What is a good question?
To be an effective professional, you need to understand the point of asking good questions. The purpose isn’t just to find out information, and it isn’t meant to influence someone to see things your way, or to solve problems for them. Instead, the aim is to create as many opportunities as possible for patients or colleagues to think about their stories in new ways. The understanding they reach and any action they decide to take as a result may not be what you expected or what you hoped for. We don’t prejudge what is right for the client – unless we think the patient is in danger or the client is at risk professionally. Often, the change that occurs in the conversation is a cognitive one rather than a concrete decision. For example, clients may realise through the conversation that what they were already thinking or doing was right all along, and feel more comfortable about it. Alternatively, they may reach an entirely different view of the problem, perhaps seeing their own part in it rather than feeling it was somebody else’s fault.
Good questioning is not the only kind of utterance in effective conversations, but it is a better way of creating openness and possibility than any other form of speech. Good interviewers can demonstrate how well they have understood a client simply by asking questions that correspond appropriately to the language and the emotions present in the conversation. This is why we discourage the familiar routine of empathic noises (eg ‘I hear what you’re saying’), reflecting back (eg ‘so what you’re saying is…’), reformulation (eg ‘it sounds to me as if…’), and interpretation (eg ‘I think what’s really going on here is…). Unlike some other methods, we try to avoid direct inquiry into emotions (including the ubiquitous ‘how did you feel about that?’). For some clinicians this question has become an automatic response. It is sometimes asked without real sincerity and may not be what the other person wants to speak about. If someone is feeling strong emotion and chooses to express this, it is perfectly possible to allow this to happen through sensitive questioning without insisting on it. A question like ‘how did this experience affect you?’ will nearly always be more helpful than a statement like ‘you must have felt very angry’. Although this may have been said with the intention of expressing empathy it can be experienced as clumsy and may be off the mark anyway.
We draw on the ideas of a group of therapists known as the ‘Milan Team ‘ who proposed three principles for good questioning: hypothesising, circularity, neutrality. Later one of the team, Gianfranco Cecchin, proposed a fourth principle: curiosity.
Hypothesising
There are instances when it is useful to form a series of conscious working hypotheses in one’s mind as a conversation proceeds and to use these to generate appropriate questions. However, some people do seem able to question clients through intuition without necessarily identifying the hypotheses that led to them – or only becoming aware of these afterwards.
Where hypotheses are fully conscious, we advise against sharing these openly with clients, because this may lead to the supervisor’s assumptions taking over and suppressing what the client can actually say or think. In the case of the example above, it is easy to imagine that declaring each hypothesis as it arose could be helpful if the supervisor was right about every single one of them (and the client had already thought through all these aspects of the problem in advance). However this can be oppressive if they turn out to be wrong – and possibly based on the supervisor’s own experience alone – or if they are more or less correct but badly mis-timed because the client is only realising them with some difficulty during the interview itself. For every one occasion when a supervisor shares a totally accurate hypothesis and moves the interview forward with great speed as result, there are probably a hundred examples where supervisors are convinced they are absolutely right and hijack the interview by offering their own version of events, leaving their clients somewhat worse off than if they had never asked for supervision in the first place.
One advantage of identifying one’s own hypotheses and examining them critically is to help you avoid barking up the wrong tree. Sometimes an interviewer will pursue a whole line of questioning based on a single unexamined assumption, perhaps based on their own experience: this is called ‘being wedded to your hypothesis’. When it’s clear that an interview is going nowhere, it’s always worth reviewing whether an assumption of this kind is present and then adjusting it.
Circularity
One of the most fundamental principles of narrative-based practice is that questions should be linked to something the client has already said. Whenever possible it is worthwhile for interviewers to pick up on words or phrases from the client’s own narrative rather than choosing these from their own vocabulary, or substituting other words and phrases that may seem almost identical but have significant differences for clients. Following another person’s exact language is a way of showing empathy and interest through careful listening.
Effective professionals have an ability to sense cues that have ‘life’ or ‘weight’ in them and to tune out of everything superfluous, while others seem to pick cues at random from the client’s flow of words and hence ask questions that are irrelevant or trivial. One corrective to this, particularly for learners, is to check constantly with clients which among several cues it might be most helpful for the supervisor to follow, and to be willing to review the conversation or wind it backwards whenever a question seems to lead down a blind alley or makes the interview go slack (e.g. ‘you mentioned earlier that there were two aspects to this problem: which of them is foremost in your mind at the moment?’). Another approach is to ask the other person how the conversation is going for them, what they are getting out of it, and what is still missing for them.
With good conversations, there is a circularity of emotions as well as words. Some poor supervisors meander, while others go straight for the jugular vein. Effective ones seem to move forward at exactly the right pace to keep the conversation taut without provoking either boredom or defensiveness in clients. When the client seems vague or unfocussed, they become more precise and assertive in their questioning. When the client tenses up and they sense they have run up against a ‘wall’ in the conversation, they ease up gently but not too much (or they pause to talk with the observer or team if there is one).
Neutrality
Neutrality as a term sometimes causes confusion because it implies that professionals have no views or opinions of their own. This is obviously impossible. However supervisors can still follow the discipline of not showing their views or opinions to clients.
For most learners it isn’t easy to master to process of turning a hypothesis (whether conscious or intuitive) into a question, and then making sure that the question doesn’t give everything away by its wording or intonation. That is one of the reasons for using structured training methods in small group work. With practice the process becomes internalised and hence easier. For some people it fits so well with what they believe to be effective and ethical conversational practice that it becomes effortless.
There are sometimes situations where the interviewer stands in a significant power relationship with the client (for example as trainer and trainee, or employer and employee) or the two people normally work together in a shared context like a team or practice where their own interests may differ. In such situations, attempts by supervisors to show neutrality can be dishonest. They can turn into ‘narrative-based manipulation’, where the interviewer performs apparently neutral interviewing while actually aiming to influence the client to consent to one pre-meditated outcome. Neutral interviewing of a client in this situation is certainly possible, but only up to a point. For example an interviewer can show curiosity into why a trainee or colleague takes a particular position, if he or she accepts that the other person’s position is entirely reasonable from their own perspective.
However at some point the interviewer will need to declare his or her own position (if this isn’t already obvious) and will need to conduct the rest of the conversation based on the fact that there is a real difference of opinion: both parties now need to address how to manage that difference. This may entail an interviewer in a position of power exerting their authority and declaring that they cannot be neutral about the action they need to take. Where the supervisor and client are equals within the same power structure, the next step may be to explore together what the consequences of their difference will be within the wider system and who else might be implicated by it. If this cannot strictly be conducted in a neutral way, there is certainly no reason why it cannot be amicable.
Curiosity
Patients often report that it wasn’t the questioning that helped most in a conversation (at least so far as they can remember) but the overall stance of curiosity in their interviewer. Indeed, we have often seen clunky questions do the trick so long as the interviewer was genuinely engaged and curious. ‘Text book’ questioning can achieve nothing at all if delivered in a way that seems rehearsed or inauthentic. There may be a few specific questions in any interview that stop clients in their tracks and lead them to say ‘that’s a really good question’. There may be other questions that they chew over during the course of the following week so that the interviewer may never even learn what a good question it was. However many of us have had the humbling experience of being congratulated by a client after an interview for asking fantastic questions that we never actually asked: our clients imagined that they heard the questions that they really wanted. In these instances, it is probably the quality of the interviewer’s curiosity that enables the client to imagine the perfect question even though the supervisor hasn’t actually asked the ‘right’ ones at the time.
Tomm’s framework for asking questions
The principles of the Milan Team were later developed into a framework for questioning by Karl Tomm, a Canadian professor of psychiatry. He called it “interventive interviewing”, implying that conversations, conducted through questions, can make a difference to how people view and understand things and are therefore really ‘interventions’. We prefer to call these interviews “conversations inviting change”.
From watching videos of the Milan Team at work, Tomm drew up a theoretical framework for using questions as interventions. Although his original premise was that therapeutic conversations aim to relieve mental pain and suffering and produce healing, the concepts are not restricted to therapy. Tomm has argued that you can transfer the underlying principles to any conversation where someone is trying to help someone else (or a group) view a problem or dilemma in new ways, including supervision and team facilitation.
Tomm’s scheme is helpful in promoting self-awareness in relation to the quality, variety and effects of different questions, particularly in the early stages of learning narrative-based practice. As he points out, the taxonomy doesn’t map very well onto many real-life conversations. Our observation is that it can also can hamper people if they try to follow it slavishly. Like riding a bike, it is probably best learned then forgotten.
However it is useful for learners to know the distinctions Tomm makes between lineal questions (e.g. ‘who else works with you?’), strategic ones (e.g. ‘what would happen if you raised this problem at a practice meeting?), circular ones (e.g. ‘who gets most upset in your practice if you don’t always follow clinical guidelines?’) and reflexive questions (e.g. ‘if the doctors couldn’t resolve their disagreements, who do you think would be the first one to leave?’). It’s certainly worth noting that all these questions are open ones, in the sense that they don’t begin with verbs and hence open the possibility for narrative development rather than inviting the answer ‘yes’ or ‘no’.
Lineal questions
You may feel more comfortable calling these ‘linear’ questions. These are investigative questions with which clinicians are very familiar as they form the basis of medical history taking: what, who, why, when, where? They are very useful questions that help the interviewer and interviewee orient themselves, set the context and gain clearer understanding of the interviewee’s story. They are based on ‘lineal assumptions’ that assume that things have simple causes and effects. They bring out facts but the drawback is that they tend to establish an existing story that does not necessarily help the interviewee to see new paths or options. Unless used with caution this type of question may convey a judgmental attitude and embed pathology and an unchanging narrative.
Some examples:
What has happened?
How long has this been an issue for you?
Who else is involved?
Who else believes……..?
What have you done about…….?
Circular questions
These could be also be thought of as interactional questions. They are exploratory and assume that everything is connected with everything else (‘circular assumptions’). Circular questions are used to bring out patterns that link events, perceptions and behaviour. They are founded on curiosity to create a dynamic view of the interviewee’s situation. There are many different types of circular questions but most fall into the categories of “difference questions” and “contextual questions”.
Some examples:
How do you think x sees you?
How do you imagine x thinks you see her?
When x gets angry what does y do?
When the consultant/senior partner is stressed what effect does that have on the receptionist?
Was the nurse more likely to show this attitude problem before or after her colleague went on sick leave?
Strategic questions
These are corrective, leading questions where the interviewer embeds advice in the question. They can be helpful when a supervisor needs to act as an instructor. They are a way of saying “If I were you I would do…” but offering advice as a question leaves some room for the interviewer to reflect on their response. These questions can be experienced as reassuring and supportive or as challenging and constraining and may get interviewer and interviewee into an oppositional stance. They should therefore be used sparingly.
Some examples:
What do you think would happen if you:
started a disciplinary procedure?
just ignored this?
spoke to one of the partners/the clinical lead about this?
got some legal advice?
What would the advantages and disadvantages be if you:
said exactly what you think?
asked x to do y?
just told her what to do?
asked what she would like?
pointed out what it says in her contract about this?
Reflexive questions
Tomm thinks of these as the most facilitative questions. They invite people to consider something familiar in a new context. The aim is to perturb the interviewee’s thinking in order to help them develop new and more constructive ideas. Using reflexive questions assumes that people are autonomous and cannot be instructed directly. They may offer a more creative approach but can sometimes make people feel confused.
Some examples:
What will happen if nothing changes? / How long do you think you could put up with the situation if it doesn’t change?
What would be happen if you did nothing? / Who else do you think would be the first to act if you did nothing yourself?
What’s the best thing / worst thing that could happen of you asked the team to discuss these issues?
If we could find a solution to this problem what other problems might be exposed as a result?
What can we do to move this conversation forward?
What would you do if this happened again?
From these examples it should be clear that the same question may fit into different categories depending on why and how it is asked. There may be a difference between the interviewer’s intention in asking a question and the actual effects of that question on the interviewee. This may be because there is a difference between the interviewer’s intentions and what they actually do, or because there is a difference between what the interviewer asks and how this is heard by the interviewee. These mis-matches can be minimised by experience and by close attention to language, both verbal and non-verbal. However, the interviewer has to take responsibility for asking questions without always knowing what their effects might be. Although some questions elicit an immediate response, the interviewer may not always be aware of the inner reflections that may be generated and some questions may linger for a long time beyond the immediate conversation.
References:
Cecchin, G. ‘Hypothesizing, circularity, and neutrality revisited:
An invitation to curiosity’, Family Process 1987; 26: 405-413.
Halpern H, McKimm J. Supervision. In J. McKimm and Swanwick T. (Eds) Clinical Teaching Made Easy. London: Quay Books, 2010.
Launer J. Narrative-Based Primary Care: A Practical Guide. Abingdon: Radcliffe., 2003
Launer J. Training in narrative-based supervision: Conversations inviting change. In: Sommers LS, Launer J, eds. Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement. New York NY: Springer, 2013, pp.163-176.
Palazzolli-Selvini, M., et al. ‘Hypothesizing-circularity-neutrality. Three guidelines for the conductor of the session’, Family Process 1980; 19: 3-12.
Tomm, K. ‘Interventive Interviewing: Part III. Intending to ask lineal, circular, strategic or reflexive questions?’ Family Process 1988; 27, 1-15.