In the Room

Questions with a Punch: Your Favourite Question

As a therapist we develop our own repertoire of high-impact questions. Such questions open up territory in clients’ lives in powerful ways.

Much of my work in a child and adolescent mental health context requires that I chart back into a child’s developmental history, gain a sense of the child’s underlying temperament or emerging personality, and become aware of significant events in the family’s history including mental health issues and family scripts (Byng-Hall, 1985). After completing a three generation family tree, I find the following question allows me to respectfully approach all three of these areas. Hat tip Evril Silver for this one.

Of all the people in your family (referring to the genogram), who does this child remind you of the most and why?

I have always found answers to this question informative. Sometimes I need to ask the question without the child in the room, as well as with the child present. Sadly many mothers tell me that their child reminds them of an abusive ex-partner. However even in this instance we are then able to move onto exploring ways in which the child is just a child, rather than the parent’s representation of the ex-partner (Fraiberg, 1975). The parent is then more able to take charge when necessary, rather than stepping around the issue of control to avoid feared conflict (Marvin et al, 2002).

The question also allows easy entry into discussion of family mental health issues – often the parent’s concerns for their child are linked back to difficulties experienced by other family members (e.g., schizophrenia). Again, once space is opened up for exploration of such issues, parents are often able to revise some of their perceptions and concerns (family scripts). On occasions when the question is asked with both parents present, marital conflicts may surface where it becomes apparent that one parent ‘blames’ the other for their child’s behaviour. Progress can be made here by addressing such implicitly-held beliefs openly. There are many other benefits, including of course discovering possible genetic influences.

So what is your tried and tested question? Please share it with the readership of this Blog…

Mark

Guest Blogger Returns

Guest blogger, Mark Donvoan returns posting the question: What is your favourite question?

The Short and the Long of it: What’s on my Bedside Table.

I have just picked up the recently published paperback version of R. Horacio Etchegoyen’s book: Fundamentals of Psychoanalytic Technique. This book was first published in 1991 and has been on my must read for some time. At some 800 pages it needs quite some time to be read and digested. However Etchegoyen has a delightfully easy to read style and makes many of the complex concepts of psychoanalysis readily understandable, at least to me who always struggled to some degree with Freud in the original. The focus of the book is on technique and not theory and it goes well beyond the last book of this type which in my view was Greenson’s book: The Technique and Practice of Psychoanalysis which sadly only every got to Part I.

For those of you who cook I liken this book to Madeleine Kamman’s book: The Making of a Cook. Everything is covered in fine detail but this is no dry technical tome, the personal character and passion of the author comes through on page after page. It is book you can read solidly or dip into repeatedly and always come up with something new. I have a soft spot for Argentineans. A favourite poet of mine is Gorges Luis Borges. His poem: Another Poem of Gifts hangs on my wall, a reminder to keep life in perspective. Racker’s book on countertransference I return to with some regularity.

If Etchegoyen’s book is a Kamman then Coren’s book Short Term Psychotherapy is a Jamie Oliver cookbook. Short, slightly frothy with a few great recipes. Coren whips through the shorter dynamic psychotherapies in fifty or sixty pages with a competent brief few pages on each. It is the middle of this book which is the more satisfying for me with a number of chapters devoted to technique in shorter term therapy integrating a number of ideas but particularly Malan’s. There is a nice discussion for example on the when, how and the need to make transference based interpretation in shorter term dynamic therapy. These chapters are extremely practical and easy to understand. I would recommend this as an introductory text for anyone thinking about taking up short term psychodynamic therapy.

 

 

What do you Know and how do you Know it: Socratic Dialogue II

One of the difficulties with Carey and Mullan’s paper discussed in the first post is that you come away from it thinking Socratic question is multi-defined with a number of different purposes and therefore is not a useful or functional technique. Nothing in my view could be further from the truth. I think a more useful way to look at this is that a lot of techniques have received the same label but this has nothing to do with their usefulness.

I want to look at a couple of these in more depth. I think with any technique it is useful to look at both the technique as well as the purpose or purposes for which it is to be used. It can also be useful to think about the outcomes that occur in therapy as a result of using this technique.

For myself I have found it far more useful to go outside of psychotherapy literature to find helpful stuff on Socratic questioning.A good example would be R Paul’s book: Critical Thinking: What Every Person Needs to Survive in a Rapidly Changing World.

Of all places I came across this useful summary of Paul on a site about teaching engineering. Here is another useful site with a summary of Socratic Techniques also citing Paul. Both these sites have a good range of questions you can also use as a therapist. I have included a range of them below.

Socratic questioning is a simple yet strong method for exploring ideas or statements in depth and breadth. In its simplest form, it involves:

• Selection of a question or issue of interest
• Clarification of the question or issue
• Listing and critical examination of Support, Reasons, Evidence, and Assumptions related to the central statement
• Exploration of the Origin or Source of the statement
• Developing and critically examining the Implications and Consequences of the statement
• Seeking and fairly examining Conflicting Views (alternative points of view).

Paul divides the questioning up into six types. I find understanding these different types of questioning really useful as it helps me to keep in my head where we are up to in the Socratic process. It is much more useful in my view to view Socratic questioning as a process with a set of steps than to see as a tool to get to some place. In my experience going through the process of one type of question after the other always yields something useful. As Padesky would put it, when you do it this way the client ends up owning the discovery or insight with no pressure to accept the therapist’s point of view on anything. This fits well with one of my little sayings in therapy along the lines of that it is the client’s job to do the work i.e. they have responsibility for the outcome. Usually in supervision it gets framed in the reverse when I say to a supervisee “if you are working then the client is not working”.

Paul's six questions include:

Clarifying questions

• What do you mean by ______?
• What is your main point?
• How does ____ relate to ____?
• Could you put that another way?
• Let me see if I understand you; do you mean _____ or _____?
• Could you give me an example?
• Could you explain that further?
• Could you expand upon that?

Assumption questions

• What are you assuming?
• What could we assume instead?
• You seem to be assuming ____.
• Do I understand you correctly? You seem to be assuming ____.
• How would you justify taking this for granted?
• Is it always the case?
• Why do you think the assumption holds here?
• Why would someone make this assumption?

Reason and evidence questions

• How do you know?
• Why do you think that is true?
• Do you have any evidence for that? What difference does that make?
• What are your reasons for saying that?
• Can you explain how you logically got from ____ to ____?
• Do you see any difficulties with your reasoning here?
• What would change your mind?
• What would you say to someone who said ____?
• Can someone else give evidence to support that response?
• By what reasoning did you come to that conclusion?
• How could we find out whether that is true?

Origin and sources questions

• Where did you get learn this?
• Do your friends or family feel the same way?
• Have you always felt this way?
• What caused you to feel this way?
• Did you originate this idea or get it from someone else?

Implication and consequences questions

• What are you implying by that?
• When you say ____, are you implying ____?
• But if that happened, what else would happen as a result? Why?
• What effect would that have?
• Would that necessarily happen or only probably happen?
• What is the probability of this result?
• What is an alternative?
• If this and this are the case, then what else must also be true?

Viewpoint and perspective questions

• You seem to be approaching this issue from ____ perspective.
• Why have you chosen this rather than that perspective?
• How would other groups/types of people respond? Why?
• What would influence them?
• How could you answer the objection that ____ would make?
• What might someone who believed ____ think?
• Can/did anyone see this another way?
• What would someone who disagrees say?
• What is an alternative?

Begging the Question: Socratic Dialogue Part I

Ask any Cognitive Behaviour therapist do they use Socratic Dialogue as one of their techniques and they will all say “yes”. Move to a clarifying question such as what do you understand Socratic Questioning to be and the waters become murky very fast. This technique appears to be one of the most difficult ideas to learn in CBT partly because everybody suggests using it but very people can clarify exactly what the technique is.  The technique has been promoted by therapists from Adler and Winnicott through to Padesky and Beck.

For many therapists any type of open questioning gets called Socratic Dialogue. Maybe it sounds better saying I engaged in Socratic dialogue with the client compared to I questioned them about themselves for an hour.

Finding an agreed upon definition of Socratic questioning in psychotherapy or even within Cognitive Behavioural Therapy is next to impossible and it is pretty clear that Socrates has been hijacked as a brand name for all sorts of questioning techniques. Tim Carey and Richard Mullan in their paper: What is Socratic Questioning (no free access)are clearly totally gobsmacked by the lack of definition and outright contradiction surround this concept in psychotherapy. The range of conflicting definitions is quite remarkable and as Carey and Mullan remark somewhat ironically, Socrates often used his dialogue as way of reaching a clear definition.

Despite the stated importance of the Socratic Method for psychotherapy (A. T. Beck et al., 1993; J. S. Beck, 1995), clarity regarding this procedure is chimeric. Someone wishing to learn Socratic questioning could not discern from the literature what the procedure was, when it should be used, how it should be used, or what it should be used for. Indeed, a question as seemingly banal as the title of this article—“What Is Socratic Questioning?”—cannot be answered from existing descriptions. It seems that the term “Socratic method” can refer to almost anything at all. The discrepancy in the section describing the purpose of Socratic questioning is instructive. If Socratic questioning is concerned with changing minds, then a technique designed not to change clients’ minds could not legitimately be called Socratic questioning. It would seem inherently underhand and deceptive to advocate a process of self-discovery if it was the case that predetermined “discovery” was on the agenda. Currently, however, Socratic terms are used to refer to both changing minds and not changing minds.

Should one have the end point of the inquiry process in one’s mind or should it be an open ended go anywhere inquiry. Padesky in her paper: Socratic Questioning: Changing Minds or Guiding Discovery, for example would argue that using guided discovery should be utilised not to change a client’s mind but to allow the client to explore and reflect on their thoughts and behaviours. However even a brief reading of the old man himself indicates that Socrates had a pretty good idea where he was going on when he started out on his dialogue and his job was to make others come around to his way of thinking. There appears to be considerable debate about the degree to which one should have an end position in mind when one is using this technique.

The Angle of the Dangle: Facing Your Client

Every therapist has their own needs in the room. This may be the distance you need from your client to the angle your chairs face when sitting with your client. A lighter post today with a short questionnaire on your favourite seating arrangement. Look at the following  seating arrangements below and pick the one that is most comfortable for you. I am sure the more psychodynamic of the readers will be able to interpret what each of the chair angles means. Personally I am a fifteen degrees man myself.

Make Free Online Polls

More Interesting Psychology and Psychotherapy Blogs

The more I am out in the blogosphere the more I am slowly becoming aware of other psychotherapy and psychology blogs out there. A few more to comment on that I have come across over the last two weeks and they are now listed on the blogroll. Psychotherapy Perspectives is a blog by an American private psychotherapist. The focus is mainly on psychotherapy treatment issues. One I particularly liked was on boundaries in psychotherapy.

 
Clinical Psychology and Psychiatry: A Closer Look is a blog by an academic and seems to focus mainly on critiquing drug trial research.. He certainly seems to know his stuff as he takes the studies a part in minute detail. PsychHealth is another Australian blog with a focus on health psychology. Good regular posts on health topics with a psychological focus.

The PsychotherapyBlog appears to focus on much wider issues than psychotherapy. In fact aside from a few good nuggets of psychological comments buried in the posts it is hard to find an article dedicated to pure psychotherapy. Nonetheless some enjoyable comment.

Psychoworld provides a newsy regular update of interesting research from mainly clinical and social psychology aspects. This has a nice layout that is easy to read but could do with the addition of an RSS feed or email update widget.  This blog is similair to the more well known Dr Deborah Serani which also provides a well informed and steady diet of interesting psychology research.

James Fennessy has a blog on modern psychoanalysis appropriately titled Modern Psychoanalysis. This is a serious blog with regular writing on aspects of psychodynamic treatment. His latest post provides some comments on initial engagement with a client.

 

Loose Lips Sink Ships: Therapist Self-Disclosure

Self disclosure in response to a question by the patient or as a technique to enhance therapy is a complex issue. Many of us utilise self disclosure as an empathic way  of normalizing patient behaviours, feelings or thoughts. Self disclosure may also be used as a way of enhancing empathy by saying “see I am like you”. This can be particularly important in groups that may feel marginalized in our culture such as by gender, orientation or culture.

So what do our clients think of our disclosures or for that matter our non-disclosures. An article in last years Counselling and Psychotherapy Research, looks at just this issue. The paper by Jean Hanson is called. Should your lips be zipped? How therapist self-disclosure and non-disclosure affects clients.

Albeit with a small sample she looked at qualitative themes in client narratives to uncover their views on their therapist instances of both disclosure and non-disclosure.

When participants reported disclosure as helpful, their reasons were similar to therapists’ rationales for disclosing. This supports both theory and empirical studies of therapists’ beliefs about the effects of disclosures. The greatest effect was on the alliance. The participants in this study valued their therapists’ disclosures because they contributed towards:

• a real relationship,
• a sense of connection, intimacy, closeness or warmth;
• trust, safety, or a decrease in alienation;
• a sense of being deeply understood, welcomed or cared about;
• an opportunity to identify with the therapist;
• a sense that the therapist would take responsibility for mistakes

Participants appreciated disclosures that made them feel their relationship was more egalitarian: the relationship seemed more balanced or mutual; the therapist appeared more human or fallible; or the disclosures helped them to be more autonomous.

Managing non-disclosure appears to be a more complex task in that on one level you are frustrating the client’s immediate need to attempt to meet what is perceived by the therapist as a more important need.

The most important element of skill that emerged from the few helpful nondisclosures in this study was that skilled therapists would frame their refusal to answer questions compassionately, in a way that clients could understand and accept as beneficial, even if they initially had negative feelings. For example, Lynn’s therapist would not comply when she begged him to give his opinion about decisions she was about to make. Although she felt frustrated in the moment, he had conveyed to her that he was refusing because he trusted her to make her own decisions. Ultimately, she felt validated by his ‘gentle firmness’.

The most often cited skill deficit in connection with non-disclosure was rigidity. Cardinal had a therapist who did not disclose as a matter of principle. Once she asked him casually where he was going for his vacation, and he replied that it was his policy not to disclose his personal business for safety reasons. Cardinal felt insulted that he did not take her character into account.

Skilled disclosures and non-disclosures tended to contribute toward the development of a positive alliance, while skills deficits were likely to slow or damage its development. However, a positive preexisting alliance mitigated the effects of skills deficits, while a negative or nonexistent alliance exacerbated the effects and could tip the scale towards termination.

Skilled disclosures and non-disclosures tended to contribute toward the development of a positive alliance, while skills deficits were likely to slow or damage its development. However, a positive preexisting alliance mitigated the effects of skills deficits, while a negative or nonexistent alliance exacerbated the effects and could tip the scale towards termination.

Responding to Client Questions II

There seem to be a number of questions that therapist’s get asked with some regularity.

Questions about shared experience

Questions about shared experience are common and include questions about the therapist’s personal life such as age, marriage, sexual orientation, race and children but also shared problems such as depression of anxiety. These questions often relfect concern that the therapist will not really understand or really empathise with the patient.

Are you concerned that because I don’t have children I may not understand what it is really like for you?

Questions about qualifications and experience

These questions often arise out of concern as to whether the client can be helped. At the base of these are often schemas around being defective, unlovable or too crazy. The difficulty is that questions about qualifications and experience often tap into the therapist’s incompetence schema and create anxiety in the therapist or a feeling of being attacked. Responding directly to the question may allay the therapist’s anxiety but does nothing about the client’s anxiety.

Part of you worries that I may not have enough experience to help you. Tell me more about that.

Questions about treatment

Most of us are likely to give some indication to the client about the probable length of treatment. However the degree that this is useful for the client is unclear.

…..describing the therapeutic process to a patient is similar to describing how something unusual tastes. It is difficult to capture the essence of the experience in words. Furthermore, many clinicians feel that the duration of treatment cannot be predicted ahead of time; much of it depends on the nature and extent of the patient’s difficulties, the degree to which the patient wishes to work on these difficulties, and external and internal obstacles that may arise along the way.

If treatment was to take a long time how would feel about that?

If treatment were to take a shorter time how would you feel about that?

Feldman suggests the following general responses for any questions that occur.

• Can you help me understand why that information is important for you to know?
• Can you help me understand how that information will help you?
• I have found that people ask questions that are really important to them. Perhaps you could help me understand why that question is important to you.
• I have found that the questions people ask are related to some of their difficulties. It might be helpful if you could tell me a bit more about your question.
• I am concerned that if I simply answer your question I would be robbing us of the opportunity to understand what might lie behind the question.

Responding to Client Questions

Questions from the client in psychotherapy usually always create some degree of anxiety in the therapist. If nothing else it puts the therapist momentarily on the spot while they think about their response. On another level it breaks one of the rules of therapy i.e. that client’s are there to talk about themselves.

This is an aspect of practice that is rarely written about in any of the psychology or psychotherapy journals or books for that matter. The only significant paper I have found on this is by Tamara Feldman in the Journal of Contemporary Psychotherapy. Fortunately Feldman’s paper is superb and probably obviates the need for further papers on the matter. For those of you that have the time, (access appears free) I highly recommend this paper. Much of this post is a summary of her ideas. While Feldman is clearly a psychodynamic therapist her article is relevant for any type of therapy. Ralph Greenson is his book The Technique and Practice of Psychoanalysis also has some discussion of client questions in his chapter on Technique of Analysing Transference.

Because a patient asking questions creates anxiety in the therapist we often attempt to minimise this by formulating blanket rules about patient posed questions. It is not uncommon to hear a therapist say, “always answer a question with a question”.

Two men are walking down a corridor together

The first turns to other and says, “…and what do you do for a living?”

The second replies, “What makes you ask?”

"Ah I see you are a psychologist", responds the first.

The other common rule is to try and answer the question factually unless it transgresses the therapist’s boundaries. Both these rules fail to accommodate the fact that questions can be asked by a client for a number of reasons. Responding to questions becomes all the more difficult when we may have only met the client for one or two sessions and have no clear formulation or intuition as to what may be driving the question. Does the client feel safe enough to explore the needs or fears underlying the question? Not knowing the client’s style may inhibit our sense of humour and make our response somewhat more formal. Will setting boundaries on the questions asked, hinder or enhance the therapeutic alliance. At these early stages we have to rely more on the art than the science of our practice and often the best we can do is guess and take a punt.

So why do clients ask questions?

• Client may simply want information.
• Client may want to focus away from themselves. The question serves as a defence against affect or anxiety.
• The client is attempting to meet a need through the question.
• The client may be wanting to strengthen the relationship by engaging more with the therapist.
• The client may be wanting to equalise or change the nature of the relationship with the therapist.