How a Pediatrician Learned Therapeutic Language

After decades of interacting with children, teens, and parents as a pediatrician, I felt pretty confident about my communication skills. One of the challenges that awaited me, however, as I took on the position of medical director of the MedPsych unit at Hasbro Children’s Hospital, was the emphasis on consistent, therapeutic messaging. It demanded carefully chosen words that coordinated smoothly with what the patient and family were hearing from the rest of the team.

At first, some of the word choices struck me as overly self-conscious. I teased the psychiatrists about their avoidance of the word “but.” They avoided it in therapy, in team discussions, and in meetings.

So when an annoyed teen pronounces, "You don’t know what you are talking about!" and demands to go home, she will hear: “I’m glad you’re being honest. It's important to know how you really feel. And we really believe that our plan will help you reach your goals.”

I sat in on patient team meetings with a mix of curiosity and skepticism, trying consciously not to raise one know-it-all eyebrow at the nitpicking semantics, wondering how the heck it was any different than saying what I would have likely said: “Well, I’m glad you’re being honest, but we believe…”

I was not hearing the invalidation the word "but" can carry.

There were other linguistic minefields as well. Carla was suffering from a conversion disorder that convinced her she could not walk. She had made significant progress in our program and no longer used a wheelchair. Carla was ready for an outpatient program. The whole treatment team was there, but I was running the meeting.

“Couldn’t I keep the wheelchair at the day program just in case I need it?” she asked.

“You know now that your body can walk, and that it was the illness that was telling your body it was weak,” I responded. “We don’t want to set you up for failure by reintroducing a wheelchair you don’t need.”

The patient and her father both gave a slight twitch of their heads and looked a little uneasy, but overall it felt like a good meeting, and I left satisfied that we had done a good job of preparing this family for the next level of care.

A few minutes later there was a light knock on my office door, and Dan walked in. “That was great,” he said. “You did a really nice job. I can tell you’re going to be good at this.“

What I did not immediately see was that this was the start of a “feedback sandwich.” Say positive things, then give the feedback, and then wrap it up with more encouragement.

“You did a great job of reminding Carla why she wouldn’t be using a wheelchair anymore,” he added.

I could hear the “but” coming in my head. Yes, even if he didn’t use that word exactly, it was going to be a distant cousin of “but.”

Dan took a pause instead of a conjunction and then went straight to a new sentence, without any ifs, ands, or buts. I have to admit it worked. What he was going to say next was not going to invalidate the positive message he had just offered.

“You said you didn’t want to set them up for failure,” Dan continued. “Failure is a pretty loaded, negative term, especially for our patients who tend to feel very unsure about themselves at this point. Carla reacted a bit to that. The most important thing we offer our patients is hope. And we really are very hopeful that she will do well in the Partial program. If she regresses, we know that is a predictable course of recovery. We are not expecting failure. Can you see the difference?”

I couldn’t. At least not in that moment. What I was thinking was, “You’ve gotta be kidding me!”

What I actually said to Dan was, “But"—there it was again!—"doesn’t that mean the same thing? Don’t they know it means the same thing?”

I could feel my face crease with confusion as I stared at the space above Dan’s head. Dan just sat there with a friendly expression. The remarkable thing about therapists is that they are so comfortable with not saying anything. I tend to be a verbal gap filler and I was learning that that can be a communication problem in itself. A short pause can be a way of inviting the other person into the conversation.

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“OK,” I finally said. “But you’re going to have to keep helping me with this. It's like I need to learn a whole new language.”

“And you will," he answered with a smile. “You’re already doing great. We’re very lucky to have you.”

Feedback sandwich complete. I had to admit that a formulaic approach to dialogue did not necessarily exclude authenticity and warmth.

Dan patiently stayed on message with me those first few months, with frequent good-natured reminders. When I chimed in during the morning meeting, “I know the milieu therapists are getting frustrated but I really need them to do this,” Dan would get that smile on his face and say, “And you really need them to do this.”

It didn’t take long for me to catch on, mostly because I experienced firsthand that subtle word choice could reorient me to what the patient was actually hearing in our conversation. I became aware of how often in the course of a day we choose “but” or a negative slant like “avoiding failure” rather than “preparing” for success.”

The guy fixing your muffler probably doesn’t notice or care about any of this, but the more personal the conversation, and the more vulnerable the person you are talking to, the more helpful this kind of dialogue can be.