Can therapists use reformulations without disempowering the client?

The short answer is yes! The reasons why follow…

There is some anti-reformulation sentiment in person-centred therapy

Therapeutic reformulations, simply put, refer to the speaker (usually the therapist) summarising what the client has just said. Here’s a (completely fabricated) example that is not based on reality whatsoever, nosireeboborjim:

Client: Why does nobody comment on my blogs?

Therapist: It makes you sad that nobody comments on your blogs.

That is a silly example, of course. But I hope it gives you an idea about the aim of therapeutic reformulations. It’s not just a case of summarising what has been said but speaking to what is unsaid (the sadness, in this example). Reformulations can therefore be used to help the therapist communicate their feelings of empathy with the client.

But how can that be done without the therapist assuming power over the client?

Ding ding ding! That’s the ‘six million dollar’ (for want of a more modern reference) question. Therapists, like person-centred therapists, aim for ‘egalitarian’ (meaning, equal) relationships. Can somebody summarising your feelings on your behalf be in an equal relationship with you? That’s quite the matter of debate.

On the one hand — yes. Isn’t that the purpose of therapy? Couldn’t somebody in an equal-but-not therapeutic relationship help you understand how you feel by summarising your feelings for you?

On the other hand — therapy isn’t a normal ‘equal’ relationship, like a friendship might be. Not to start, at least. And sometimes not at all. It usually requires work to get there. And some people think the idea of egalitarianism is a myth anyway, and others still think it being unattainable is not as problematic as you might assume. Therapists may hold power over clients because they have expertise — qualifications, publications, a privileged position — you name it. They might make efforts to ensure the relationship is equal but are they necessarily successful? Can they ever be? It’s questions like this that keep people like me awake at night. Seriously.

So you’re saying that reformulations… Wait, what are you saying?

That title was a cheeky nod to linguistics research about reformulation use in therapy — as reformulations often start with the word ‘so.’ It is also an acknowledgement that it is a complex area — because it truly is! I analysed reformulations and considered whether they can be used to empower the client. Empowerment in person-centred therapy is related to power because equal therapeutic relationships should help the client to become empowered. So it was really important to consider how reformulations related to power and, so, empowerment.

What did I find?

The first thing I noticed was the sheer frequency with which therapeutic reformulations were used by the therapist. They comprised almost every turn. The second thing I noticed was how difficult they are to analyse — they are often used with other linguistic features; and they seemed to occur in different ways to one another.

What does the linguistics research say about therapeutic reformulation use and power?

This part was intriguing. Person-centred therapy (and, in fact, other) theorists tended to talk about therapeutic reformulations and how they were potentially damaging as they meant the therapist had more power than the client. But the linguistics research showed a different picture. For example, recent research by Wu (2019) says that there are different types of reformulations.

What do different types of therapeutic reformulations mean for client empowerment?

Reformulations may be divided into ‘gists’ or ‘upshots.’ Reformulations by gist mean that a person summarises what the other person has said without adding any evaluation about the content of what has been said. Reformulations by upshot include an evaluation. Thinking about the earlier example again,

Client: Why does nobody comment on my blogs?

Therapist: It makes you sad that nobody comments on your blogs.

Is this reformulation by gist or upshot? Well, it adds evaluative information (that the person feels sad that nobody comments on their blogs), so possibly comes from the ‘frame’ of the therapist. That is, unless the client has said elsewhere that they feel sad that nobody comments on their blog. Maybe just before this they said something like,

Client: I’m feeling really sad about the state of the comments on my blogs.

Then the therapist asked, “Can you tell me a little bit more?”

It’s a silly example but I hope that it helps to show how reformulations can take different forms. Imagine if the therapist said, “man, you must feel such a loser,” after this. Then the client said, “but I never said or felt that?” that would definitely constitute a reformulation by upshot. And the client might say that it is inaccurate too which I hope gives you a bit of an insight into my other findings, about how reformulations by gist, when used by the therapist, can also be used for empathy.

But all this talk about the therapist — what about the client?

This is a good question (thanks me!) because another criticism of research about therapy is that it tends to consider therapists rather than clients. Or that clients are only considered in terms of harm being done to them. That work is important, of course — but research can also consider their perspective from other, more positive perspectives.

I found that clients too use therapeutic reformulations. The difference was that clients could also use reformulations by upshot. In other words, there are no conversational rules that stop them doing so.

This has interesting implications for power in the therapy room.

Theorists speculate that therapist reformulations mean they have power over the client which, as we’ve discussed, is inadvisable in person-centred therapy. However, there are different types of reformulations and (at least) one type seems possible to use without it meaning the therapist has power over the client. But the client also uses reformulations — and can use both types. So, does the client in fact hold more power than the therapist?

Well, only if you don’t account for the complexity of power. There are, in fact, several types of power — and they can be enacted at various times for various purposes, even within a single conversation. Fascinating stuff, right?

What about responses?

I also considered the responses by clients to the reformulations used by the therapists (mostly this way round as therapists used reformulations far more than did clients, which makes sense when you consider the aim of the therapy is about the client).

I found that clients tend to respond to therapist reformulations by either ‘confirmation and extension,’ or ‘disconfirmation and extension.’ These terms come from linguistics literature — they mean that the client would either agree and extend or disagree and extend. That doesn’t sound ground-breaking of itself but it is really important in therapy. By adding that extra information, whether their interpretation is right or not, the therapist has lots of extra therapeutic information to respond to in a, hopefully, empathic manner. Even if it isn’t immediately empathic, the client offers information to help ‘correct’ the interpretation so empathy can be reached at a later stage.

It’s also an interesting finding when you consider how this relates to linguistics research, like ideas from politeness theory.

What does politeness have to do with therapist reformulations and client responses?

Some suggest that an unempathic therapist reformulation might be met with a dissatisfied client response — so they might change the subject or not respond at all. This type of response tends to be more likely than outrightly stating that a person is wrong, according to politeness theorists. The findings suggest though that clients do often tell their therapist they are incorrect, although they often soften this by saying things like, “well kind of… But…” and adding further information. Either way, this indicates that clients follow politeness rules but that it is possible to do so in a way that is empowering to them — by allowing them to add their own perspective, and to encourage a more appropriate empathic response by the therapist, even when their interpretation has been ‘wrong’.

Another interesting finding was that power can also be ‘dampened’ or mitigated, if you prefer, by using other types of linguistic features in combination with therapeutic reformulations. Specifically, hedging, questions, personal pronouns, and metaphors. I’ll talk more about combining linguistic features to empower clients in another post.