What Do I Say? E-Book

Linda N. Edelstein

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 606

Veröffentlichungsjahr: 2011

Beschreibung

The must-have guide to honestly and sensitively answering your clients' questions Written to help therapists view their clients' questions as collaborative elements of clinical work, What Do I Say? explores the questions--some direct, others unspoken--that all therapists, at one time or another, will encounter from clients. Authors and practicing therapists Linda Edelstein and Charles Waehler take a thought-provoking look at how answers to clients' questions shape a therapeutic climate of expression that encourages personal discovery and growth. Strategically arranged in a question-and-answer format for ease of use, this hands-on guide is conversational in tone and filled with personal examples from experienced therapists on twenty-three hot-button topics, including religion, sex, money, and boundaries. What Do I Say? tackles actual client questions, such as: * Can you help me? (Chapter 1, The Early Sessions) * Sorry I am late. Can we have extra time? (Chapter 9, Boundaries) * I don't believe in all this therapy crap. What do you think about that? (Chapter 3, Therapeutic Process) * Why is change so hard? (Chapter 4, Expectations About Change) * Will you attend my graduation/wedding/musical performance/speech/business grand opening? (Chapter 20, Out of the Office) * Where are you going on vacation? (Chapter 10, Personal Questions) * I gave your name to a friend . . . Will you see her? (Chapter 9, Boundaries) * Should I pray about my problems? (Chapter 12, Religion and Spirituality) * Are you like all those other liberals who believe gay people have equal rights? (Chapter 13, Prejudice) The power of therapy lies in the freedom it offers clients to discuss anything and everything. It's not surprising then, that clients will surprise therapists with their experiences and sometimes with the questions they ask. What Do I Say? reveals how these questions--no matter how difficult or uncomfortable--can be used to support the therapeutic process rather than derail the therapist-client relationship.

Leseprobe

Contents

Cover

Half Title page

Title page

Copyright page

Dedication

Preface

Acknowledgments

Part 1: Client Questions in a Broad Context

INTRODUCTION TO PART 1

WHY DO CLIENTS’ QUESTIONS CAUSE APPREHENSION?

WHAT DO THE DIFFERENT THEORIES ADVISE?

REMEMBER, IT’S NOT ABOUT YOU

GUIDELINES FOR ANSWERING QUESTIONS

STYLE AND LANGUAGE CONSIDERATIONS

FURTHER THOUGHTS

Part 2: Client Questions and Responses by Topic

INTRODUCTION TO PART 2

Chapter 1: The Early Sessions

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 2: Experience

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 3: Therapeutic Process

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 4: Expectations About Change

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 5: Techniques

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 6: Professional Role

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 7: Money

QUESTIONS

RESPONSES

MONEY QUESTIONS UNRELATED TO THERAPY

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 8: Confidentiality

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 9: Boundaries

QUESTIONS

RESPONSES

BOUNDARY SLIPS

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 10: Personal Questions

QUESTIONS

RESPONSES

QUESTIONS ABOUT THE THERAPY RELATIONSHIP

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 11: Sexuality

QUESTIONS

RESPONSES

QUESTIONS THAT INVOLVE THE THERAPIST

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 12: Religion and Spirituality

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 13: Prejudice

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 14: Stigma

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 15: Physical Appearance

QUESTIONS ABOUT THE THERAPIST

RESPONSES

QUESTIONS ABOUT THE THERAPEUTIC ENVIRONMENT

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 16: Dreams

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 17: Therapists’ Reactions

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 18: Individual and Cultural Differences

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 19: Involving Others

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 20: Out of the Office

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 21: Keeping in Touch

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 22: Life Events

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Chapter 23: Ending Therapy

QUESTIONS

RESPONSES

FURTHER THOUGHTS

SUGGESTED READINGS

Concluding Thoughts

References

Index

About the Authors

What Do I Say?

Copyright © 2011 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.

Published simultaneously in Canada.

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Library of Congress Cataloging-in-Publication Data:

Edelstein, Linda N.What do I say? : the therapist’s guide to answering client questions / Linda N. Edelstein, CharlesA. Waehler.p. cm.Includes bibliographical references and index.ISBN 978-0-470-56175-1 (pbk.); 978-1-118-06146-6 (ePDF); 978-1-118-06147-3 (eMobi); 978-1-118-06148-0 (ePub)1. Counselor and client. 2. Psychotherapist and patient. I. Waehler, Charles A. II. Title.BF636.6.E34 2011158′.3—dc22                   2010051401

To my clients, past and present, because I admire their courage, honesty, hope, and hard work. —L.N.E.

To my students, with thanks for all that we have learned together, and for the places we will go. —C.A.W.

Preface

For many years we have consulted with each other about our work as psychotherapists, teachers, and supervisors. We have always agreed on how much we enjoy working with new professionals and having a hand in the next generation of clinical work. Last year, we discussed writing down answers to clients’ questions to arm therapists because we knew that questions and answers is a topic that is rarely written about, despite therapists’ anxious concerns. When we seriously got down to writing this book, we realized that rather than arm practitioners as if they were going into battle, we wanted to empower therapists to view questions and responses the same way they see other collaborative pieces of clinical work.

Most books about the psychotherapy process devote a couple of paragraphs to admitting that clients ask questions and that these questions probably have significant meaning. These comments also suggest that we ought to use clients’ questions effectively in the growth and healing process. It is rare, however, to find a full discussion of questions. Specific suggestions for answers are even more uncommon. Instead, we have seen that serious conversations about how to respond to questions are left to supervision or thrown into courses as a byproduct of other work, if at all. But we knew from our own clinical experiences, from teaching, and from consulting to other clinicians that clients ask a lot of questions, often very good questions. Unfortunately, therapists can feel flummoxed when this happens because they haven’t had opportunities to sort out their concerns, beliefs, and practices.

The more we consulted with other therapists and with students about the idea of a book about clients’ questions and therapists’ responses, the more we uncovered all kinds of previously unspoken feelings, mostly discomfort and apprehension. Concerns such as “I don’t want to lead my client down the wrong path,” “I won’t know the answer,” “I’ll reveal too much,” “I’ll look stupid,” “I’ll feel stupid,” and “I’ll say the wrong thing” came from both novice and experienced therapists. We began to think that being asked questions by clients conjures up images of the horrible third-grade teacher who put you on the spot, or the mean kids who snickered, or the parent who quizzed you during dinner. Questions then begin to feel like an inquisition, and responding becomes a competitive win-or-lose game. But therapy isn’t a test; it’s not even a quiz—it is a relationship. For better or worse, you and your client are tethered together, and if either of you fail, both of you fail.

We know that, as mental health service providers, your effectiveness is related to how comfortable and competent you feel in the room with your clients. If you are anxious, distracted, or fumbling around for what to say, your ability to be attentive to your clients—to be a healthy and professional person in the room—will be compromised. At these confusing times, you wish that you could have a quick consultation with a supervisor or colleague. Later, in the car or in the shower, you come up with an ideal response and wish you had thought of it earlier. We wanted to write a book that helps mental health professionals feel confident during anxiety-provoking situations with their clients.

This book is set up so that both beginning students and more experienced practitioners can think about their interactions with clients’ questions. We want this to be the book that therapists wished they had read before they sat across from a client and felt overwhelmed by inadequacy. At one time or another, every therapist has wondered unhappily, “Why didn’t my supervisors or professors prepare me for this?” We hope to serve readers in ways similar to the ideal supervisor, who helps formulate the words that express what the therapist wanted to say. Lonnie, a Smith College MSW graduate, called this book, “a supervisor in my backpack.”

We conceptualized this book as practical and friendly, and we have tried to write it in that spirit. We imagined that we were sitting around with some of our favorite graduate students and colleagues and having fun with the ideas. Linda actually had dinner parties with her team of graduate students where they shared their developing thoughts. Charlie talked about these issues with his colleagues in a group private practice and reviewed them with his advanced practicum classes.

We also surveyed graduate students and asked them, “What client questions make you apprehensive?” We received about 70 generous replies with hundreds of questions that would give even the most seasoned professionals reason to pause and reflect. We used the questions generated by the surveys, added ones from our own combined halfcentury of practice, and went to experienced colleagues for even more questions. We gathered an excellent, super-sized collection that we grouped into logical categories. We could have simply considered ways to respond to client questions that would get you past the awkward moments, but to do so would be similar to telling you to close your eyes during the scary part of a movie. Instead, we have devoted this book to thinking about ways to use client questions to enhance therapy.

First, we address ways to think about client questions and potential therapist responses in terms of general constructive strategies. To this end, we talk about some big-picture considerations as well as make focused observations about language and word use.

Second, knowing that clinicians are frequently faced with questions on specific topics, we have organized the questions and responses into 23 of the most commonly asked subject areas. We move through these 23 topics in an organized manner, asking numerous questions, examining underlying issues, proposing possible responses, and ending with further thoughts and references for additional reading. We present our rationale and thinking behind the responses. Some questions and their answers are challenging because the context is complicated, whereas others are more straightforward. These are all meant as jumping-off points for our readers. The ideas are useful to consider ahead of time so that you are more at ease during sessions. We have written in a conversational tone and illustrated our ideas with examples from our own lives and work, and from the experiences of our guest clinicians, both seasoned and brand new. In reading the experiences of others and writing down our own, we relearned that many experiences are common and, although we need to treat our work seriously, we are better off when we take ourselves lightly.

In reading, we expect that you will skip around to topics that challenge, confound, or confront you. If you do jump around from topic to topic, please recognize that certain themes could easily be considered in all chapters (e.g., ethics), but they are not repeated in every applicable chapter. Several topics, like diversity and boundaries, have specific chapters of their own and also are germane to all other areas.

Although we want to inform, even prod, you by the considerations we have brought into this text, we don’t want you to use the proposed responses in a cut-and-paste fashion with your clients. To do so would take away your individuality and the special quality that emerges from forging unique relationships with clients. Instead, we trust that you will modify, individualize, and personalize your responses. Our language can be easily incorporated into a therapy conversation, but we know that good therapy is not done by following a script. Although thinking ahead can be helpful, therapy evolves from the interactions in session. You respond in the moment to a client’s very personal, idiosyncratic statements, and no two sessions are ever alike. As you personalize the elements in the book, you will become increasingly spontaneous and confident.

The material in this book comes from a variety of theoretical orientations. Some theories emphasize different aspects of client treatment, but many elements, known as common factors in the literature, cut across different orientations. These elements account for a great deal of the successful change we all work toward with clients. We have used therapist responses that fit into a common-factors approach. You may notice that two core ideas related to psychotherapeutic work permeate the book:

1. The more that our clients know about their affective, cognitive, and behavioral thought patterns, beliefs, attitudes, hopes, desires, and fears, the more gain is possible in psychotherapy.

2. The positive, constructive, respectful, attuned relationship created between you and your client is at the heart of the change process.

With these two ideas in mind, you will see that we use some psychodynamic terms because we were both trained and continue to be informed, particularly at the conceptual level, by theories that appreciate the power of our clients’ internal dynamics and irrational conflicts. Linda considers herself a feminist therapist, and Charlie describes himself as an integrative, multitheoretical therapist. We both value clients’ cognitive, affective, and behavioral learning. We appreciate their contextual, cultural, and systemic concerns, as well as individual differences, and have integrated aspects of the major theoretical orientations into our work and into our attempts to formulate consistent, well-considered responses.

We are also informed by the Presidential Task Force on Evidence-Based Practice in the American Psychological Association (2006), which created a policy statement that says, in part, “Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 284). This sentence reflects the three components that help direct successful therapeutic interventions: empirical evidence (broadly defined), clinical expertise, and client characteristics.

With regard to empirical evidence, we have reviewed the literature and, not surprisingly, little experimental data exist that have examined the dialogue of questions and responses. We have enjoyed and absorbed the theoretical discussions when we could find them, reviewed the research and and practice recommendations, and then attempted to present the material in ways that mirror the actual activity and flow of the therapeutic session or supervisory discussions. At the end of each chapter, we have included sources that might be interesting to our readers.

Clinical expertise, our own and others’, heavily guided our responses to questions. We tried hard to capture everyday examples of queries and, more importantly, to examine what clients reveal with their questions. In doing so, we hope to expand your therapeutic understanding of material that can help clients change.

With regard to client characteristics, in specific chapters you will see some references to individual differences such as race, religion, sexual orientation, age, socioeconomic status, privilege, or ability, but more often, you will read many comments urging you to appreciate each client. We also know that our readers are individuals with as much variety as our clients. In this way, each therapeutic relationship reminds us that people connect despite their perceived differences. In Chapter 18, Individual and Cultural Differences, we have included many of the specific questions that come up with regard to individual differences.

You will notice that we chose to alternate our description of therapists and clients as male or female rather than addressing them in the text as him/her or he/she. We certainly recognize that clients and therapists can be either gender, but including he/she or him/her all the time is awkward and changes your experience as a reader. We hope this does not inadvertently promote any gender stereotypes. Also, we have included many examples from clients and clinicians. Most clinicians are identified and clients’ identities are changed (although we have permission to use their stories) to ensure confidentiality.

If you want to get in touch with us for questions or comments, Linda is available through email, [e-mail] or through her blog, www.lifeaintforsissies.com, where you can join the conversation. Charlie can be reached at [e-mail].

Linda N. Edelstein, Evanston, ILCharlie A. Waehler, Akron, OH

Acknowledgments

Linda

I never wanted to write a book about therapy, unless it was a mystery novel, so when Charlie and I came up with this idea about questions and answers, it was an unexpected gift. During the writing, I’ve had the opportunity to think back over the years and reflect on many significant moments in treatment. I’ve also gotten clearer about some ideas that matter to me. I’ve been a therapist for a long time, and this book became the culmination of teaching, clinical work, reading, conversations, and personal thought. Mostly, it has been a lot of fun.

Even with Charlie, a co-author who envisioned the book just like I did, writing is a notoriously solitary process, but I have received a lot of help. I want to thank my dynamic graduate student team of Damon Krohn, M.A.; Jessica Bell, M.A.; Elizabeth Marklein, M.A.; Dina Zweibel; and Greg Rizzolo. The team independently researched chapters, generated original ideas, and added information and liveliness that would have been missing otherwise. In the very early stages, Luna Sung worked on preliminary versions of the chapters about prejudice and stigma.

My writing group is made up of loyal friends who are also esteemed colleagues, Margit Kir-Stimon, Ph.D.; Melissa Perrin, Psy.D.; and, for awhile, Joan Liataud, Psy.D., all of whom remained on call for reading, editing, and complaining. I want to thank Nancy Newton, Ph.D., my comrade on many projects over the years, who has generously and endlessly been able to take my thinking to more creative places and pull me out of mental mud. Additional thanks go to my office partner, Patty Shafer, Ph.D., who was willing to talk with me about clinical work and theory; Keira Dubowsky, who helped with the cartoons (that never made it to the final version of the book) and other creative ideas; and Jennifer Dubowsky, M.S.O.M., who very patiently listened to the process of writing and encouraged everything, including the website and blog so that we can continue the dialogue.

Also, special thanks to friends Anita Adams, M.B.A.; Ken Adams, J.D.; Karen Drill, M.A.; Janna Dutton, J.D.; Eve Epstein, J.D.; and Hedda Leonard, who were all very kind to me, made themselves endlessly available to discuss this project, and who are probably as happy as we are that the book is done.

Charlie

Those of you who know me well know that I am a collector. I like to cling to valuable thoughts, ideas, and wisdom, as well as relationships, connections, and all sorts of experiences. This book has provided a wonderful opportunity to sort through many different ideas, combining and reworking them with novel notions to give them new life and energy: that has been a joy for me. Most joyful among these has been the opportunity to create new connections with students who provided invaluable assistance in identifying, exploring, clarifying, and energizing ideas that have enriched this material. Chief among these people has been Sam Gregus, whose blend of curiosity, wisdom, hard work, and good cheer kept advancing the work. Other students who assisted in a variety of activities have included Zack Bruback, M.A.; Sara Carnicom; Jill Hendrickson, Ph.D.; Jennifer McDonnell; Lindsay Newton; and Jennifer Underwood. Colleagues who have also been of assistance have included Mark J. Hilsenroth, Ph.D.; and James L. Werth, Ph.D.

I also want to acknowledge the support and understanding I have received from my immediate and extended family as I have taken private time to work on this material. I hope that all the delayed gratification necessitated by the work will prove worthwhile. I also appreciate the support and understanding from my professional colleagues and graduate students for the time and energy that has gone into this project. Thanks, too, to Linda, who has again proven to be a great fellow traveler.

Linda and Charlie

Early in the process, we were guided by Margaret Zusky from John Wiley & Sons, who led us to our editor “in perpetuity” Rachel Livsey. We have been very lucky to work with Rachel, who commented on all aspects of the project with laser-like accuracy. Also, thanks go to senior production editor, Kim Nir. To gather client questions, we surveyed graduate students in Ohio, California, Illinois, and Virginia. They filled out surveys and provided us with hundreds of examples of questions that make them anxious. We used many of them. This also helped us to realize that we wanted to gather more clinical examples than those we could cull from our own careers, so we asked other students and colleagues to share their experiences as guest clinicians and they graciously consented. Their contributions have made the book richer than it would have been otherwise. We are grateful to the people who allowed us to use both their stories and their names: Jeremy Bloomfield, Psy.D.; Margit Kir-Stimon, Ph.D.; Carol Kerr, Ph.D.; Damon Krohn, M.A.; Elizabeth Marklein, M.A.; Mary Miller Lewis, Ph.D.; Nancy Newton, Ph.D.; Melissa Perrin, Psy.D.; Hinda Pozner; Abbey Prujan, M.A.; Lee Rodin, M.S.W.; Tammi Vache-Haase, Ph.D.; and Naomi Woods.

Particular thanks to Carol Kerr, Ph.D., who advocated for and wrote most of the chapter on Individual Differences. Thanks also to Mark Epstein, J.D., a mental health lawyer who reviewed the chapter on Confidentiality, and Meghan Roelke, Psy.D., who distributed surveys to her class at The Chicago School. At the completion of the writing, before publication, we had the good fortune to be reviewed by six anonymous clinicians and educators who read carefully, commented artfully, and brought some new ideas to the project.

To our clients from whom we have learned much and who have allowed us to use their questions and experiences, thank you. We hope we have been faithful to the spirit of our collaboration.

PART 1

Client Questions in a Broad Context

INTRODUCTION TO PART 1

Eileen dropped heavily into the chair and opened her second session with questions. “When will I stop feeling so guilty? Will I ever get over this? How do I forgive myself?”

Zac, her therapist, was stumped. These direct questions prompted a flood of racing thoughts that filled his mind. Which approach would be best? Should he answer the question, pose questions himself, or explore, but how could he make the transition into meaningful exploration? Or would it be better to use reflections like “You’ve had another rough week,” or take the question at face value and provide information? And if he did try to answer the question, what was the correct answer? He didn’t want to sound glib or provide false reassurances; at the same time, she was asking for a reason to hope. He knew what some theories said about processes of guilt and forgiveness, but Eileen was her own unique individual. Their therapeutic alliance was new and untested. How could he prompt further examination without making her feel dismissed or put down? How could he use this moment to gain credibility and trust as an empathic listener?

Eileen might be 30 or 70 years old. She might be in prison for murdering her child or feel guilty because she has fallen in love with her co-worker. She may be reacting to a transgression that occurred 2 weeks ago or 20 years ago. Zac might be analytic, eclectic, cognitive-behavioral, or feminist. What remains a constant is that clients ask questions, and clinicians often find themselves wanting to know more about how to reply in ways that are thoughtful and intentional. This isn’t an unusual example. Zac knew that Eileen’s questions revealed some of her most intimate struggles and intense emotions. He was also filled with his own thoughts and feelings. He wanted, as most clinicians do, to engage Eileen, to respond in ways that deepen their dialogue, and to provide clarity and hope to his client.

As caring, social beings, people who have chosen to become mental health practitioners are usually pretty comfortable conversing with others. We all practice active listening skills such as empathic paraphrasing, open-ended questions, and nonjudgmental reflective statements to encourage therapeutic conversations. We have learned various intervention techniques so that we can help guide clients to be more effective in their lives. At times we stumble through these skills. Everyone does. But for the most part, we feel confident knowing what to say and what to ask in order to interact therapeutically with our clients. And then a client asks a direct question.

Direct questions, even when they are innocent and innocuous, often catch us off guard. When the question feels challenging or intrusive, self-protection is often the natural first reaction, and we want to shut the conversation down. Our sense of control has been upset; it feels like the tables have been turned. After all, aren’t we the ones who get to ask the questions?

We have each been in practice for more than 25 years, but it isn’t hard to recall our jumbled reactions from the client questions of earlier days. In answering their questions, we wanted to be brief, but not simple; to engage our client’s curiosity, but not parrot back the question; to avoid giving direct advice, but not sidestep a request for assistance. We wanted to sound wise but knew that how we sounded was less important than promoting our client’s therapeutic goals. Good manners said that we ought to be polite and forthcoming, but this is therapy, and the goal is additional exploration of our client’s own ideas. We wanted to examine the overt and covert meanings of the question, but not become interrogating detectives; and we wanted to express ourselves without making the conversation about us.

In short, we wanted to practice our craft well and that made us anxious, particularly when we were faced with difficult questions. So, for better or worse, we responded and moved on, but we were sometimes left believing that we could have been more effective. We knew that there would be other questions from other clients, and we wondered what a more experienced therapist might have been able to do. We realize now that we had the skills; we just hadn’t focused them on responding effectively to questions. With all our training and reading and clinical placements, no one had ever addressed answering questions as a significant aspect of everyday therapy. We hope to change that.

WHY DO CLIENTS’ QUESTIONS CAUSE APPREHENSION?

Answering clients’ direct questions can be perplexing for several reasons. Consider your own practice, and see if any of these seven reasons apply to you:

1.Client questions represent a shift away from the normal therapeutic pattern in which the therapist asks the questions. When this activity is reversed, you may feel like your role has been usurped, leaving you perplexed, unprepared, and feeling like you have lost control of the process and content.

2.Client questions reflect different motives. They can be variously intended as inquisitive or invasive, engaging or deflecting, polite or intrusive, clarifying or complicating, solicitous or dismissive, congenial or offensive, curious or aggressive, innocuous or challenging, helpful or obstructive. And this list is not exhaustive. Many questions represent a combination of several of these motivations and a variety of complicated communications—no wonder they can be disconcerting.

3.Questions can make you feel very responsible, and although you want to be helpful, you are rightfully reluctant to take on the influential role inherent in providing a specific answer. If you believe that you help your clients when you promote autonomy, critical thinking, and self-examination, then providing simple answers to questions is nearly impossible.

4.You will not always have the answers. Optimal answers to client questions are always going to be highly personalized and idiosyncratic to what is going on with this client at this time in his life. It is daunting to think about having to answer and address all these unique meanings.

5.You may have recognized that many answers take the focus and energy of the session off the client and put it on you. This isn’t the attention you want.

6.Because your answers reveal much about you, they also highlight the nonclient, nontherapist relationship. You may not want to head in that direction.

7.As you probably know from answering questions tossed out by family and friends, there is a serious possibility to disrupt the relationship with the wrong answer. Potential misunderstandings abound.

Your ability to respond effectively is enhanced by increased awareness, knowledge, consideration, and experience. Clients’ questions and your responses can be used constructively when you are prepared. The many questions and potential responses we offer in the 23 topic chapters provide ways for you to think about the attitudes and strategies that work best for you as you receive client questions, clarify them, and respond successfully, turning the interchange into effective psychotherapy.

Charlie

Toward the end of every intake interview I conduct, after I have spent most of our time asking questions and exploring the client’s answers, I say “I have asked a lot of questions here. I wonder if you have any questions for me?” Usually after brief reflection, most clients respond “No, none that I can think of now.” Sometimes I get a general, appropriate question along the lines of “So what do you think is going on?” or “Is there any hope for me?” or “What do we do now?” Sometimes I get a question like “Why did you ask me about …?” or “What is your training to do this work?” or “Have you ever seen anyone like me?” I believe that client questions yield additional information with which to formulate beginning diagnostic impressions. As important as this information can be, when I invite questions my main goal is to communicate my desire to have the client be a fully involved, valued participant in the therapeutic process and to authorize him to ask questions and be curious in our work together.

Clients want to know that they are understood. You can show understanding in many ways other than directly responding to questions. When a client asks plaintively, “Do you know how painful relationships can be?” he does not want his therapist to say, “Yeah, I’ve been married 15 years and at times it’s really hell. In fact, recently we have been going through a tough patch involving …” as a response. He also doesn’t want to be met with silence. He wants empathy and understanding. He also wants a smart, sympathetic ear that will help him explore and clarify his struggle. We hope that you will neither dismiss questions nor answer them reflexively without exploration. Appropriate statements in this example involve words like “I can see that you are struggling now. Tell me about your relationship.” or “What has become painful for you at this time?” or “Relationships can certainly be painful; what’s going on for you?”

WHAT DO THE DIFFERENT THEORIES ADVISE?

Various theories have good reasons for proposing seemingly contradictory advice about answering client questions—they work with different models that believe in distinctly different strategies for change. With the exception of psychodynamic and psychoanalytic theorists, almost nothing has been written directly about responses to client questions. Because this book focuses exclusively on that topic, we have little guidance, but we also have no shackles. It is an opportunity to examine the basic principles of different theories and extrapolate reasonable ideas about their attitudes toward answering client questions.

You probably have opinions about the major theories—the ones you like and those that leave you cold; the ones whose principles make intuitive sense and others that require intellectual stretching. You may even consider yourself a firm disciple of one theory. As you read about the theoretical approaches to answering questions, you may find, as we have, that your philosophical leanings don’t match exactly to your practice when it comes to answering questions. Don’t worry; as you get further into the topic chapters, you will be increasingly able to discern what questions you want to answer, how you want to answer them, and why you are making that particular choice.

We begin with traditional psychoanalytic perspectives, because they are clearly stated. This view says that therapists should resist answering direct questions and instead promote their client’s fantasy. The less the client knows about the therapist, the more the client is able to generate fantasies regarding the therapist. Clients are told this information at the beginning of treatment so they are not dismayed by a lack of response coming from their analysts. Both parties agree that these fantasies become valuable therapeutic material. The alliance between the analyst and client is based on many factors, but therapist verbosity is not one of them. The technique reflects the underlying theory. Freud encouraged therapists to be neutral with their patients, so as to reflect nothing but what was shown to them (Freud, 1912/1959). Orthodox analytic perspectives about client questions have traditionally tended to see them as resistance, defensiveness, or avoidance. If that is your view, you might interpret a question with “You would find it easier to have me talk than you.” or “You would rather have me explore this topic than you doing it.” or “You are avoiding talking about your life.”

Greenson (1967) suggested that, from the analytic point of view, the first time a client asks a personal question, you encourage him to explore his reasons for asking. After listening to the client’s associations, Greenson would explain to the client that by processing the question’s meaning instead of answering, he and the client could gain a greater understanding of the significance of the question. Furthermore, he informed clients that most of their questions would not be answered so he did not appear unnecessarily cold and unresponsive. The second time a client asked a question, he remained silent. So, if you are strongly analytic, you have a model that provides clear reasons and guidelines for responses.

Other psychodynamic clinicians take a softer approach. Langs (1973) cautioned that unnecessarily frustrating responses to realistic and appropriate questions may serve the therapist’s defensive and hostile needs, rather than the positive work of the client and the therapy. Langs maintained that realistic and reasonable questions may have deeper implications, but he urged clinicians to maintain a reasonable and human balance between a direct answer and the need, when indicated, to analyze rather than respond to the question. Today, many self-psychology and relational psychology practitioners would agree. If you believe that replying to some questions more directly, especially early in therapy, will encourage engagement with treatment and with you, then you have support. Feldman (2002) suggests that, in the initial stages of therapy, useful responses both validate the client’s curiosity and encourage further exploration in ways that are consistent with how the therapy process will be approached in future sessions.

Wachtel (1993) contended that a categorical refusal to answer certain client questions creates an implicit power struggle and adversarial relationship that may inhibit the client’s connection with the therapist, stop questions about the therapeutic process, and diminish your client’s willingness to share her wonderings with you. He stated, “One should not equate answering the question with abandoning one’s interest in understanding its meaning and, conversely and equally importantly, one should not assume that the only way to discover its meaning is to refuse to answer it” (p. 225).

Much has happened in psychology since Freud’s 1912 dictum to “be impenetrable,” but not with regard to answering questions. Glickauf-Hughes and Chance (1995) noted that, “the few guidelines that are provided for responding to clients’ questions derive from Freud’s emphasis on therapist abstinence in the therapeutic relationship” (p. 375). If, like us, you are eclectic or work from other models, your guidance comes from extracting ideas from existing theoretical principles in specific models that make sense to you and your work.

Carl Rogers was a psychologist in the humanistic tradition and the father of client-centered therapy, which had its roots in Freudian thinking. Client-centered theory has many factors in common with other major viewpoints but also diverges significantly. Practiced with less orthodoxy today than it was in the 1960s and 1970s, Rogerian thinking has received little credit for the powerful influence it has exerted on many of the relational and humanistic approaches that are popular today. The hallmark of Roger’s client-centered therapy is a nondirective approach that is based on the belief that each individual is basically responsible for himself and capable of coming to his own healthy decisions. For example, even out of context, we imagine that if a client asked, “Are you gay?” Rogers would have recommended a response such as, “You wonder if I am gay.” In adhering to theory, the answer would be nondirective and unanswered. There will be occasions when you have what Rogers referred to as “those troublesome questions from the client,” when your client wants to know your convictions about how people ought to act or what they should believe and “you begin to wonder. The technique is good, but … does it go far enough! Does it really work on clients? Is it right to leave a person helpless, when you might show him the way out?” (Rogers, 1946/2000, pp. 420). If you believe that people have the potential to work out their own answers, and will do better with no intercession from you, then you have no need to answer most questions.

Pure behaviorism, as practiced by B. F. Skinner in the 1970s, was both a psychological approach and a philosophical belief that thoughts and feelings could not be verified and, as such, were not scientific. From this perspective, answers to questions would be irrelevant. Techniques that resulted in measurable behavior change were the focus. It is rare to find many radical behaviorists today. Out of behaviorism, beginning in the 1960s, writers such as Aaron Beck and Albert Ellis guided that branch of psychology toward what we now refer to as cognitive-behavioral treatment (CBT).

Cognitive-behavioral theories approach psychotherapy and client questions from a perspective that is quite different from the psychoanalytic and psychodynamic approaches. The basic belief is that psychological disorders involve current, conscious dysfunctional thinking, so CBT theory and techniques seek to challenge and modify a client’s dysfunctional thoughts and behaviors. In keeping with the theory, CBT practitioners use a variety of techniques, including the Socratic dialogue (questions that guide clients to become active participants in finding their answers, often by examining cognitive and behavioral evidence), assignments, journaling, relaxation techniques, thought-change records, role-plays, generating alternatives, and other strategies. Treatment is usually of shorter term than that of most dynamic or feminist models and discourages dependency on the therapist. This is not to say that the therapy relationship is ignored, but rather that CBT relies on nonspecific elements of the therapeutic alliance such as rapport, genuineness, and empathy. Questions are met with empathy and pursued with regard to the client’s thoughts and the subsequent impact on behavior. The same question that was asked above, “Are you gay?” would be answered, or not, and then examined with a goal of understanding thoughts and behaviors; for example, whether the client thinks that a gay therapist would be better able, or less able, to help. “Tell me your thoughts about gay therapists” might be a suggestion from a CBT clinician who is interested in whether the client thinks that similarities in sexual orientation is a good thing, or not. The clinician pursues the implications of these thoughts. For example, does the client only feel comfortable hanging out with gay (or straight) friends? Does the client gauge the merit of the treatment based on certain characteristics of the therapist?

Questions about the therapist and the therapeutic relationship, fodder for psychoanalytic therapists who attend strongly to transference and counter-transference, would be noted by CBT practitioners but not addressed directly and certainly not elevated to center stage. If techniques are the mechanisms of change, then it isn’t surprising that the literature does not speak to responses that explore the therapeutic relationship. Instead, writers might encourage client questions that help clarify the strategies in which they are engaged. In deciding how to respond, CBT practitioners may feel comfortable disclosing their solutions to problems or providing didactic comments because the client is learning new strategies. However, questions that seem to be off-task are inconsequential to the treatment.

In his article on neutrality, Greenberg (1999) noted that the clinician invariably participates somewhere in her client’s schema of relationships. So, we urge practitioners to consider your place in your client’s world and participate with awareness and intention. Going even further with the idea that a clinician will occupy a significant place in her client’s set of relationships, humanistic and feminist theoreticians contend that a real relationship, in addition to the therapeutic relationship, exists between therapist and client, and this relationship is an important ingredient of therapy. This observation makes treatment a collaborative endeavor in ways dissimilar to both analytic and cognitive-behavioral therapy. Feminist therapies (there is not just one) grew out of the women’s movement of the 1960s, when some psychologists promoted the idea that a client’s personal experience was embedded in political situations and reality, and was not simply a function of unresolved internal conflict or dysfunctional cognitive patterns. Feminist therapy is technically a practice driven by eclectic theory and informed by feminist philosophy and scholarship. It grew out of the dissatisfaction with societal rules that blocked men and women’s potential for growth and development. The writers encouraged awareness of factors that were external, as well as internal, to clients’ lives and experiences.

Laura Brown and Lenore Walker are two writers who have clarified tenets of feminist therapy theory. Walker defines them as egalitarian relationships; power; enhancement of women’s strengths; non-pathology-oriented and non-victim-blaming; education; and acceptance and validation of feelings. There are feminist therapists who are psychodynamic, cognitive-behavioral, behavioral, and eclectic. The theoretical underpinnings blend with the basic tenets of feminist therapy to determine how you think about and answer questions.

Again, until now, no one has written specifically on what these tenets mean in the context of answering questions, but the basic principles of the feminist models provide some information. When you consider an egalitarian relationship as being significant for the therapist and her client in order to model personal responsibility and assertiveness, answering some questions directly is appropriate. Another principle, that of teaching clients to gain and use power, also encourages direct answers on the part of the therapist, because this teaches the client that she will be able to elicit responses. Finally, acceptance and validation of your client’s feelings lends itself to value appropriate self-involvement, which removes the we-they barrier of traditional therapeutic relationships. For these reasons, feminist therapists may be more willing to directly answer the question “Are you gay?” Then, depending on their theoretical views, they could pursue a discussion.

Because of these ideas about collaboration and empowerment, notions about self-disclosure and answering questions are different from the other theoretical viewpoints and have caused some conflict in feminist therapists who are also psychodynamic clinicians. Some disclosure in response to client questions may promote the desired goal of having a therapist-client relationship that is closer to egalitarian and therefore more empowering to clients, but it does not further analytic principles of encouraging fantasy. Practically, therapy lives in the grays, not in black or white. Decisions such as when and how to disclose can be unsettling to all therapists, who are often forced to come up with their own sense of when to answer, taking into account their personal experiences, as well as their client’s personality, problems, history, and the multitude of other individual and cultural factors that must be considered.

You can see that the placement of boundaries in answering questions depends, to a great degree, on your theoretical viewpoint and is also influenced by the client, the problem, the relationship, and the myriad of factors that go into making all your clinical decisions. In this book, we take a middle-of-the-road perspective in deciding how to respond to client questions. From this perspective, client questions are received, explored further when appropriate, and understood collaboratively. When properly received and responded to, client questions represent an opportunity to promote further client understanding as well as advancing a healthier appreciation of, and attitude toward, increased personal curiosity and self-understanding. Whatever your responses are, you play a key role in what happens next in your client’s development, so try to be clear in your own mind about the interactions that you establish.

REMEMBER, IT’S NOT ABOUT YOU

At times we were tempted to use the phrase “Remember, it’s not about you” to begin each chapter in this book. Whether a client’s question is reasonable or flattering, intrusive or insulting, personal or generic, it is not about you. The question may say something about you and may be quite insightful, but as your client’s production, it remains primarily about her. Questions, how many or how few, reveal information about the questioner. You can learn a great deal about your client’s personality and coping style from the quantity of questions she asks.

Linda

I used to treat a man and his wife who were very different in their personalities and approaches to the world. He was aggressive, independent, and, in his words, “walked to the beat of my own drum.” His wife was very gentle but independent. He never had questions for me; he wanted to talk about himself and went out of his way to tell me that “I don’t want any input from you; I just want to think out loud.” On the other hand, she had a million questions for me and about me. They were ostensibly in treatment to discuss child-rearing disagreements, but one dynamic that underlay their stated objectives was that she was, not surprisingly, overly concerned with others and what they thought and, also not surprisingly, he was guilty of not listening to anyone else, making unilateral decisions, and doing things his way with little regard for her wishes. Their approach to asking me questions was instructive and reflected other aspects of their attitudes toward their children, business associates, and the community.

Therapy is about both of you working to understand your client. As you will see in the topic chapters, this means that sometimes you answer questions directly whereas at other times you won’t. Sometimes you will answer a question from one client and not answer the same question when it comes from another client. You respond in ways that are sensitive to and personalized for this client.

With regard to the statement “It is not about you,” think of a continuum of answers from “Me” at one end to “Client” at the other. Good therapy always spends more time on the client end of the continuum. Responses to client questions will always have the intent of bringing understanding to the client’s life and pursuits. Unavoidably, there will be times when conversations will be about you. You will have emergencies, need to reschedule because of a family problem, take a vacation, or recover from an illness, and it may be appropriate to provide your client with legitimate information about you. There will be other times, for valid reasons, when you must put your needs before your client’s. It is better to cancel a session with a client than to fake your way through a meeting when you are sick or distracted by other pressing issues.

GUIDELINES FOR ANSWERING QUESTIONS

In responding to clients, your attitude is as important as your words. Therefore, when questions present possibilities to advance your client’s treatment goals, we encourage you to do the following:

1.Receive the question respectfully. Your client has taken a risk by asking a question, and you want him to know that you are receptive to his questions. Be sure that you understand the question; paraphrasing is still the best way to clarify your comprehension.

Charlie

I was at a wedding and involved in a discussion about traditional values and the role of marriage. The group was large, and after several different, strong opinions (including my own) had been proposed, two women who had staked out a position quite different from mine asked “What are you?” I have learned that answering “psychologist” can become a conversation stopper or lead to lots of bad jokes, and I could see that this discussion clearly was primed for that. In some situations, I say “teacher” or “writer” or “social scientist” to avert the jokes. While I was trying to figure out what response I wanted to give to this question, one of the women jumped in and said, “Because she is a Taurus and I am a Gemini.” I really misunderstood that question.

Paraphrasing invites your client to rephrase, clarify, correct, or to consider the question in broader or deeper terms. This often leads him to shed more light on the query or examine the question further.

2.Promote your client’s curiosity about the question whether you decide to answer it or not. You can always provide encouragement by asking your client to elaborate on the question. Clients need support in order to allow themselves to ask questions, be open to new information, and to wonder about novel ways to look at themselves and their undertakings. If they feel ridiculed, the conversation withers rather than opens up. In the outside world, people often find themselves in situations where not knowing is shameful. Therapy is a place where not knowing is expected, acceptable, and just another step toward figuring things out.

3.Answer your client sufficiently to keep her engaged. What constitutes sufficiently will vary with different questions and different clients. One-word answers rarely feel sufficient, but a 10-minute monologue is overkill. You can check back with your clients to assess the adequacy of your response, but it will probably be obvious as you observe what your client does with your response—ignores it, works with it, or amends it.

4.Explore possible underlying and idiosyncratic meanings with your client. You are presented with a chance to teach lifelong self-observation skills. You want clients to internalize a process of raising questions about their lives, thinking through their problems, and valuing themselves in ways that will sustain them over the long haul. If you want clients to become increasingly self-reflective, model inquisitiveness.

At the same time as we suggest guidelines, we also recognize that there is no formula for answering questions. Your choice of answer depends on the question, the client, the relationship, your comfort, the point in treatment, and your goals. In the chapters that follow, you will see ample illustrations of types of questions, types of responses, and the rationale for responding as we did. Generally, there are seven possible directions to take when you respond to client questions, and you have the skills for each.

1. Answer simply and directly and let the question go. Like Freud’s famous quote, “Sometimes a cigar is just a cigar,” some questions are just questions.

Examples of questions in this category: “Where do I sit?” “Is another time available on Tuesday?” “Pretty tulips, where did you get them?”

2. Answer and relate the question back to your client’s life, turning the question into a discussion that is pertinent to your client. Example of a question in this category: “Did you have

a good Mother’s Day?” Examples of a response: “Thanks, the day was lovely. We had a great brunch. How was your Mother’s Day since your mother moved to Arizona?”

3. Inquire about the question and then answer (if needed) and use the question to reflect on your client’s life in the present. Example of a question in this category: “Why did you go into this field?”

Example of a response: “I’m glad to answer, but I’m curious about what made you ask that question today?”

4. Inquire about the question and don’t answer because it is getting too personal (it is your decision about what questions are “too personal”) and use the question to reflect on your client’s experience.

Example of a question in this category: “How old were you when you first had sex?”

Example of a response: “That’s a question I am going to pass on answering. Can I assume that you have been thinking about age-appropriate sexual behaviors?”

5. Interpret the client’s motive for the question because the answer is usually irrelevant.

Example of a question in this category: “My marriage counselor has a much larger office than you do. Are you thinking about moving?”

Example of a response: “Perhaps you are worried about which therapist is more skilled. Could that be your concern?”

6. Refuse to answer and set a boundary.

Example of a question in this category: “Have you ever been sexually assaulted?”

Example of a response: “I know that this is a profound concern of yours, but I’m sorry, there are areas of my life that I do not discuss.”

7. Explain or educate while refusing to answer.

Example of a question: “How do you manage this with your husband?”

Example of a response: “Marriage is so complicated, and relationships are all unique. We ought to concentrate on your life.” or “It can be distracting to focus on me, and I don’t think it will help.” or even, “I may have a couple of suggestions, but let’s look at your situation first.”

Most of all, your response to questions is determined by your clinical assessment of the client, the specific question in context, and the possible motives behind the question. As those factors change, you might understand the question differently and alter your response.

The questions that your client asks are important; so are the questions that you ask yourself:

“What is in my client’s best interest at this time?”

“What is comfortable for me?”

“What lies behind the question?”

“Is this simply a way to make a further connection with me?”

“Does the question reveal some issue for my client?”

“Is my client expressing reservations about me?”

“Is this an angry, hostile, or veiled attack?”

“Is it important to have tighter boundaries, or looser ones?”

“Am I less worried about the individual questions and more concerned about the excessive number of questions?”

“Are the questions deflecting attention from my client?”

“Is my client asking in order to normalize his own experience?”

“Is my client challenging boundaries to see how far I will go?”

“Is this a simple question that has no major significance?”

“Is my client trying to figure out another point of view or determine what is normal?”

“Is my client trying to be socially appropriate and doesn’t really care about my vacation/floral arrangement/new jacket?”

You will not be flooded with questions. Responding to client’s questions will take up a small portion of your clinical life. Unfortunately, the anxiety that client questions cause occupies more space than it deserves.

STYLE AND LANGUAGE CONSIDERATIONS

We have been careful to choose accessible words for this book, just as we do in treatment, in order to ease conversations. In writing, we have avoided jargon and tried to use the words and tone that we often use with our clients, in supervision, and in consultation with respected students and colleagues. We have made these decisions based on our desire to have you think about, amend, own, and use these ideas with your clients. Some of our most powerful therapeutic instruments are words, so in this section, we focus our attention on language and phraseology that helps clinical work.

As we put together the responses to questions in the topical chapters of this book, we noticed that style and language are consistently woven together. Style refers to the way you select and arrange your answer so you will be heard and understood. Language considerations include attention to the specific words and phrases; it is an area for awareness, not carelessness. Clients listen closely to your language and remember what you say to them. In fact, some people will repeat your exact words back to you, even years later.

Style and language considerations are not unique to answering questions but are important during those dialogues, because those are moments when clients may be open to new ideas. Therefore, you want to proceed with intention when you respond to client questions. We highlight some basic practices that can be forgotten in stressful situations. Some general ideas about style and language when you answer client’s questions include: take time to formulate your response; be transparent; use metaphors and analogies; practice the soft sell; lead with positives and speak to strengths; use client language when possible; clarify jargon: yours and theirs; avoid sarcasm; and use a few key words that can make a difference.

Take Time to Formulate Your Response

Being asked a question can make you feel like you are being put on the spot, so you feel pressured to reply immediately. Take your time. Sometimes a delayed answer is the best one. When you take your time, you model deliberation. This gives permission to your client to do the same. Your thoughtful pacing may be one of the most therapeutic aspects of the interaction. To do so, you can pause and reflect before responding, or muse out loud, “Let me think for a moment about how to best respond to that.”

Be Transparent

Let your clients in on the thinking that leads to your responses. By being transparent about your thought process, you can increase the likelihood that your clients will learn the same method. When you offer the evidence that you used to reach your response, you show that you use a reasonable process that clients can learn and practice on their own. For example, when a client asks, “Should I quit my job?” you can respond using information you previously acquired and synthesized with today’s problem: “You liked your job until you got new responsibilities. It could be helpful to talk about that shift; maybe it will clarify your options.”

Use Metaphors and Analogies

Metaphors can provide a new way of looking at a situation. By objectifying the issue at hand, metaphors allow the message to bypass entrenched dysfunctional patterns and provide a chance to think about the problem in a fresh way. This helps clients gain a different perspective on themselves, their situations, and their resources, and allows clients to entertain alternative strategies and pose solutions to their problems.

Clients like metaphors because they are slightly distant from personal material, can be interesting and involving, and are less threatening and confrontational than direct statements. Metaphors simultaneously conceal and reveal. Metaphors and analogies can also appeal to people who are less amenable to oral communication and instead need visual or kinesthetic cues for them to be more involved in the therapeutic process. They can be important in working with difficult clients to enhance rapport, to make points, and to convey information in a nonconfrontational manner. The effectiveness of analogies is enhanced by choosing images that connect with the language and interests of your client, so that it relates to everyday activities.

Charlie