# 115 September 2009

"May belief be the slave of aesthetics
And the prettier doctrine apply
Where doubts arise.”

From Hallelujah Anyway
Written and illustrated by Patrick Woodroffe

(continues below)

mental health professional trainings
primary care professional trainings
psychological assessment supervision and consultations
Shawn Christopher Shea
links and recommended readings


# 115 September 2009

The Empathic Power of Closed-Ended Questions

TISA Description of the Problem: The ability to sensitively enter into the intimate world of the client’s pain is one of our greatest tasks. I have recently had the pleasure of giving a series of workshops on suicide assessment and prevention at a number of VA VISNs and Vet Centers across the United States from Louisiana and Boston to Indiana and Chicago. I have learned a lot from the clinicians that I have encountered. I would like to share a couple of questions that highlight an intriguing point. Traditionally, it is often emphasized that empathic statements are the gold key to engaging patients and that open-ended questions are the gold key for helping patients to share intimate details. Both of these statements are correct. But what is often not emphasized is that closed-ended questions can also be exquisitely useful at both of these tasks as we shall soon see below in two tips suggested by Nancy Krug, a suicide prevention coordinator from the VA center in Madison, Wisconsin

Tip: Sometimes with Vets, I find that the following simple question often opens up a barrage of unexpected feelings, sometimes even leading to an unexpected sharing of suicidal ideation. I wait until the Vet is describing his or her current stresses and then ask:

“Did you get any sleep at all last night?”

The responses are sometimes surprising. Obviously, I learn something about the Vet’s sleep disruption, but more importantly, they often begin sharing the intensity of their pain in more detail and seem to be grateful for the question, which in itself acknowledged an understanding that their pain must be great indeed.

In a similar vein, it can be difficult for Vets or soldiers to openly acknowledge being depressed (for it may be viewed as a sign of weakness) or easily acknowledge the extent of disruption their PTSD is causing them in their functioning (reflecting they may be unfit for duty). The following question seems to resonate with many:

“You know, is the PTSD messing with your head?”

This question seems to open the door to their pain and can even be a gateway for an exploration of suicidal ideation.

TISA Follow-up: I really like both of these tips from Nancy, which can uncover the sensitive material that can help us to prevent suicide with our Vets and our soldiers from Iraq and Afghanistan. They emphasize the power of clinicians to communicate empathy through the use of closed-ended questions (Both of these questions are closed-ended as evidenced by their “yes/no” nature). Indeed one of the powerfully engaging qualities that well-timed closed-ended questions can communicate better than open-ended techniques is expertise. It is our expertise (the fact that we might be able to help when others, such as friends and family could not, because we clearly have a knowledge they do not) that often generates hope. And it is the client’s hope that we can help that often leads to a second appointment and a lasting therapeutic alliance. Closed-ended questions can communicate our expertise by the fact that they show we have a familiarity with what the client is experiencing thus creating a safe space for the client and the hope that we might be able to help.

Imagine for a moment a patient suffering from severe OCD, who is convinced that their symptoms are bizarre and “crazy”. Studies have shown that many of these patients do not seek mental health help and that when they do, they often do not spontaneously offer any of their OCD obsessions or rituals to the therapist (for they are acutely embarrassed by them). Instead such patients present with their depressive symptoms or “I’m just really anxious all the time.” In short such patients may have been shouldering this pain alone for years, thinking all that time that, “I must be one of the craziest people in the world.” Furthermore, they won’t share their OCD symptoms unless directly asked about them.

Now imagine a clinician who after hearing all about the client’s depressive symptoms asks the following closed-ended question, “You know many of my clients who are feeling depressed like you are, tell me that they worry or fret a lot. Sometimes they fret about things like money or losing a job, but it’s not uncommon for them, when they are really depressed, to fret about things that seem odd to them to worry about like ‘Do I have germs on my hands?’ or “Did I leave the stove on, and the house is burning down?” stuff like that. Have you ever had frets like that, that seem odd to you, and you just can’t seem to shake them even though you want to?”

For some of these patients, this is a world-changing question. The idea that other people have these same kinds of thoughts - and that this therapist has seen them before -can be unbelievably reassuring and powerfully engaging. Some of them are careful at first saying things like, “I sort of have that, you know I wash my hands a lot. I’m sort of scared of germs.” If the clinician further shows his or her familiarity with the symptoms by saying, “Oh, I’ve had clients who wash their hands hundreds of times a day, sometimes even to the point of causing a rash,” these clients often show an expression of great relief saying, “Oh, I wash my hands at least 50 times a day.” At this point the interviewer has forged a powerful bond and may have uncovered a devastating disorder (OCD) that can now be treated. In fact I recommend that all clients be screened with such a question, for OCD is a surprisingly common disorder (lifetime prevalence rate around 2.5%) that is frequently missed by clinicians.

All of this empathic bonding because of a closed-ended question!

Thus we see that many of our responses and questions (open-ended, empathic, and closed-ended) can have an important role to play in the mysterious process we call engagement.

Tip provided by:

Nancy Krug
Suicide Prevention Coordinator
Madison, Wisconsin

TISA is a site dedicated to advancing the science and art of preventing suicide and teaching clinical interviewing