by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way
Sometimes when I am sitting with clients, I picture where in their brains I can land a question. I know that sounds strange, but it’s true. There are questions, mostly related to cognition, that keep clients located in their frontal lobe. There are also questions, most related to affect, that move clients more deeply into the hypothalamus (the location for flight or fight tendencies) or into their bodies. It isn’t exactly that I privilege one location over another. Instead, it is that it is worth understanding the neurobiological AND interpersonal impact of the questions that we craft.
As clinical social workers, our most frequent go-to intervention is to ask questions. We can talk about validation, normalization, reflective listening, and the tendency to use these techniques, but the fact is that the majority of what we say takes the form of inquiry. It is an awesome reality we have a shared interest in demonstrating authentic curiosity about our clients' lives. On the other hand, it is striking that we don’t talk more about how to craft questions and the significance of the process of seeking more information from our clients.
Thinking about questions as tools that have an impact on the pacing of a session and that deepen self-exploration informs the crafting of what we see. The first thing that I consider when I ask a question is whether or not I am seeking to down or up regulate a client. What I mean by this is that there are times in a meeting or session when a client can seem particularly deadened or disengaged. It is at moments like this that I will create a question that ideally will up regulate the client, or bring the client into the room, back to life. For example, simply asking, “What are you feeling in this exact second?” can accomplish this. You can also say, “Can you tell me where you are right now?” Notice, of course, the words “can you.” The reason why I pad the question like that is that it gives the client a protective barrier between them, me, and the intensity of the question. I am not directly saying: “Tell me where you are right now.” There is a way in which that can be experienced as intrusive and aggressive. In the work of up regulating, it is often quite hard to also remain respectful of boundaries and sensitive psychological processes. But it can be done.
To down regulate, to calm a client, I will often ask questions that might move them away from overwhelming affect. Although overwhelming affect is often a gift and essential to a client’s work, it does not often help for a client to feel completely awash in intense emotion as a session nears the end. It is our responsibility, in many ways, to prepare our clients for re-entry into the world following the intimacy of our exchanges. These questions, for me, include, “What do you plan on doing after this?” or simply, “What are you thinking about as we wrap up?” The reason I would use the word “thinking” is that cognition can often stabilize someone’s emotional state. If you move someone into the frontal lobe, with a question more directed toward that part of the brain, the hypothalamus can calm and soothe itself.
Beyond up and down regulation, I am also hoping to help clients begin to integrate their cognitions, behaviors, and affect states. There are several clinical interventions that seek to divide cognition from affect, but I am more interested in the integration of these parts of one’s self. Psychological relief often comes from feeling what you are thinking and thinking what you are feeling. Let’s say that a client is ambivalent about returning to their family of origin for the holidays. They might think that they are lazy and tired and don’t feel like driving. They might feel terrified. The goal is have them understand that they are not lazy, but in fact feeling something real, and if their thoughts can reflect that, more sound and relieving decisions can be made. But it is not just sound decision-making - having thoughts and feelings align enhances someone’s sense of self and capacity for introspection. There are questions that make this possible, and they are usually informed by clinical observations of incongruencies. For example, an observation can be made and turned into a question: “You are saying you are lazy, but you also seem quite sad. I wonder what you make of that?” That question seeks to help clients better articulate their cognition. You could also say, “What do you make of the fact that you are feeling so sad, but your thoughts don’t help us to better understand the sadness?”
Superficially straightforward, asking questions that shift, deepen, and create openings is a task that requires premeditation and savvy. We are often told not to ask our clients “why.” I am not totally sure of where this idea comes from, but I do know that even the question, “Why?” - when well timed and intentional - can bring our work to life. Thinking carefully and feeling our way into the simple efficacy of the intervention of inquiry and curiosity is clinical social work at its best.
Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. Read more about clinical supervision in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.