Feature
ASKING QUESTIONS
TO AID RECOVERY
OaveHawkesand OavidHingleyoffera list
of 42 questions
thatmentalhealthpractitioners
can askclientsto promotehopeandwellbeing
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I
Summary
Questioning
forms. There is a relationship, however, between
I the questions asked at assessments and the
is a funda.mental
part of
therapeutic relationships established between
practitioners and clients.
I
an understanding of clients' experiences and to
In asking questions, practitioners form
assess risks associated with them. The questions
relationships
with their clients, and influence
I
practitioners ask can also convey their beliefs and
I and draw on relationships between clients and
i their families, friends and other mental health
approaches to care. This article provides a list
.of ~x types of question based on the principles
professionals (Furman and Mola 1992). As quickly
of recovery and person-centred care. The list
as practitioners gather information about their
I clients' conditions, their clients gather information
. is intended to complement,
not replace, the
j
about what practitioners consider to be important.
practitionersmust maketo fulfil their
[. enquiriesthat
essential professional duties, while conveying their
Questions can be understood, therefore, as
commitment to hope, change and recovery.
statements about the enquirers' beliefs. The linguistic
i
philosopher Ludwig Wittgenstein said that questions
Keywords
can be disguised instructions that limit rather than
Solution-focused approach, questioning, recovery
promote choice (Wittgenstein 1953). For example,
.L. "~.'
=.'
~.
]
the question 'Do you want to take your medication
MENTAl HEALTHpractitioners should use
now or after lunch?' offers only an illusion of choice
because it does not include the option of not taking
appropriate language to communicate respect, foster
hope and show their commitment to diversity, choice medication at all.
Another linguistic philosopher, ]L Austin,
and recovery. There is a fundamental relationship
suggested that speech is an 'act', which suggests that
between the questions they ask when engaging
with service users and their assessments and
practitioners can demonstrate their belief in recovery
by the words they choose (Austin 1962).1£ he is
understanding of clients' experiences (Hawkes and
correct, practitioners must ensure that the questions
Hingley 2007), yet questions are often seen simply
as a means to gather information about clients'
they ask conform to the philosophies of care they
symptoms or problems;
are attempting to put into practice.
Practitioners who do not take time to enquire
This perception is understandable given that
about clients' strengths, abilities and successes in
practitioners are usually taught to base their
life, or explore how they solve problems, may not
assessments on measurable information, such as
understand the strategies clients have adopted in the
findings from risk-gathering tools, and because
past to, for example, overcome bullying at school,
questions derived from therapeutic models and
maintain jobs, bring up families, or acquire skills.
approaches are rarely included on assessment
practitioner-client
interactions,
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crucial to develop
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There is a link between the
questions asked and the
therapeutic relationship established
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Feature
The United Statestherapist MiltonErickson often
asked clients questions about seeminglyunrelated
areasof their lives to identify their successesas
well as failures, and thereby build hope (Haley
1985, Short et al200S). Repper and Perkins (2003)
state that this encouragementof hope through the
identification of strengths and abilities is essential
to the recovery process.
To help practitioners remain committed to the
recovery process, the tidal model of care (Barker
2001, 2003, Barker and Buchanan-Barker 2005)
was developed. This includes ten commitments
practitioners can make to ensure they maintain
appropriate relationships with each client:
. Value the client's voice.
. Respect the client's language.
. Develop genuine curiosity.
I: Become the client's apprentice.
. Reveal personal wisdom.
. Be transparent.
. Use the available toolkit.
iI Craft the step beyond 'what needs to be
done now'.
C Give the gift of time.
C Know that change is constant.
Meanwhile, the Eastern Development Centre has
developed a 'Whole We' programme to encourage
practitioners to engage with clients as 'whole' people
and build hope of recovery (Kennard-Campbell
2009). The programme's principles are to:
Gi Put each client at the centre of service delivery.
Iii Consider each client in the context of their
whole lives.
. Change thinking, practice and the system.
. Focus on clients' strengths during caring
relationships.
Practitioners can put these principles into practice
by referring to questions and exercises in the
Whole life workbook (Kennard-Campbell 2j)09).
Recovery-focused questions should be asked in
addition to those asked during assessments of risk
or danger, or when fulfilling other professional duties.
They can be asked throughout clinical relationships
to bring recovery-based principles into sharper focus.
11.
Questioncharacteristics
After studying reviews of Erikson's approach
to helping people (Haley 1985; Short et a12005,
Erickson and Keeney 2006) and related concepts
derived from solution focused therapy
(De Shazer et aI2007), the authors identified
six types of recovery-focused question. These are:
[! Exception.
J:: Existing strength.
. Future-focused.
IISI September 2011
. Goal-setting.
. Partitioning.
. Relationship-focused.
In a homage to the Hitchhiker's Guide to the Galaxy
(Adams 1979), the authors decided to draw up
42 questions, each of which has one or more of
these characteristics (Table 1, pages 17 and 18).
Formulating questions such as these is a flexible
process and many practitioners will be able to
draw up questions that are more appropriate to
their workplaces.
Future-focused and goal-setting questions Talking
about or asking questions that concern the present
and future, rather than the past, is not new. Freud,
for example, asked questions about the present or
future, while setting practical tasks, of at least one
of his patients (Walter 1947).
As part of Erickson's therapeutic approach he
practised a form of hypnosis in which clients were
asked to imagine that they had entered a crystal ball
and moved into the future, when their problems had
been solved. He then interviewed them to discover
about how these solutions had been reached
(Short et aI2005).
De long and Berg(1998),after being told that
only a miracle would help one of their clients,
devised a solution-focused 'miraclequestion':
'Suppose you go to bed tonight, a miracle happens
and the problems that brought you here today
suddenly disappear. It happens while you are
sleeping so when you first wake up, you will not
know it has happened. What would be different
tomorrow? What would be the first things you would
notice that would make you think your life is how
you want it to be?'
Uke Erickson's crystal ball, this question requires
consideration of the changes needed for a better
future rather than of the 'miracle'. Follow-up
'questions can include: What would you or your
family do differently if this miracle happened?
Who else would notice these changes have
happened? By asking such questions, practitioners
can understand clients' goals..
Of course, practitioners do not need to ask
the complete miracle question to engage in
conversations about clients preferred futures.
They can, for example., as.~clients scaling questions,
by which clients are askeri ;:::rate on a scale of
0 to 10 where would :he: ~<Im to be.
Relationship-focused 'P-.I..K These questions
are asked to ~
ciar;s ro see themselves
from other people s va~pn.':- es...1bis challenges
their frames of m~
":' ~
beliefs, and helps
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Feature
F,~X".!'f:""..:'~~
i~~
Characteristics
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F utu re-focused
2
II Have you been confronted with a problem similar to this in the past? How did you try
Existing strength and partitioning
What do you think needs to change in your life?
II to solve it then?
';l
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4 I How is this situation different from that on the last time we met?
How is this time different fro~-~ther
I Among
5
6
all the stress, what has been happening that you wanted to happen?
I
I
-
I If your
7
Partitioning
Partitioning
Exception
What parts of your life are how you want them to be?
I
I
" Partitioning
times in your life?
--
Relationship-focused
partner, relative or friend were here, how would they say this situation is
different from before?
~
18 I When things change, what would they notice you doing differently?
Future- and relationship-focused
I
Relationship-focused
I
and existing strength
,19 What would they sayworksfor you at the moment?
i I
,
-------------
~I~~~
~ I
p.f2
did yo~ get~ourselfto do that?
Existing strength
---
Existing strength
How did you know this was the right thing to do?
I What
Exception
was the best day you had over the past month? What did you do on that day that helped?
--
I
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I Partitioning
I
~3 lis there anything that may look like a problem to others but is part of a solution to you?
fillS
there any part of your-~urre~;~ehav~ur, thinking, feelings or rela~ionshiPsthat keeps you safe
and that you need to keep in place for the time being?
!J
I What
j)
I Why
~
.--
is the situation not worse? Are you doing something, perhaps instinctively-, that prevents
-
Existing strength
.
Partitioning
Exceptionand existingstrength
is important for you to think about to keep yourself going in difficult times?
-------
.{) Ilf you were on top form, how wouldyou handlethis?What advicewould a moreconfidentyou give?
I Where would you like to start? What
~D
Partitioning
I Existing strength
If you cannot have a miracle at this time, what is the least you will settle for?
I What
,E
I
else has worked for you this time?
it from gettingworse?
-------
...
is the most manageable
Existingstrength
Partitioning
part of this situation?
Existing strength
~1 What d'd we d'scuss last time t~at you fouod most useful?
~
i
I
r-------
On a scaleof 0 to 10, where0 is the worst your life has been and 10 is whereyouwant it to be,
Future-focused and partitioning
where are you now? What would your life one step up the scale look like? What would get you one
point up the scale? What would you be doing at 5 that would tell you 'this is better'?
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Feature
QU:~~rQIi~
for !?I'i~n~
I Characteristics
Question
23
What would your partner, relative or friend notice about you that would tell them you were at 5?
What would be different about them?
Future- and relationship-focuse
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24
(
What happened at your last meeting with the team that has since helped you?
Rei ationsh ip-focused
I and
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Did you devise a plan for changing what you need to change? What parts of the plan were you
most able to carry out? Why did they work?
existing strength
Existi ng strength
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What doesthe successof those partsof your plan tel~ou about how to handleyour
currentsituation?
Future-focused
27 I Have you had difficult problems to solve before? How did you solve them?
! Existing
j
28
-t-29
I
30
I
31
strength
What doesyoursolutiontell you aboutyour problem-solvingskills?
I
Have you ever surprised yourself by coping better than you had predicted you would? How did you
manage this?
I Exception
How did you keep going?
1
and goal-setting
Future-focused
and goal-setting
Exception- and resilience-focusel
Future-focused
What is it about you that can help you,in these circumstances?
and existing strength
t
32
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How would you advise someone else in this situation to cope with itZ
I
Relationship-focused
-L--
33
If they asked you for help, what would you say they should do?
, Goal-setting and relationship
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What are you going to do differently to ensure this is the shortest and/or most useful stay you
I and goal-setting
35
Which friends, family members, therapies, meetings, ideas, books or other resources will help you
through this situation?
'"
Future- and relationship-focused,
I have had?
- -+---
Future- and relationship-focused,
and goal-setting
t
36
I What
should we do differgntly
from other services you have received?
-+
37
Future- and relationship-focused
!
-If this were the perfect admission, day hospital stay, therapy group package, detox programme,
set of counsellingsessionsor otherservice,what would it be like?
Future- and relationship-focused
.
--+
38
How will we know that we have become part of your healing process? What would we see and
hear about you and about our conversations that would be different?
---+39
Future-focused
t
--.-
What should the staff do for you to think being involved with them is helping you?
---j-
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--
and goal-setting
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--
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---
40
If I were the ideal interviewer or worker, what would I be doing to help you? How would I be
different from other interviewers or workers?
--+-
--------
Future- and relationship-focused
--Future- and relationship-focused
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41 I How can we make this meeting the best, shortest or most useful yet?
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I Future-focused and relationship
42 i What should we do differently to ensure that we never have to meet like this again?
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--them to form connections with other people in their
lives. These questions are important, therefore, ill
goal-setting processes.
De Shazer et al (2007) say: 'We incorporate these
sorts of questions wherever possible in our sessions.
Not only do they help clients elaborate the details of
solutions, they often work when clients are unable
to find their voices in reference to their problems,
or the goals they want and need to achieve to leave
feeling satisfied.'
De Shazer et al (2007) often began interviews by
asking clients: 'Suppose you go out of here and your
best friend sees you, what would they see differently
about you that would tell them it was a good idea
to attend that appointment, that it has helped?'
Such relationship-focused questions can increase
clients' motivation to change for the other people's
sake, widen their views of difficulties and solutions,
and reflect on what their situations mean to others.
Drawn from systemic approaches to therapy
(Palazzoli et al1978), these queries are also
asked in family therapy (Walker 2004, 2005) and
in cognitive behaviour therapy (Greenberger and
Padesky 1995).
Exception and existing strength questions These
questions are asked to identify how clients' earlier
attempts to get help led to successful change. Clients
can be asked to recall what they have learned or
done since the last meetings that have been helpful
to them or that they deem to be sl!ccessful. Success
in these terms can mean behaving consistently
rather than changing, and it should be noted that
the re-admittance of clients to hospitals does not
necessarily indicate a failure of recovery.
Exception questions can be asked to identify
when clients' problems were expected but occurred
differently, or when clients respond in different and
more helpful ways to familiar events.
O'Hanlon and Beadle (1997) note that 'there are
almost always exceptions to problems: times when
they do not happen, when they do not happen in the
same ways or when there are different responses
to them. Such times can become gateways to longer
and longer periods of time when clients are free
of their difficulties'.
In asking exception questions, practitioners can
communicate their belief that clients have already
attempted to solve their difficulties, and have
followed successful and unsuccessful strategies
to do so. These questions encourage clients to
focus on small variations in routine that suggest
continuous change rather than stagnation, and
bighlight resiliency, the importance of learning new
skills and the ability to cope with trauma or stress.
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In asking exception and existing strength
questions, practitioners can also identify success
among what can be an overwhelming number of
problems. For example, if practitioners can identify
a single day in which a client felt a little different,
or during which a client's symptoms did not occur,
they can ask exception questions to explore what
happened on that day or how the client's behaviour
had changed.
The authors have asked these questions of clients
who hear voices and found that strategies such as
humming or playing music through headphones
have helped them to control the phenomena, if only
for a few hours. In asking exception and existing
strength questions, therefore, signs of control,
influence and agency over what can be seen as
all-powerful, unvarying symptoms can be identified
(Romme and Escher 1993, Hawkes 2003).
Partitioning questions These questions break down
problems into smaller, more easily assimilated
parts that can be dealt with separately. Short et al
(2005) say: 'Partitioning is a broad strategy with
almost unlimited applications. It allows for the
breaking down of negative associations by dividing
a boundless problematic reality into smaller, more
easily assimilated constituent parts.'
Partitioning questions include: 'Which of the
things that need to be changed do you want to tackle
first?' Scaling questions, which divide the steps
towards goals into smaller steps, can also be seen
as partitioning. Asking these questions encourages
clients to focus on what they can change and the
first, small steps they can make, thus promoting
hope and increasing motivation. Thus, partitioning
is part of a stepped approach to care, in which
approaches that emphasise small, achievable steps,
such as solution focused therapy (De Shazer 2007,
Cade and O'Hanlon 1993), and those that suggest
therapeutic processes, such as Kubler-Ross' (1970)
theory about grieving, can be put into practice.
Partitioning questions can also be asked to
separate the changeable from the unchangeable.
Clients can be asked, for example: 'While you
are waiting for your appointment with the heart
specialist, what can you do to make your life
just a tiny bit more bearable?' Or: 'While you are
waiting to win the lottery, what can you do to make
things better?'
These questions also allow professionals
to maintain appropriate boundaries and roles.
For example: 'I cannot find you more drugs, because
as you know this is not what the team does, so what
other issues about your life shall we talk about?'
Or: 'Suppose a miracle is not going to happen,
September2011 I Volume15 I Number ~
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Featu
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what will you settle for? What small change would
make your life a little better?'
Because these queries and conversations involve
searches for signs of resilience or skills, and can
communicate hope, the practitioners who ask
them need not adopt the traditional position of
power over 'passive' clients. They communicate
to clients the belief that they can do something
about their problems and that their situations
can change. The questioning process itself suggests
that clients have choice and that their problems
can be questioned.
Practitioners who ask questions such as the
42 listed in Table 1 are likely to become more
hopeful about the possibility for change and less
likely to assume that they are solely responsible for
solving clients' problems. More hopeful practitioners
are less likely to experience carer fatigue and
feelings of burnout.
This approach involves the exploration of
situations with clients, rather than the provision
of answers, and assumes that responsibility for
change and expertise lie with clients. It therefore
allows expression of Rogers's (1961) ideas of
positive regard and person centeredness, and of the
therapeutic usefulness of interviewers' neutrality
(Palazzoli et aI1980).
Asking these types of questions give clients
opportunities to share their strategies and self-care
skills, and to express what is valuable and helpful to
them. By listening to the answers and learning from
them they can ensure that care can becomes a more
collaborative process.
Implications for practice
By askingquestionsderivedfrom different
therapeuticapproaches,in additionto the questions
usuallyaskedto gatherinformation,practitioners
can demonstratetheir beliefin hope,recoveryand
change,while encouragingclientsto identifytheir
successes,evenin the faceof setbacksand crises.
Askingsuch questionsalsoenablespractitioners
to recognisethe strengthsof clientsand the seeds
of their recovery.
Online archive
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This articlehas beensubject
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Forauthorguidelinesvisit the
MentalHealthPracticehomepage
at www.mentalhealthpractice.co.uk
DaveHawkesand David Hingley
are seniorlecturersin the
faculty of healthand social care,
Anglia RuskinUniversity
I
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----.-.
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