The nature and use of directives and action skills

CHAPTER

Directives: 4

Questions and

Action Skills

CHAPTER OBJECTIVES

Therapists must move beyond listening and assess clients through the skillful

use of questions. The interview isn’t an investigation, but at times, therapists

may take on an investigator role (e.g., gathering information and tracking down

symptoms and/or diagnoses). In addition, therapists sometimes encourage clients

to take specific actions—actions deemed helpful for creating insight or resolving

a problem. In this chapter, we analyze questions and directive techniques often

used in a clinical interview.

After reading this chapter, you will understand:

• The many general questions available to therapists, how to use them,

and their usual effects (and side effects).

• The benefits and liabilities of using questions with clients.

• How asking some questions can be inappropriate and how asking

other questions can be unethical.

• Guidelines for using questions in an interview.

• Several different theory-based assessment and therapeutic questions.

• The nature and use of directives and action skills.

• Why directives and action skills are more or less effective with different

clients.

• A range of different directives and action skills, including explanation,

suggestion, agreement-disagreement, approval-disapproval, advice,

self-disclosure, and urging.

Questions and directives are two discrete interviewing skills that share much

common ground. Keeping these skills together in one chapter emphasizes their

similarities. However, we also highlight their differences by dividing this chapter

into two sections. Section One is devoted to helping you understand general

and theory-based questions. Section Two focuses on using directive interviewing

behaviors.

97 Sommers-Flanagan, John, and Rita Sommers-Flanagan. Coursesmart : Clinical Interviewing, John Wiley & Sons, Incorporated, 2013. ProQuest

Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1386485.<br>Created from ashford-ebooks on 2017-11-28 16:18:26. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved.

98 Part Two Listening and Relationship Development

SECTION ONE: USING GENERAL AND THERAPEUTIC

QUESTIONS

Imagine digging a hole without a shovel or building a house without a hammer.

For many therapists, conducting an interview without using questions constitutes

an analogous problem: How can you complete a task without using your most

basic tool?

Despite the central role of questions in an interview, we’ve managed to avoid

discussing them until this chapter. Gathering information is not synonymous with

asking questions, and believe it or not, sometimes asking questions actually gets

in the way of gathering important information from your clients. Throughout

this text, we hope to stimulate your creativity and help you understand the depth,

breadth, and application of other listening and communication tools. Developing

a complete range of interviewing skills will help you avoid depending too much

on questions.

Questions are a diverse and flexible interviewing tool; they can be used to:

• Stimulate client talk

• Restrict client talk

• Facilitate rapport

• Show interest in clients

• Show disinterest in clients

• Gather information

• Pressure clients

• Focus on solutions

• Ignore the client’s viewpoint

As you proceed through the section on using questions, reflect on how it feels

to freely use what many of you consider your most basic tool.

Grown-ups love figures. When you tell them that you have made a new

friend, they never ask you any questions about essential matters. They

never say to you, “What does his voice sound like? What games does he

love best? Does he collect butterflies?” Instead, they demand: “How old

is he? How many brothers has he? How much does he weigh? How much

money does his father make?” Only from these figures do they think they

have learned anything about him.

—Antoine de Saint-Exupery, ´ The Little Prince (1971)

Questions are a directive and integral part of human communication. Asking

questions, especially if you’re interested in obtaining particular information, can

be hard to resist. Unfortunately, as in the case of The Little Prince, there’s no

guarantee that the questions you ask (and their corresponding answers) will be of

any value whatsoever to the person being questioned.

DVD Clip

In the Questions and Therapeutic Questions DVD chapter, John and

Rita discuss the nature of questions and introduce the Chris & Um¨ ¨ ut

counseling demonstration.

Sommers-Flanagan, John, and Rita Sommers-Flanagan. Coursesmart : Clinical Interviewing, John Wiley & Sons, Incorporated, 2013. ProQuest

Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1386485.<br>Created from ashford-ebooks on 2017-11-28 16:18:26. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved.

Chapter 4 Directives: Questions and Action Skills 99

General Types of Questions

There are many forms or types of questions. Differentiating among them is

important because different question types will produce different client responses.

In this section, we initially organize our discussion around general question types:

open, closed, swing, indirect or implied, and projective and then focus separately

on therapeutic questions. Keep in mind that although we distinguish between types

of general questions and therapeutic questions, all forms of questioning can be used

for assessment or therapeutic purposes, depending on how the questions are used.

Open Questions

Open questions facilitate verbal output because they typically require more than

a single-word response. Open questions ordinarily begin with the word How or

What. Writers sometimes classify questions that begin with Where, When, Why,

and/or Who as open questions, but such questions are really only partially open

because they don’t facilitate talk as well as How and What questions (Cormier,

Nurius, & Osborn, 2012). The following hypothetical dialogue illustrates how

using questions traditionally classified as open may or may not stimulate client talk:

Therapist: When did you first begin having panic attacks?

Client: In 1996.

Therapist: Where were you when you had your first panic attack?

Client: I was just getting on the subway in New York City.

Therapist: What happened?

Client: When I stepped inside the train, my heart began to pound. I

thought I was dying. I just held onto the metal post next to my seat

because I was afraid I would fall over and be humiliated. I felt dizzy

and nauseated. Then I got off the train at my stop and I’ve never

been back on the subway again.

Therapist: Who was with you?

Client: No one.

Therapist: Why haven’t you tried to ride the subway again?

Client: Because I’m afraid I’ll have another panic attack.

Therapist: How are you handling the fact that your fear of panic attacks is so

restrictive?

Client: Well, frankly, not so good. I’ve been slowly getting more and more

scared to go out. I’m afraid that soon I’ll be too scared to leave my

house.

As you can see, open questions vary in their degree of openness. They don’t

uniformly facilitate depth and breadth of talk. Although questions beginning with

What or How usually elicit the most elaborate responses from clients, this isn’t

always the case. More often, it’s the way a particular What or How question is

phrased that produces specific or wide-ranging client responses. For example,

“What time did you get home?” and “How are you feeling?” can be answered

very succinctly. The openness of a particular question should be judged primarily

by the response it usually elicits.

Questions beginning with Why are unique in that they commonly elicit

defensive explanations. Meier and Davis (2011) stated, “Questions, particularly

‘why’ questions, put clients on the defensive and ask them to explain their

Sommers-Flanagan, John, and Rita Sommers-Flanagan. Coursesmart : Clinical Interviewing, John Wiley & Sons, Incorporated, 2013. ProQuest

Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1386485.<br>Created from ashford-ebooks on 2017-11-28 16:18:26. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved.

100 Part Two Listening and Relationship Development

behavior” (p. 23). Why questions frequently produce one of two responses.

First, as in the preceding example, clients may respond with “Because!” and then

explain, sometimes through very detailed and intellectual responses, why they’re

thinking or acting or feeling in a particular manner. Second, some clients defend

themselves with “Why not?” or, because they feel attacked, they seek reassurance

by confronting their therapist with “Is there anything wrong with that?” This

illustrates why therapists usually minimize Why questions—they exacerbate

defensiveness and intellectualization and diminish rapport. On the other hand, for

cases in which rapport is good and you want clients to speculate or intellectualize

regarding a particular aspect of life, Why questions may be appropriate and useful

in helping your client take a closer, deeper look at certain patterns or motivations.

Closed Questions

Closed questions can be answered with a yes or no response. Although sometimes

classified as open, questions that begin with Who, Where, or When direct clients

toward very specific information; therefore, we believe they generally should be

considered closed questions (see Putting It in Practice 4.1).

Closed questions restrict verbalization and lead clients toward specific

responses. They can reduce or control how much clients talk. Restricting verbal

output is useful when interviewing clients who are excessively talkative. Also, closed

questions can help specify behaviors and symptoms and thereby be helpful for conducting

diagnostic interviews (e.g., in the preceding example about a panic attack

on the New York subway, a diagnostic interviewer might ask, “Did you feel lightheaded

or dizzy?” to confirm or disconfirm the presence of panic attack symptoms).

PUTTING IT IN PRACTICE 4.1

Open and Closed Questions

The four sets of questions that follow are designed to obtain information

pertaining to the same topic. As a way of comparing how clients might

react to these different question types, imagine how you might answer

these questions.

1. (Open) “How are you feeling about being in therapy?”

(Closed) “Are you feeling good about being in therapy?”

2. (Open) “After you walked onto the subway and you felt your heart

begin to pound, what happened next?”

(Closed) “Did you feel lightheaded or dizzy after you walked

onto the subway?”

3. (Open) “What was it like for you to confront your father after having

been angry with him for so many years?”

(Closed) “Was it gratifying for you to confront your father after

having been angry with him for so many years?”

4. (Open) “How do you feel?”

(Closed) “Do you feel angry?”

Notice and discuss with other classmates the differences in how you

(and clients) are affected by open versus closed questioning.

Sommers-Flanagan, John, and Rita Sommers-Flanagan. Coursesmart : Clinical Interviewing, John Wiley & Sons, Incorporated, 2013. ProQuest

Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1386485.<br>Created from ashford-ebooks on 2017-11-28 16:18:26. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved.

Chapter 4 Directives: Questions and Action Skills 101

Sometimes, therapists inadvertently or intentionally transform open questions

into closed questions with a tag query. For example, we often hear students

formulate questions such as, “What was it like for you to confront your father

after all these years—was it gratifying?”

As you can see, transforming open questions into closed questions limits client

elaboration. Unless clients faced with such questions are exceptionally expressive

or assertive, they’re likely to focus solely on whether they felt gratification when

confronting their father (as in the Putting It in Practice 4.1 example). Consequently,

clients may or may not elaborate on feelings of fear, relief, resentment, or anything

else they’ve experienced.

Closed questions usually begin with words such as Do, Does, Did, Is, Was, or

Are. They’re very useful if you want to solicit specific information. Traditionally,

closed questions are used more toward the interview’s end, when rapport is already

established, time is short, and efficient questions and short responses are needed

(Morrison, 2007).

If you begin an interview using a nondirective approach, but later change

styles to obtain more specific information through closed questions, it’s wise to

inform the client of this shift in strategy. For example, you might state:

Okay, we have about 15 minutes left and I have a few things I want to

make sure I’ve covered, so I’m going to start asking you very specific

questions.

Beginning therapists sometimes are coached to avoid closed questions. This

is often (but not always) good advice because closed questions are frequently

interpreted as veiled suggestions. For example:

Client: Ever since my husband came back from Afghanistan he’s been

moody, irritable, and withdrawn. This makes me miss him terribly,

even though he’s home. I just want my old husband back.

Therapist: Have you told him how you’re feeling?

In this case the client is likely to feel as though the therapist is suggesting that

she open up to her husband about her feelings. Although this may (or may not) be

a great idea, using a closed question instead of an open question pulls the client

along in a specific direction. Instead, an open question like, “How have you been

dealing with these feelings?” allows the client to tell you about what’s she’s been

doing before a suggestion is implied or offered. Overall, closed questions are a

very helpful interviewing tool—as long as they’re used intentionally and in ways

consistent with their purpose.

Swing Questions

Swing questions can be answered with a yes or no, but are designed to invite more

elaborate discussion of feelings, thoughts, or issues (Shea, 1998). In a sense, swing

questions inquire about whether the client wants to respond. Swing questions

usually begin with Could, or Would, Can, or Will. For example:

• Could you talk about how it was when you first discovered you were HIV

positive?

• Would you describe how you think your parents might react to finding out

you’re gay?

Sommers-Flanagan, John, and Rita Sommers-Flanagan. Coursesmart : Clinical Interviewing, John Wiley & Sons, Incorporated, 2013. ProQuest

Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1386485.<br>Created from ashford-ebooks on 2017-11-28 16:18:26. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved.

102 Part Two Listening and Relationship Development

• Can you tell me more about that?

• Will you tell me what happened in the argument between you and your

husband last night?

Ivey, Ivey, and Zalaquett (2011) wrote that swing questions the most open of

all questions: “Could, can, or would questions are considered maximally open and

contain some advantages of closed questions. Clients are free to say ‘No, I don’t

want to talk about that.’ Could questions suggest less interviewer control” (p. 85).

For swing questions to function effectively, you should observe two basic rules.

First, avoid using swing questions unless rapport has been established. If rapport

isn’t adequately established, a swing question may backfire and function as a closed

question (i.e., the client responds with a shy or resistant yes or no). Second, avoid

using swing questions with children and adolescents. This is because children

and adolescents often interpret swing questions concretely and may respond

oppositionally (J. Sommers-Flanagan & Sommers-Flanagan, 2007b). The two

following examples illustrate this potential problem when interviewing youth:

Counselor: Would you come with me back to my office?

Young Client: No.

Counselor: Could you tell me about how you felt when your dad left?

Young Client: No.

As you can see, using swing questions with young clients (especially if you

don’t have positive rapport) can produce an awkward and unhelpful situation.

Indirect or Implied Questions

Indirect or implied questions often begin with I wonder or You must or It must

(Benjamin, 1987). They’re used when therapists are curious about what clients are

thinking or feeling, but don’t want to pressure clients to respond. Following are

some examples of indirect or implied questions:

• I wonder how you’re feeling about your upcoming wedding.

• I wonder what your plans are after graduation.

• I wonder if you’ve given any thought to searching for a job.

• You must have some thoughts or feelings about your parents’ divorce.

• It must be hard for you to cope with the loss of your health.

There are many other indirect sentence stems that imply a question or

prompt clients to speak about a topic. Common examples include: “I’d like to hear

about … ” and “Tell me about. … ”

Indirect or implied questions can be useful early in interviews or when

approaching delicate topics. They’re gentle and noncoercive and so they may be

especially useful as an alternative to direct questions with clients who seem reticent

(Chad Luke, personal communication, August 7, 2012). It should also be noted

that when overused, indirect questions can seem sneaky or manipulative; after

repeated “I wonder… ” and “You must… ” probes, clients may start thinking,

“Stop all this fluff and just ask me whatever it is you want know!”

Projective or Presuppositional Questions

Projective questions help clients identify, articulate, explore, and clarify unconscious

or unclear conflicts, values, thoughts, and feelings. Solution-focused

Sommers-Flanagan, John, and Rita Sommers-Flanagan. Coursesmart : Clinical Interviewing, John Wiley & Sons, Incorporated, 2013. ProQuest

Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1386485.<br>Created from ashford-ebooks on 2017-11-28 16:18:26. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved.

Chapter 4 Directives: Questions and Action Skills 103

therapists refer to projective questions as presuppositional questions (Murphy,

2008). These questions typically begin with some form of What if and invite client

speculation. Often, projective questions are used to trigger mental imagery and

help clients explore thoughts, feelings, and behaviors they might have if they were

in a particular situation. For example:

• What would you do if you were given one million dollars, no strings

attached?

• If you had three wishes, what would you wish for?

• If you needed help or were really frightened, or even if you were just

totally out of money and needed some, who would you turn to right now?

(J. Sommers-Flanagan & Sommers-Flanagan, 1998, p. 193)

• What if you could go back and change how you acted during that party

(or other significant life event), what would you do differently?

Projective questions are also used for evaluating client values and judgment.

For example, a therapist can analyze a response to the question “What would

you do with one million dollars?” to indirectly glimpse client values and selfcontrol.

The million-dollar question also can be used to evaluate client decisionmaking

or judgment. Projective questions are sometimes included in mental status

examinations (see Chapter 7 and the Appendix).

Perhaps even more than with other types of questions, your use of projective

questions is only limited by your creativity. One of this book’s authors, John, likes

to use projective questions to explore the depth or dynamics in relationships. For

example, with a 15-year-old male client who was struggling in school, John asked,

“If you did really well on a test, who’s the first person you would tell?” The client

responded, “My dad.” This response was significant in this case because the boy

had a very strained relationship with his father and yet, based on his response to

the question, he was still very interested in getting his father’s approval. Table 4.1

summarizes the various types of questions and usual client responses.

Table 4.1 Question Classification

Word Question

Begins With Type of Question Usual Client Responses

What Open Factual and descriptive information

How Open Process or sequential information

Why Partially open Explanations and defensiveness

Where Minimally open Information pertaining to location

When Minimally open Information pertaining to time

Who Minimally open Information pertaining to a person

Do/Did Closed Specific information

Could/Would/

Can/Will

Swing Diverse info, sometimes rejected

I wonder/You must/

I’d like to hear

Indirect Exploration of thoughts and feelings

What if Projective or

presuppositional

Information on judgment and values

Sommers-Flanagan, John, and Rita Sommers-Flanagan. Coursesmart : Clinical Interviewing, John Wiley & Sons, Incorporated, 2013. ProQuest

Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1386485.<br>Created from ashford-ebooks on 2017-11-28 16:18:26. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved.

104 Part Two Listening and Relationship Development

Benefits and Liabilities of General Questions

Therapists vary in their beliefs and habits with regard to questions. To explore

this, sometimes we assign students the task of conducting a brief interview in

which they only ask questions (no paraphrasing allowed!). Some students have a

very positive reaction to the assignment, whereas others openly hate it. We get

similar responses when the assignment is to use predominantly solution-focused

questions. Student reactions have included:

• I felt more in control.

• I felt more pressure.

• It was like I was asking the same question (about positive goals) over and over

again.

• The solution-focused questions really help me help the client stay positive.

• It was hard to think of questions while I was trying to listen to the client, and

it was hard to listen to the client while I was thinking of what might be a good

question to ask next.

• I seemed to have less patience. I just wanted to get to my next question and

kept cutting in to ask more questions.

• I felt less pressure. I really liked asking questions!

As an assessment or therapeutic tool, questions have both benefits and

liabilities. Whether a given question functions in a positive or negative way

depends on many factors, including the therapist’s skill and the client’s sensitivities.

Table 4.2 includes potential benefits and liabilities of questions.

Overall, although exceptions are possible, the more you emphasize questions,

"Is this question part of your assignment? We can help"

ORDER NOW