typically seek consent before saying the next thing that I am going to say. This can be as simple as, “Do you mind if I ask you a question?” or “Would it be helpful for me to share some of things that I am noticing?” The simple act of seeking consent before saying the “next thing” provides a corrective experience for clients who have been intruded upon, treated disrespectfully, and have not been given an adequate amount of control over their own healing processes yet.
Third, when determining what to say next in a trauma-informed manner, I always think about pacing first and foremost. To be sure, trauma is defined by the presence of a chaotic experience that has left someone feeling out of control and without a sense of comfort and peace. This disruption in their lives means that they don’t always know how to maintain safety for themselves in evolving relationships and connections. While there is tremendous pressure to make change, progress, and growth, these things really can’t occur until a sense of safety is compulsively established. I ask clients, more often than not, "Are you feeling safe right now? What would make you feel safer? How do you feel about how we are talking about this?" Let the process slow down in order for it to ever move at a proper pace.
4. Think About Biopsychosocial Identity
Although it almost feels banal to say, the fact is that every client has had a totally different life experience leading up to our meeting with them. Some clients grew up in houses where yelling was constant, with a level of poverty that created intense feelings of pervasive scarcity, with a level of marginalization or oppression that has forced them to hide important pieces of themselves. So, for a client who is trans or on the LGBTQ spectrum, it can feel a certain way when we say something like: “It must be so hard to keep a secret.” Secret keeping might actually be someone’s way of life, and strategically so. We don’t want to say the next thing in a way that is embedded with normativity and presumptiveness. The next thing we say should always be informed by a very careful understanding of someone’s identity.
This can particularly be true, also, when working with neurodiversity. For example, I have a client who proudly identifies as being on the autism spectrum. I said to her, in an early session, “That sounds lonely.” She was completely alienated by the depth of assumption in that simple reflection. The fact is that she rarely feels lonely and that being alone is what is most comfortable and preferable for her. We need to consider that what we want to say next is typically born of our own world view and social location. And we need to try to determine how to step out of this space in order to enter the realities and nuances of our clients’ experience.
5. Say Nothing
Finally, I often offer the simple supervisory option to new social workers growing clinical relationships that they don’t actually have to say anything at all. Unlike most conversations, clinical and therapeutic interactions are not as simple as a back and forth dialogue. Sometimes, the less we say the better, providing the opportunity for our clients to delve more deeply into their own minds in the presence of another person, someone who is simply listening and trying to learn more about what they have not had a chance to say aloud up until this moment in their lives.
Dr. Danna Bodenheimer, LCSW, is the founder of Walnut Psychotherapy Center, and the executive director of the Walnut Wellness Fund. She is the author of Real World Clinical Social Work: Find Your Voice and Find Your Way and On Clinical Social Work: Meditations and Truths From the Field (The New Social Worker Press).