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Questions for productive treatment sessions

May 1, 2009
by Brian Duffy, LMHC, LADC-I
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Here are some ways to get clients to participate more openly

Some substance abuse clients are easy to work with, and some are not. Some are accurate reporters, some have selective memories, and some are chronic liars. Bottom line: It can be a challenge getting clients to open up, to speak the truth, to articulate what's really on their minds.

This article provides examples of questions that have proven useful in my work with clients. I have organized these ideas in no particular order.

Even with a client I see every week, getting the session started can be awkward. “How was your week?” is an appropriate question, but it can lead to a litany of events and situations that keep us from discussing more important issues. Often, I rely on a simple “What should we be talking about today?” This reminds the client that he/she plays a role in deciding how we use the hour. It implies that we're here not to chat, but to do some work.
Brian duffy, lmhc, ladc-i

Brian Duffy, LMHC, LADC-I

New client

With a new client, I will ask if he/she has ever worked with a counselor/therapist. If the answer is yes, I will ask: “What was that like for you? What did you like or dislike about that experience?” This can provide valuable information and keep me from replicating mistakes made by the previous therapist.

Goal setting can pose a challenge. Ask a client what he wants to achieve in the short and long term, and he'll provide some generic statement about being happy, being sober, being rich, etc. That's too broad. One way to get at specific goals is to ask: “If you had a magic wand, what would your life look like? What would an average day be like?” This is not a new intervention, but it is still a clever way to get a client to articulate what he wants to achieve-where he wants to go. Armed with a vision of the client's goals, the two of you can co-author a plan of action to get him on a path toward reaching the goals.

When working with a client who is ambivalent about recovery and resistant to participation in 12-Step meetings, I will ask: “What percent of you is interested in getting sober? One percent? Fifteen percent?” Usually a client will admit to some level of interest. Then, we examine the AA preamble, which states that the only requirement for membership is a desire to stop drinking. (It can be a huge desire or a tiny desire.) When a client understands that it's OK to be uncertain about his/her commitment to sobriety, participation in 12-Step meetings becomes less threatening, and he/she is better able to attend with an open mind.

Recent relapse

Working with a client who has relapsed recently, I'll simply ask, without sarcasm or judgment, “So, how was it? Did you have fun?” I'm serious with the question and I must work with whatever the response might be. Usually the client shares that the relapse wasn't pleasant, since there were consequences. Clients must learn that it doesn't get better out there-and the lesson will have greater impact if they arrive at that conclusion on their own.

Next, I'll want to gather another important piece of information: “What do you think led up to the relapse?” Clients initially will focus on the events immediately preceding the relapse, and that's fine for starters. But we also want to study the behaviors that have been occurring in the weeks or months prior to the relapse, so I'll ask: “Looking back over the past several weeks, were there any changes in your life?” I am hoping the client will recognize some problem behaviors (or errors in thinking), but often I am forced to probe with some closed-ended questions, such as: “Have you been going to the same number of meetings each week? Are you speaking with your sponsor every day? Are you gambling? Are you dating? Are you working the same job, the same hours?

Our goal, of course, is to identify-and then avoid-behaviors and thinking that might have led to the last relapse. Previous relapses are a wonderful tool by which to shape the relapse prevention plan.

Shy or guarded clients

Sometimes clients want me to tell them exactly what to do. For example, a client facing a high-risk situation, such as a family gathering where alcohol and drugs will be present, will want me to create his strategy. But my job is to prepare that client for when he is on his own, so I'll respond by asking: “You tell me. What should you do? What could you do?” Most clients eventually will consider their options, such as bringing a sober friend, not going at all, having an escape strategy, etc.

Occasionally I am able to get at what's really on someone's mind by asking: “What are you hearing at AA meetings these days? What thoughts have stuck with you?” This doesn't always bear fruit, but it is worth a try. Another way to enhance communication is to get away from the office setting. Some clients are less intimidated and more talkative when we go for a walk or a drive. It puts us on a more equal footing.

Consistent with Motivational Interviewing techniques, I often preface questions with language such as: “Help me understand…” or “Please say more about that.” If a client's words are not consistent with his actions, I have an opportunity to explore the discrepancy. I will point out what appears to be the discrepancy, and ask: “What am I missing here?

Uncharted territory

We counselors sometimes fall into the trap of pretending to know things we don't. This is an unnecessary approach that clients quickly recognize. Faced with a client with an ethnic background unlike my own, I might ask: “What is it like, living in a strange culture, away from home? What was it like, growing up in China? What do you like/dislike about living here?