Staff Update
Summer 2007
The Art and Science of Using Socratic Questioning Techniques in Lifestyle Counseling
Linda Gonder-Frederick, Ph.D.
Asking "good" questions is the cornerstone of many of the helping professions, including teaching, guiding, coaching and counseling. Unfortunately, few training programs adequately teach practitioners how to ask good questions or what constitutes a good question. Even in my own field of psychotherapy, where the question reigns supreme, students rarely receive systematic training in the science/art of productive inquiry. This is unfortunate because asking good questions is probably the most difficult skill to master in the helping professions, and an area where both novice and experienced practitioners have the least confidence in their abilities.
This article is going to explore the art and science of formulating and asking good questions in lifestyle counseling settings. In addition to highlighting the fundamental role of the question, we will explore attitudes and mindsets that interfere with good questioning techniques, some of the qualities that characterize good questions, and the concept of Socratic questioning in lifestyle work, including specific examples of effective open-ended questions. The role of Socratic questioning in Motivational Interviewing and Cognitive-Behavioral Therapy in lifestyle change will be reviewed. Last but certainly not least, the important role and use of active listening skills in lifestyle work will be examined.
The Fundamental Role of the Question
Asking questions is one of the most effective methods for increasing an individual's active participation and engagement in a discussion or session. This is essential in lifestyle interventions because, by definition, people have to be actively engaged in the process. The process of lifestyle change involves an enormous amount of "activity" on the part of the individual, including self-monitoring, self-motivation, goal setting, behavioral practice and follow-through, seeking support, and problem-solving. Using questions as the primary mode of communication during sessions also helps ensure that the patient[1] is "doing the work" and that the counselor is not working harder than the patient. In addition, an emphasis on exploring questions in sessions or meetings helps to convey the important message that this work requires and depends primarily on the patient's effort.
Using questioning techniques, as opposed to more passive techniques such as giving advice or information, challenges the individual more, and challenges are a necessary part of lifestyle change. Good questions are also more likely to elicit new information and perspective, and provide an opportunity for new ideas and options to emerge. Together the counselor and individual gather new data, examine this data in different ways, and decide whether or not the new data has any implications for lifestyle decisions and behaviors. Through this process, the individual learns new skills in self-evaluation and problem-solving, which are critical to making positive changes in eating and activity.
Barriers to Asking Good Questions
A number of factors can be barriers to asking good questions in counseling sessions, including the lack of training and confidence mentioned above. The human tendency to "assume" also plays a key role. Whenever a practitioner makes an assumption, this decreases the likelihood that a good question will be asked. Asking good questions depends on a mindset characterized by curiosity, not assumptions. One of the best lessons in my training as a psychotherapist came from an early clinical supervisor, who constantly asked me why I had not been more curious about something a patient said or did - why I had not asked more questions. I realized that in these moments I usually was assuming that I understood (or that I should understand) what the person meant, what the person was feeling, and what the person did. And, with those assumptions in hand, there did not appear to be any reason to explore further.
Another attitude that interferes with a curious mindset is that many in the helping professions still harbor the belief that their primary job is to know all of the answers, and that we can best help by giving people the "right" answers. Knowing the right answer is definitely useful in some situations; for example, when educating patients, diagnosing problems, and deciding what type of intervention might be appropriate. But knowing the answers is often less useful in other settings, especially those in which the practitioner's task is to help an individual evaluate and change deeply ingrained feelings, thoughts, attitudes, behaviors, and habits. Unfortunately, the practitioner's right answers are often of little use to patients. They have to discover the right answer for themselves.
So the first step in mastering the art of therapeutic questioning is to begin to ask more questions when working with individuals. In clinical supervision, I ask my trainees to monitor the extent to which they use questions during sessions, versus how much time they spend talking to patients, or giving advice. Even as an experienced therapist, I know how easy it is to fall into the advice giving groove. For this reason, one of the ways in which I "grade" my own performance in sessions is by how much time is devoted to inquiry versus advice giving. In addition to self-monitoring on the part of the practitioner, another exercise to improve questioning skills is to review sessions, and identify points where statements, opinions or advice giving could have been reframed as a question. This exercise can also be done in vivo during sessions by stopping when getting ready to give advice (or make other helpful statements) and instead formulating a question.
The Technique of Socratic Questioning
Of course the goal is not simply to ask more questions, but to ask "good" questions. Good questions do have some common properties. By definition, they are non-judgmental. Unless you are engaged in pure information-gathering, such as during certain phases of patient assessment and diagnosis, good questions are typically open-ended, not closed (yes-no). Another way to recognize a good question is that it has the potential to yield an unpredictable response. When the practitioner asks a question with only a few possible responses, or a very predictable response, there is often a specific agenda, such as helping the patient to see a specific point or see a situation from a specific perspective. When a question is completely agenda driven, the patient's response is almost irrelevant. While this type of questioning can be useful in limited amounts, it should not be confused with truly open or "Socratic" questioning.
The process of Socratic questioning has been described as a process of "guided discovery" (1) between a counselor and patient. Socratic questioning aims to stimulate thinking in patients or clients and, ideally, draw their attention to important information that they are not focusing on. Good questions are challenging and make the individual "work" to understand themselves with more clarity, see a situation from a different perspective, and generate new options. It is helpful to remember that good questions do not have to be phrased in the form of a grammatical query. Some questions are not likely to lead to productive work, while some statements are. Look at the following responses by two practitioners and decide which is likely to be more fruitful: Practitioner 1) "Do you think you met your goals last week?" or Practitioner 2) "I'm wondering how you would evaluate your progress last week."
One cliché about psychotherapy is the therapist who repeatedly asks the patient the same question - "So, how did that feel...So, how did that feel?" To some extent, such clichés are based in reality. Therapists do ask about feelings quite often, and this can be a helpful technique. There are also jokes about therapists' tendency to answer questions with "another question" and this again is based in truism. This reflexive response helps to avoid advice giving. My patients usually smile when they realize that they have asked me what I think or what I would do in a particular situation. They know that my response will be, "What do you think?"
There are numerous Socratic questions that can enhance the process of guided discovery in many different situations, and it can be helpful to keep some of these "tried and true" questions in mind. Table 1 summarizes some of the questions that many counselors and therapists find frequently useful.
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Table 1. Some Helpful Socratic Questions What changes would you like to see? What kind of change do you want to make? Can you think of anything you could do in this situation? What are the advantages of doing this? What are the disadvantages of doing this? What do you think would help? What do you think is getting in your way? Was there a time when you were in a similar situation? What helped? What didn't help? What do you think is going to be your biggest obstacle when you try to make this change? Can you think of any personal qualities or characteristics you have that could help you? Are there ways you can increase the likelihood that you will succeed? What would you tell your best friend if s/he was in the same situation? How are other people going to react to this change? Who can support you? What evidence do you have that you can (or can't) make this change? What impact would making this change have on your life? |
Helpful Statements in Counseling Settings
As shown in one example above, statements can also serve as an invitation for deeper inquiry and exploration. Some of these "open-ended" statements include:
- I'm wondering how you feel, what you think, how you reacted...
- Tell me more about that...
- I'm curious about...
- Describe what that is like for you...
- I'd like to explore that in more detail...
Other types of declarative statements essential to effective counseling
Include those that reflect what the patient is describing or experiencing. Again, however, reflective statements should be used judiciously and as more than simply an "echo" of what people have just said. Statements that communicate empathy are also critical for developing and maintaining a positive working relationship and sense of rapport and understanding with the patient.
The type of statement practitioners often forget are summarizing statements, in spite of the fact that these can be extremely helpful. We are often not as aware as we should be of just how much happens during sessions from the patient's perspective - how many issues are covered, how many ideas are generated, how many pieces of information are conveyed. Summarizing forces the practitioner to organize, prioritize and capitalize on all of these. Some counselors prefer to ask the patient to summarize at the end of sessions to make this process even more active and challenging. Summarizing is particularly important in types of work, such as lifestyle intervention, where one of the major purposes of the session is goal-setting.
Motivational Interviewing
As highlighted in the recent post by Anne Wolf, M.S., R.D. and Co-Principal Investigator on the ICAN project, motivational interviewing (MI) techniques can be a particularly effective method for identifying barriers to lifestyle changes and developing realistic, individually-tailored goals. MI can be viewed as a highly specific type of Socratic questioning designed to elicit a "guided discovery" of an individual's ambivalent thoughts and feelings about specific lifestyle changes, and possible resolutions to these conflicts. Even though MI is highly focused and goal-oriented, the questions asked by the practitioner are completely open-ended, and therefore more likely to trigger new ideas and perspectives.
Both MI and Socratic questioning are based on the same premise - that persuasion is not an effective method for achieving lifestyle change, no matter how well-intended the persuader is. Both of these perspectives (and techniques) aim to help practitioners avoid the ineffective but highly human tendency to resort to answering questions and giving advice when trying to produce behavior change in others.
Cognitive-Behavioral Therapy and Lifestyle Change
Socratic questioning is an essential tool used in cognitive-behavioral therapy (CBT) for lifestyle change. CBT uses many of the techniques that are common to all lifestyle work, including self-monitoring and evaluation, motivation enhancement, goal-setting, problem-solving and reinforcement. However, CBT also focuses on counterproductive, distorted or irrational thought patterns and beliefs that interfere with desired lifestyle changes and overall quality of life. In CBT, the therapist "listens" for comments that reflect irrational thinking, and then uses Socratic questioning to explore and challenge these thoughts and beliefs. In CBT, patients are also educated about the different patterns of distorted thinking, how to monitor their own automatic thoughts for these, and how to alter these thought patterns when they occur. In the vernacular, the goal is to decrease "stinkin' thinkin'."
All of the different types of distorted thinking are relevant to lifestyle decisions and behaviors. Below is a list of some of the most common with examples.
- All or Nothing Thinking: "Since I ate a doughnut this morning, I might as well just declare it a "bad" day and eat whatever I want." All or Nothing Thinking bounces from one extreme to the other, and characterizes the "restraint-binge" cycle.
- Discounting or Dismissing: "I know I've skipped my daily walk for a few weeks now, but this shouldn't make that much difference to my weight or fitness level." This type of thinking is also key in a lot of "mindless" eating, such as eating while preparing food or "grazing." Self-monitoring techniques are directly aimed at altering discounting or dismissing thought patterns.
- Over-Generalization: "Well I didn't eat breakfast so I should be able to have fries with my lunch." In over-generalization, the person jumps to a conclusion based on very little or inadequate evidence.
- Wishful or Magical Thinking: "I know I promised myself that I would stop buying ice cream at the grocery store, but this time I won't eat it at night and I will control my portions." Magical thinking is characterized by the idea that a problematic situation will "just work itself out" somehow and "things will be different this time" without any real plan or support system in place.
- Self-Defeating or Pessimistic Thinking: "I've tried everything there is to try but nothing works for me." This type of thinking needs to be addressed through appropriate goal-setting, with a focus on extremely realistic goals that can be met in a short time period (e.g., walking for 10 minutes tomorrow, eating high-fiber cereal instead of a fast food breakfast one time in the next three days).
Other components of CBT are also used in lifestyle counseling, including behavioral experimentation, skill development, creating a supportive environment, coping training and relapse prevention, all of which utilize Socratic questioning techniques.
Listening Skills
The usefulness and effectiveness of Socratic questioning techniques depends highly on how well the practitioner listens to the patient's response. Listening skills are even more under-emphasized than questioning skills in most teaching, counseling, and therapy training programs. This is unfortunate since listening intently to what people say, how they say it, and when they say it often serves as the basis for formulating good questions. Rarely are trainees taught what exactly they are supposed to be "listening for." At the beginning of a meeting, it is often helpful to "listen for" the patient's current emotional status and any changes in their feelings or circumstances that are relevant to the work or goals of the session. The seemingly casual "How's it been going" or "How have you been doing" serves as the first Socratic question to make these initial assessments.
Listening for signs of what is called "resistance" in some disciplines and "counter-motivation" in others is also important. In some training programs, this is called listening for the "but" which can be an expression of mild disagreement on one end of the continuum to argumentiveness on the other end. These responses by patients are important, and may indicate that the practitioner is moving too fast or pushing the person too much. Other signs that the practitioner and patient are not "on the same page" include the patient interrupting, ignoring, or changing the topic. When these occur, it is time for the practitioner to take a deep breath, take a step back, begin asking questions, listen to the patient, and increase understanding. When counselors do not stop and redirect the process at these moments, it can be easy to slip into a closed question and answer mode, or advice giving.
In addition, the value of "listening for success" cannot be over-emphasized. In lifestyle work (and other situations aimed at changing attitudes and behaviors), it is especially important to listen for any "movement" toward a positive change or goal - even any passing thought or subtle behavior that moves in the desired direction. Success does indeed breed success. And the only way that a person can increase their sense of confidence and self-efficacy (essential elements for behavior change) is to experience some degree of success.
Conclusions
The process of lifestyle counseling, like any other form of counseling, is best thought of as a process of "discovery." In this process, the practitioner uses thoughtful and thought-provoking questions to guide the patient toward change in attitude, feelings, motivation, beliefs and behaviors related to food intake and physical activity (and other lifestyle habits). In this framework, the practitioner is not expected to know the "right answer" for individual patients or to persuade patients to change behaviors. Rather, their job is to create a supportive environment in which the patient can actively explore their own thoughts, feelings, motivation and habits, then make decisions and set goals for lifestyle change. This environment will also help patients to learn problem-solving and coping skills that will help them achieve and maintain these changes.
A focus on questioning and exploration can also help counselors to remember that they are not the ones ultimately responsible for the patient's decisions and lifestyle choices. Instead, their job is to listen actively and intently, understand where the patient is in the process of lifestyle change, and keep their work (and questions) focused on the patient's goals, motivation and barriers. Lifestyle counselors often face unique pressures to "get results" and "succeed" in their work with patients. In part, this occurs because the goals are typically concrete and measurable, even though they are also quite difficult to achieve and maintain. For these reasons, it may be even more important for lifestyle counselors to remember the process of guided discovery and the fundamental role of the question.
A final thought. Even though the art and science of asking good questions is the cornerstone of counseling, this does not mean that it is never useful for practitioners to give advice or information. Education is also a fundamental process in lifestyle change. For example, it is often important to work to improve health "literacy" concerning nutrition and physical activity. Many patients also have significant misperceptions and "misinformation" regarding lifestyle that need to be addressed. For these reasons, it is appropriate that the beginning stages of counseling are often characterized by more time devoted to the task of patient education. Even during the early stages, however, it is critical to make sure that educational material matches the patient's goals and level of readiness for change. It is also useful to remember that most of the time, the real barriers to lifestyle change are not the lack of information and understanding, and that the most effective method for discovering these real issues and effective solutions is to ask good questions.
References
1. Padesky, C.A. Socratic Questioning: Changing Minds or Guiding Discovery? Keynote Address, European Congress of Behavioural and Cognitive Therapies, London, 1993. Available at www.padesky.com.
HIC# 11143