The case for cutting someone off

It will possibly surprise people who know me in real life, but when I'm working with a client, I am very good at being silent. It's not that I'm not an innately good listener; it's a skill I've honed over time as a clinician. I've written before about using silence in my work. Sometimes it's the only way to get the client to open up. Most people don't like to sit awkwardly not speaking for a long period of time so they'll start talking just to fill the void. It's a very useful clinical tool. But this blog post is about the opposite and sometimes necessary approach of making people STOP talking.

I generally work with older patients. Forgive me for generalizing, but sometimes they kind of... ramble. They're often socially isolated and their trip to the doctor is part of their socialization. I'm happy to fill that role a little bit; isolation leads to depression and anxiety, which I'm often helping the patient learn to manage. But sometimes (twice this past Thursday, actually), allowing the patient to just go on and on (and ON) about random topics is a detriment to the therapeutic process. 

There's such a focus on active listening in this profession that I think we sometimes forget that we don't have to let patients go on about nothing for an hour. We don't have to listen politely to some long story about the broken washing machine someone's mother refused to replace five years ago (not kidding, this particular anecdote was like ten minutes long). Especially in my role, where the focus is meant to be 20-30 minute sessions that address strategies for how to cope with a specific issue, it's not a good use of the patient's time. 

But asking clients to stop talking is a tricky proposition. This past Thursday, faced with two different patients who couldn't seem to get to the point, I must admit that I hesitated to cut them off. I often write about the importance of building rapport. How can I build rapport if I cut someone off and say, "Ok but why are you here?" And yet, I need to know! What is the problem? Not the long list of grievances you have against every single member of your family (that took up nearly an entire hour) but the problem you are facing right this minute. Is it insomnia? Depression? Anxiety? We have limited time; let's use it to DO something. 

I think a lot of social work roles are like this. Our time is limited; case loads are high. We are tasked with building trust immediately so we can dive into the main issue and look for solutions. Unless you're doing long-term psychotherapy, there usually isn't time to begin from the beginning.

But how do we do it without putting the patient on the defensive? I vote for being compassionate but also goal-focused. "Wow, it seems like you have a lot going on. What specifically brought you in today?" This typically works. Of course, there are always patients who just aren't redirectable: their anxiety is overwhelming or they're just bad communicators. On Thursday, with one patient who really wandered from topic to topic with barely a breath in between, I finally interrupted her and said, "You seem really scattered today. Let's try focusing on what you want to work on right this minute." She wasn't particularly pleased with my assessment but she did focus: she had a goal in mind and she wanted to start figuring out how to accomplish it. Yes! That's why we're here! 

We should err on the side of active listening and compassionate presence. But we should also not let patients steamroll us with rambling thoughts that lead nowhere. Part of our role is to clarify what people are saying and help them start the steps that lead to meaningful change. Sometimes that means a gentle interruption: let's talk about what we can do today.