AN ADHERENCE SCALE for the
CONVERSATIONAL MODEL
THIS SCALE IS DESIGNED to be useful in gauging whether a particular therapist is working according to the Conversational Model (CM). Eight categories of therapeutic response are rated, with four to eight items in each category. There are a total of 40 items. Many of the items can be scored dichotomously. It is suggested that each item is rated 0, 1, 2, with the rating of 1 indicating an equivocal adherence.
In other systems, adherence scales involve scoring a whole session—a highly laborious and expensive procedure. The method we recommend is more generally usable. It involves the rating of only a few minutes of conversation. This approach is consistent with the notion of the “minute particulars,” which implies that in the small details of a conversation are embedded the elements of a much larger system.
The conversational sample is randomly chosen at a point about halfway through a recorded therapeutic session. A transcript is insufficient for this purpose because the inflections and tones of voice are crucial. The sample should include at least five conversational units, where each unit is composed of the patient’s expression and the therapist’s response. An example of such a sample is given at the beginning of Chapter 6, where the opening to a session between Marguerite and her therapist is discussed.
Scoring of the therapist’s response should ideally be performed by someone familiar with CM. Alternatively, Chapters 3, 6, and (for some situations) Chapter 7 offer a guide. Examples of most of the items on the scale are given in these chapters.
Before scoring the sample, the rater should study it and calculate what the maximum score could be, since not all items will be applicable to this particular part of the conversation. Traumatic intrusions, for example, may not always be evident. The therapist’s responses are then rated. This score, T, is then expressed as a percentage of the ideal maximum score, M—that is, the score equals T/M × 100.
Those using this scale will need to create their own normative data. This scale has not yet been piloted. What is put forward here is a suggested guideline for measuring adherence, and it is capable of development by those who use it.
The categories of therapeutic response and items reflective of each category of response are as follows. It should be stressed that neither the list of categories nor the number of items is exhaustive, but they provide a snapshot view of capable use of CM.
1. Immediacy
• The therapist’s response is closely “coupled” with the expression and the patient, using appropriate emotional tone.
• The therapist uses that which is expressed by the patient (i.e., the actual words).
• The therapist responds to that which is most “alive” in this expression.
• The therapist tends to use the present tense.
• Trauma is processed as if in the present.
2. Right-Hemispheric Language
(This term refers to what Vygotsky called “inner speech”; see Chapter 2.)
• Therapist uses inflections of voice to express feeling.
• Therapist avoids asking questions.
• Therapist uses sentences without pronouns.
• Therapist tends to omit the subject of sentences.
• Therapist’s contribution may be incomplete or asyntactical.
• Therapist’s response has a “shaping” intent.
3. Mutuality
• Therapist uses language of the patient.
• Therapist uses speculative tone, as if inviting an elaboration of his or her contribution.
• Therapist gives evidence of careful listening.
• Therapist respects patient’s “agenda” (i.e., subject chosen for discussion).
• Therapist does not “translate” (i.e., turn the expression into his or her own language).
• Therapist “stays with” or “tracks” an evolving theme and feeling.
4. Positivity
• Therapist amplifies positive tone.
• Therapist finds and affirms hidden or muted positive affect.
• Therapist responds to that which is spontaneous.
• Therapist “stays with” positive affect.
5. Representation
• Therapist uses empathic imagination to put into words what is most immediate and essential of patient’s experience.
• Therapist uses tone of voice to represent emotional core of patient’s experience.
• Therapist uses figurative language (e.g., metaphor, the patient’s, and his or her own).
• Therapist gives sensory aliveness to the patient’s experience.
• Therapist facilitates the patient’s own representing.
6. Reflection
• Therapist potentiates reflective awareness of patient.
• Therapist introduces reflection with appropriate timing.
• Therapist uses propositional speech (i.e., syntactical, including pronouns).
• Therapist’s demeanor is one of coparticipant in a reflective process.
7. Changing the Chronicle
• Therapist listens with intent to a boring account.
• Therapist finds what is most “personal” and capable of imaginative development in this account.
• Therapist helps patient elaborate and enlarge this aspect of the account.
• Therapist finds some unifying image in the clatter of details presented to him or her.
8. Processing Trauma
• Therapist identifies and responds to intrusion of traumatic memory.
• Therapist does not proceed with traumatic processing when patient is not ready for it.
• Therapist acknowledges his or her part in triggering disjunction, when this is appropriate.
• Therapist, with patient, builds up the “scene” of the traumatic intrusion into the therapeutic conversation.
• Therapist, with patient, builds up the “scene” of traumatic memory affecting a relationship outside therapy. (Scene includes patient’s feelings, self-attributes, tendency to respond, attributes given to the other, expectations of the other, voice/posture/demeanor of patient, and patient’s experience of physical attributes of other).
• Therapist, with patient, moves toward changing the script, at an appropriate time when the script and scene have been well laid out.