Barrett L. Dorko, P.T.

          At every workshop I hear the same question at least once; "Just what exactly do you say to patients while you're treating them?"

          This is commonly asked by a therapist with as much clinical experience as I, and sometimes more. The question makes me pause, and I never answer it directly.

          I'm reminded once again that for all our efforts to become more technically skillful and knowledgeable, our communicative skills are a separate matter.

          In "The Creative Moment: Improvising in Jazz and Psychotherapy" (Adolescent Psychiatry 15:1988), Russell Phillips writes, "Seasoned (therapists) do not repeat stock phrases. They draw from the wellsprings of their own lives and respond to each phase of care in a new way. They associate patients' problems with their own experiences."

          I've found that getting to the point where any therapist can seamlessly speak of internal processes in a coherent fashion and instruct another to do an exercise properly takes a lot longer than I once thought it would. I know that after twenty five years of speaking to patients daily, I still struggle at times to make myself understood, and that I can look back upon very recent interactions that could have been handled better on my part.

          I ask my classes, "What's your sharpest, most effective and potentially damaging tool?" The experienced students know the answer immediately, and shift uncomfortably as they remember those times when they cut a patient with their voice and were never able to repair that rift.

          This explains why people long in practice continue to hope that I can with some sort of canned spiel save them from making that mistake again. I can't.

          In his article, Russell equates highly skilled verbal interaction with the art of improvisation in musical performance, and points out that it begins with a certain degree of technical mastery unavailable to any beginner.

          Beyond that, he says that it requires access to our personal past, an ability to focus on the present, and some comfort with the relinquishing of control. It is no wonder that our skills with this grow so slowly.

          I've noticed that inflection, timing and cultural awareness can make a tremendous difference when I speak as well.

          I do have one piece of advice that is certain to help if only you can follow it; say less. By that I mean that you should search for phrases and metaphors that allow the patient to appropriately fill in the blanks.

          Personally, I find that lines of poetry relevant to the issues of fear, selfhood, confusion and the common experience of pain we all face at one time or another have a much better chance of being understood than most of my prose. Great poetry, after all, is great simply because we cannot resist it. I've found that certain lines said at the right moment cannot fail to move my patient precisely in the direction they need to go.

          Of course, when I mention this in class, people want me to tell them just exactly which poem I use and when.

          I resist this as well. I tell them that true mastery rises in an individual way from each of us in turn, and that amid the complexities of the clinic we can only start with what we have. This we should acquire ourselves.

          I remind them too, that the best and worst of the words I say usually surprise me as they emerge, and, hopefully, I then learn a bit more about the person who said them.