DIRECTIVES: QUESTIONS & ACTION SKILLS CHAPTER 4 Uzm. Psk. Özlem Ataoğlu

Since we have a progress in the session, we can move to questions Asking questions is directive, you take control over the session

GENERAL TYPES OF QUESTIONS Open – ended Questions It aims to gain more verbal information from the patient The answer is never short/one – word, it is more of explanation Mostly we use “HOW?” and “WHAT?” questions “Ne oldu da terapiye şimdi gelmeye karar verdiniz?” “Şimdiye kadar bununla nasıl başettiniz?”

The question “WHY?” includes patterns of accusation that leads the patient defend her/himself This will break/weaken the bond between you and the patient because s/he will think that you are not on her/his side, but more of a judge  drop out The patient starts to use defense mechanisms BUT we want to see the patient NAKED Intellectualization/Rationalization is the mostly used defense mechanisms but we do not want this since it will break the bond

Close – ended Questions It includes “Yes/No” answers, one – word or specific information Mostly we use “WHO?”, “WHERE?”, “WHEN?” questions Verbal information is limited It is advantageous if the patient talks too much, you can limit the information. Also, you can use for categorization/framing. If you are looking for a specific information, you can use this type. If you have a strong therapy bond, to wrap up, when you have a time limit, you can use this type

If you give a specific data/information to the patient, s/he may focus on that P: I am pregnant. T: Woow, congratulations! Here, the patient feels that she should be glad because of this situation. However she may also experience fear, anxiety and shock. Because of your reaction, she may inhibit her reactions so you have to leave your own beliefs outside of the room.

It is always more useful to start with open – ended questions to close – ended ones. Try to collect information, do not put boundaries, let him/her speak, then say you want to collect specific information: “Bilgileri ayrıntılandırmak istediğim 1 – 2 alan daha var, izin verirseniz onları sormak istiyorum.”

Swing Questions The answer can be “Yes/No” as well, but the goal is to detail the emotions, beliefs, behaviours, the situation and discuss it It helps us to understand whether the patient is ready to discuss the issue or not. The question ends with “-ebilir misiniz?” It actually asks the question “Do you want?” and gives the message that “You control this situation”, we do not direct the patient

IMPORTANT Unless you do not develop a therapeutic alliance, the patient may think that you are not interested in his/her story. The patient can be shy and decides not to open her/himself up. If the patient does not give an answer, it functions as a close – ended question Children and adolescents are contradictory – they will generally tend to say “NO!”

Indirect/Implied Questions It includes phrases such as “Merak ettim de…”, “Şu ilginç geldi…”, “…… zor olmalı.” The therapist is curious but does not push the patient to answer We need to be curious in order to create a curiosity in the patient that causes him/her to explore the pattern We do not use this too frequently, it will sound unreal, try to use it after your therapeutic alliance has developed

Projective/Presuppositional Questions It aims to explain and realize the conscious and unconscious emotion, belief and behaviour progresses We want the patient to create a hypothetical case We try to trigger the mental images “Size bir güç verecek olsaydık, ne olmasını isterdiniz?” It can function as projective tests – we try to collect personal values, beliefs, images, etc. “Hayatınızdaki her şeyden bir şeyi/kişiyi kazanmak için vazgeçecek olsaydınız bu ne/kim olurdu?”

THERAPEUTIC QUESTIONS Other questioning techniques are directive, direct/encourage the patient to think, feel, evaluate the situation Solution – focused therapists use therapeutic questioning mostly  they do not comment, confront, or push the patient. The focus is on today and the future, NOT the past What is going on today, what does the patient want today, how does s/he believe to solve the problems, etc. Solution – focused therapists say that if we direct the patient anyway, we should direct them to the positive, hopeful, functioning patterns

The Pretreatment Change Question There are evidence that after the patient makes an appointment, s/he starts her journey of change within the therapy sessions So, firstly we ask “İlk aradığınızdan bu yana neler değişti?” If the patient says nothing has changed or there is no distinct change, then we can say “Seansların verimli/olumlu/iyi geçmesi için ne isterdiniz?”, “Daha kötü olmamak için ne gibi değişim olmalıydı hayatınızda?” Let’s say the patient says “İş aramaya başlamak iyi olurdu.”, then the therapist may ask “İş aramanın ne açıdan iyi olduğunu, bunun için nasıl bir motivasyonunuz olması gerektiğini düşünüyorsunuz?” For a positive change, we promote and make emphasis on personal skills  this will start the solution process

Scaling Questions We use this to see clearly the potential change on the patient In order to do this, we use scales (as we do in CBT) T: Geçtiğimiz haftadan bu yana hissettiğiniz en yoğun duygu neydi? P: Muhtemelen kaygı. T: 0 ile 10 arasında derecelendirirseniz tüm haftayı, kaygıya kaç puan verirdiniz? P: Sanırım 7 diyebilirim. T: Peki diyelim önümüzdeki hafta bu soruya 6 olarak cevap verdiniz. Bunu söyleyebilmek için ne yapmış olurdunuz(neyi farklı yapmış olurdunuz)?

The try to make the solution as concrete as possible for the patient We put the focus on noticeable change More we focus on positive change, more we create the change to do it

Percentage Questions The logic is the same with scaling questions Percentage Questions The logic is the same with scaling questions. Focus on the positive changes and direct the patient to concrete descriptions T: Çok depresif olduğunuzu söylüyorsunuz. %5lik bir iyilik hali için farklı ne olurdu? P: Traş olabilirdim. T: O zaman %5lik değişim sizin için traş olmak. Peki %10 daha az depresif olmak nasıl bir şey olurdu sizin için? P: Muhtemelen işe gidebilirdim.

Unique Outcomes/Redescription Questions It is generated by Michael White In order to successfully complete some specific tasks, we direct the patient to create his/her own personal methods It focuses on the experience, not the problem. Even if it sounds so regular, you need to make emphasis on this because this is a triumph for your patient The goal is to show the patient that s/he has the control over the problem

T: Bunu nasıl yaptınız. Kuaföre gitmeyi nasıl başardınız T: Bunu nasıl yaptınız? Kuaföre gitmeyi nasıl başardınız? Böyle hissetmek için kendinize ne söylemiş olabilirsiniz? If the patient talks about personal success, triumph, patient gives you a chance to use this to promote him/her, be happy for her, be curious about the process, search for it with the patient Instead of asking “Kaygılandığınızda aklınızdan neler geçiyordu?”, you can say “Kaygıya rağmen sakin kaldığınızda kendinize ne diyordunuz?”

Presuppositional Questions As if the positive change has been already done by the patient, ask questions to define the change in a detailed way It aims to create a personal target and to do that, ask suppositional questions. By this way, the patient is directed to success, target – oriented, positive change “Varsayalım artık kaygını kontrol edebiliyorsun, bunu sürdürmek için neler yaparsın?”, “Artık alkol almamana en çok kim sevinir?”

The Miracle Question This question type is the mostly used one by solution – focused therapists It analyzes the factors of positive perspective, how to develop it and how to maintain it Especially if your patient says the situation is hopeless and nothing can change this, this way of asking is beneficial to use “Farz edelim ki bir mucize oldu, bir şeyler değişti. Bu mucizenin olduğunu nasıl anlardınız? Ne farklı olurdu?”

Also, you need to create curiosity in your patient “Size değişik bir şey soracağım… (pause, eye contact). Sorum şu (pause). Her şeyi normal seyrinde yaptığınızı düşünelim bugün. Yattınız ve siz uyurken bir mucize oldu ve sorununuz çözüldü. Uyandığınızda neyi farklı bulurdunuz?”

Externalizing Questions Therapists with more of theoretical background claim that problems are egocentric – they are internalized by the patients Solution – focused therapists externalize them  psychiatric disorders are not because of the person, it is presented as a more outer force “Sorun ne zaman çıktı?”, “Kaygı ne zaman geldi?”, “Bunu sırtından almak mı istersin yoksa beraberliği sürdürmek mi?”

Externalizing makes the patient feel that s/he can fight with the symptoms It can be used in a symbolic way and the patient should do the description T: “Kaygıyı nasıl görüyor olurdun burada oturuyor olsaydı?” P: “Kırmızı, şeytan gibi, gülümsüyor.” ** What can be the risks of this technique?

HOW TO USE GENERAL QUESTIONS Prepare your client for questions Before you ask loads of questions to your patient, warn him/her This will make your client less defensive and create stronger therapeutic bond “Size çok çeşitli sorular soracağım. Bunun amacı sizin hakkınızda ayrıntılı bilgi edinebilmem. Sorularımın bazıları size anlamsız gelebilir fakat hepsinin bir amaca hizmet ettiğini bilmenizde fayda var. Eğer bununla ilgili sormak istediğiniz bir şey olursa durdurup sorabilirsiniz.”

Don’t use general questions without nondirective listening techniques Use your general questions WITH nondirective listening techniques Asking questions too frequently will confuse your patients’ mind, may lead them to forget what they were going to say or cannot express themselves in the way they have wanted It may feel like they are not in a therapy session, but in a court STOP YOURSELF and do not ask more than 3 questions in a row

Make your questions relevant to client concerns and goals If you want to ask questions as an expert, firstly you need to focus on your patient’s problems and ask about them For instance, suppose that your patient has PTSD who can (and probably will) show depressive symptoms. At that point, in order to collect the symptoms you may want to question those depressive symptoms which may sound so irrelevant to your patient At that point, you need to focus on the PTSD history, THEN explain why you are going to do a symptom check (its rationale), THEN if it is OK for the patient, you can do it Otherwise your patient may lose interest to the sessions

Use questions to elicit concrete behavioural examples Try to collect concrete examples to your patient’s thoughts, because if not, you may be missing some distorted ideas Start with swing questions, then if it is still too general, then move to more concrete questions “Sınıfta istenmediğimi biliyorum.”  Swing question?  Concrete question?

“Kendini beceriksiz hissettiğin an evde neler oluyordu “Kendini beceriksiz hissettiğin an evde neler oluyordu?”, “Kimler vardı?”, “Nasıl bir ortamdaydın?” If there are uncompleted parts in your patient’s example, use more concrete questions to fill them because there may be still distorted beliefs

Be cautious about sensitive areas If you are at the beginning of your sessions (let’s say first 3), do not talk about sensitive areas – status, religion, ethnicity, sexual problems, politics, failures, etc. ONLY IF the patient checks in with a crisis situation (suicide or homicide), you can talk about those areas “Burada size bazı sorular sormam gerekiyor. Sizin için uygun mudur?” If you direct your patient to another institution/unit, then the important thing is to collect information as much as possible, not the sensitive areas “Bu değerlendirme amaçlı bir seans, sizi ilgili birime yönlendirmeden önce bazı bilgileri edinmem gerekiyor.”

DIRECTIVE INTERVIEWING TECHNIQUES GOAL is to push the patient to change beliefs, emotions and behaviours – kind of persuasion technique While you are doing this, you need to consider your patient’s clinical status and what is best for your client. THEN use these techniques if your patient needs a change and if s/he is ready to change Which intervention should be done for your patient, when you should do and how you will decide to do it is your responsibility here, as an expert Your patient’s responsibility is to decide whether to do it or not In order to make a progress, we decide which areas they need to change, use techniques to make it easier for them to change

Psychoeducation It means you give information to your patient about the Therapy and its progress A symptom’s meaning and its outcomes How you will apply the therapy technique and the interventions

Make it clear with your patient about the roles and what to expect and not to expect from the therapy: “Size burada bir uzman olarak yol göstermeye çalışacağım, danışan olarak sizden beklediğim kendinizi olduğu gibi ortaya koymanız olacak. Ne yapmanız ya da yapmamanız gerektiğini söylemeyeceğim.” Most of the people know nothing about the therapy process, roles and limits  its your job to inform them Do not leave your patients with uncertainty, inform them regularly

If your patient is not sure about what to say or whether it is OK to say  always encourage them to explain all of their thoughts that come up to their minds: “Burada her şeyi konuşabiliriz, gündeme alıp almayacağımıza sonra beraber karar veririz.” If your patient is not still ready about the roles, therapy process, inform and clarify him/her again You need to inform your patient that they may sometimes feel unhappy/irritated/angry during the therapy process Some of your patients will say they are afraid of getting mad, losing control  tell them that this is a normal progress for you’re his/her disorder which will not make them crazy Explain the anxiety circle to your patient  a part of their psychoeducation process

Suggestion (öneri) It can be perceived as advise (tavsiye), but they are different When you suggest something, you bring it to your patient’s mind indirectly whereas when you advise something it is more like offering, more directive “Yarın kantine girmeyi deneyebileceğinizi düşünüyorum.”  SUGGESTION: curiousity, directs to behaviour, belief change, emotion experience “Yarın kantine gitmelisin, bu senin için iyi olacak.”  ADVISE: direct, tell what to do

With adolescents, use this like: “Daha iyisini yapabileceğine inanıyorum.”  gives the impression that “I am a trustworthy person!” Your suggestion may not be accepted by the patient. Then, do not insist but what you can talk about with your patient?

Giving advise Therapist – centered, tells what to do, gives the impression that “I am the expert here.” At the beginning of our sessions, we do not give advise. As we do this in our daily lives too frequently, we should be very careful about what we say Sometimes, we need to give advise. WHEN?

If you are ABSOLUTELY sure about your patient has done EVERYTHING and still could not find a way out Talk about this with your patient in a detailed way, try to be sure s/he tried everything, explore the problematic area Ask what s/he has done so far to solve this, which choices s/he has taken into account, whether there is a missing information to solve the problem An early advise will cost your patient not to develop problem solving strategies So try to avoid as much as possible from giving advises, ask questions such as “Daha önce benzer problemleri nasıl çözdünüz?”, “Neleri baz alarak tercih yaptınız?”

Agreement/Disagreement Being with the same idea with your patient and telling this to him/her What is its advantage? The patient will feel more secure, open up more freely Develop therapeutic bond If you patient thinks that you are a trustworthy expert, then your approval means they are right Approval gives you the role of “expert” Your patient’s guided discovery process may slow down

If you will disagree with your patient in sensitive areas (political, religion, social, etc.), your therapeutic bond may weaken The ideal disagreement method is to use nondirective listening techniques (silence, nodding your head) Your disagreement goal has to be related to your therapy goals, it should not be based on personal beliefs  defense

You have to disagree if your patient’s maladaptive thoughts, emotions and behaviours affect his/her life, and functionality, cause stress  give information about the field, try to make them gain adaptive thoughts What if your patient says she beats her son every time he behaves in a spoiled way? Even if your patient believes that it is beneficial and you know contradictory evidence, you will not give a lecture about “being a good parent” BUT discuss her parental goals (of course if there is no abuse, if there is, then call social services)

Urging It includes directing and insisting on something We do not use this very frequently unless there is a crisis such as Child abuse – if the abuser is your patient, then urge him/her to report him/herself in order to protect the child Women abuse – you may urge your patient to leave with her children and go to a shelter Patients with anxiety disorder need urging to try a new situation BUT more preferable one is suggestion

Approval/Disapproval It is similar to feeling validation It involves positive patterns (belief, emotion, behaviour) It strengthens therapeutic bond It looks like agreement/disagreement  this is more related to social harmony Approval is more authoritative  “Ödevini yapmaman doğru olmamış”

Self – disclosure This can be used for your patient to gain more insight It means you have something in common and you can be a model with your life Career – Family – Personal life issues “Ben de bazen çok yorulabiliyorum” “Ben de problem yaşıyorum hayatımda, her an çözemediğim çok oluyor.”