As a matter of technique I am going to propose a number of questions. They can be thought of as hooks with which to catch the essential information, or as hooks on which to place the information gathered by a trawling technique. As a first example of this we have:
HOOK 1. As an opening question, use "How would you like to start? Some people prefer to talk about the problem in their own words. In other cases it is easier if I ask questions. Which would you prefer?"
The nature of the problem
There are two traditional ways of catching fish: a net or a line. The two traditional ways of finding out what is in someone's mind are either the trawling technique of letting him or her talk and talk without interruption, at the end of which you hope to have caught all information of value, or the line and hook technique of asking questions. (And if you look at a question mark in a certain way it does look a bit like a hook, does it not (try up-side-down)?)
In practice we may use a combination, with due sensitivity to the inclination of the client.
At one extreme I remember one client who gave me the story of her life for six hours, spread over four sessions, as smoothly as if it were a written autobiography. It would have been quite wrong to interrupt during the telling: we must always remember that there is for many a definite need to be listened to and understood, quite apart from any other help offered. At the other extreme there are individuals whose minds are so confused that it is necessary to ask some specific questions in order to tease out any semblance of order.
The only reason clients come is because there is something bothering them. But it is very important to avoid jumping to conclusions. I have lost count of the number of times I have talked with a prospective client on the phone, and after five minutes been quite confident that I understood what the problem was, only to find at the first session that I had got it quite wrong.
One reason why this happens is that clients will not open up about very personal matters until they have achieved confidence in the therapist. Thus they may start by talking vaguely of stress and needing to relax, when what really worries them is a sexual problem. At times this can be reversed.
One client presented her problem as being extreme masochistic tendencies in her sexual relationships, but it slowly became obvious that the real worry had to do with avoiding facing certain deep fears and insecurities. For her the latter showed weakness, and weakness she despised far more than a mere sexual deviance.
Another reason for initial problems is the different meanings that people give to words. "Paranoid", for example, means to some people something like "mad", to others "emotionally disturbed", to others it means "thinking others are scheming against me".
None of these is what is meant by the word in its technical sense as, "The name given to one type of functional psychosis, viz. that in which the patient holds a coherent, internally consistent, delusional system of beliefs, centring round the conviction that he (or, more rarely, she) is a person of great importance and is on that account being persecuted, despised, and rejected." Gregory (1987) Bib .
Here are some questions which can help to clarify the exact nature of the problem, and to avoid any misunderstandings about it.
"Tell me in your own words about the most recent time when you had this problem."
HOOK 2. "What feelings did you have at the time?"
HOOK 3."What physical sensations did you notice at the time?"
HOOK 4."What were you thinking at the time?
The purpose of these specific questions is to build up a clear idea on your mind of the complex processes which are going on in the client.
Let us take for example a person who comes stating that the problem is "blushing". This one label can stand for a variety of different problems. We might find that a particular female client blushes only in the presence of a male in authority and that it is accompanied by feelings of fear, physical sensations of trembling and thoughts that she hopes he will not approach any nearer. (We may then suspect that the problem is primarily sexual.)
Another client might report that it only arises when he is about to address a large group of people, at which point he feels very self-conscious, there is a sensation of shaking in the voice and the thoughts in his head are, "I am going to make a fool of myself." (We may then suppose that the central problem is self-confidence, or similar.) It will be clear that the psychodyanamics of these two cases are totally different, and consequently any help given is also likely to be on quite different lines.
Although I have indicated one-line answers to the questions above, in practice the questions will stimulate quite a lot of information which will throw more and more light on the problem, and often show it to be fundamentally different from what it first appeared.
Origins
Problems do not generally arise for no reason. Extreme phobias of water do not arise without cause, for example. It is usually very important therefore to use
HOOK 5. "When did the problem start? Tell me about the earliest occasions you can remember."
If we find that the first time the client approached a swimming pool she nearly drowned, as happens not infrequently in the case of such a phobia, we have found out something of great importance when it comes to solving the problem.
But this question may also show up any changing patterns in the problem over the years. It is a common phenomenon for an initial problem to become confused in many ways as time passes because the worry about the initial problem can generate further symptoms which can in turn create further anxiety or depressions.
There are times, however, when the connection between the origin of the perceived problem and the real cause is not so obvious. A classic instance of this is the delayed onset of extreme distress, anxiety or panic attacks which can arise six months or more after a bereavement. Typically the bereaved person has repressed the grief for that time. More extreme cases involve the repression of traumatic material from as far back as early childhood.
In order to discover such origins the following questions (6 and 7) are very useful.
HOOK 6. "Can you think of any big changes or upsets or bereavements in the year before it started?"
It is a fact that most people find most big changes rather traumatic, but the current ethos is that we should be able to adjust to them with the ease of well-oiled machines. As a result quite a few problems arise that we, as therapists, can help comparatively easily, because they involve short-term transitions. The client merely needs some help and support while going through a change in life.
"This father took his little girl to the playground. She wanted to go on the swing. He let her, but stood by to make sure that she swung safely. To begin with he was happy, but then he noticed that she was starting to swing to what he felt was a dangerous height. He decided to "take control" and, when the swing was at its highest, pushed it down firmly. For a few seconds he was relieved to see the swing descending rapidly. But then, to his alarm, it rose even higher than before. He had learned nothing, however, and in his alarm he again pushed down firmly when the swing was at its highest!"
You may picture father and child together getting into a more and more frantic state with every swing of the swing.
Steinbeck, in Sweet Thursday Bib, writes, "There are some people who will say that this whole account is a lie, but a thing isn't necessarily a lie even if it didn't necessarily happen.There are far too many people who make their problem, whether it is anxiety, hypochondria, shaking etc. etc. worse by acting just like that father and panicking when the problem is at its peak with the predictable result of making it even worse the next time.
External causes
Let us next turn to the third big class of reasons why the problem continues: external factors. Such factors most commonly involve other people. Here is a question which will rapidly reveal problems in that area.
HOOK 11. "What do people close to you advise?"
This may seem a little indirect, but it gives a way for the client to talk about husband or wife or father or mother without seeming to blame them at all. This is quite important, for a lot of problems arise because a person does not feel that it is right to go against the feelings or opinions of a loved one. Nevertheless the answers should reveal to you the extent to which the family, friends or employers are the cause of the continuation of the problem.
Related problems
There is another potentially very important area that the above questions may fail to fish adequately. It is quite common for the initial presented problem, as observed above, to be at most part of a more general problem or problems. It is often necessary both for reasons of time, and for reasons of allowing the client to gain trust in you, to leave this area until a second session. But sooner or later it is well worth bringing out in some form the question:
HOOK 12. "If you look back over your life, would you say that you have had any other significant problems to deal with?"
This might catch significant facts like hating boarding school, a disease, an aborted child, a broken relationship, a sleep problem, sexual malfunction and so on, which the client may not think to be relevant, though they often are.
Collect your own hooks.
I have suggested twelve "hooks" or questions above. It will be obvious that they are not to be applied like an inquisition. In many cases they will remain unspoken, though we will have them in our minds in order to structure the form of the discussion.
You will have many of your own favourite questions. Perhaps you are not fully aware of what they are. It can be a useful exercise to note down those that have passed the test of time. (And you may care to share them with others
The disciple said, "Thank you, wise master, thank you. I will immediately seek the right questions and then I, too, will be wise." And he left.
The Master shook his head sadly. "Once a fool, always a fool. There is no wisdom in merely knowing the right questions. Wisdom begins with understanding the answers to the right questions." |
