There is currently an insidious trend among clinicians, slowly swelling like groundwater after a storm. A way of presenting information that seems on the surface to be oriented toward building a shared understanding with our clients, but that in fact helps to shut down their thoughts, reactions, or corrections. Right?
I have been surprised recently by how often I hear this question at the end of statements by therapists. It usually follows a statement of fact, in which the person speaking assumes that the listener agrees. I have seen it occur in academic or clinical talks presented to large audiences of clinicians, in supervision, therapy groups, and even when speaking directly to individual clients.
When you get depressed, you don’t want to do anything, right? You just want to lay in bed all day.
So your child is using these outbursts to beg for attention, right? That’s the only way he knows how to get it, right? So you need to work on shaping that behavior by reinforcing positive behaviors and ignoring negative ones.
When we haven’t been sleeping well, we tend to engage in behaviors that cause further problems with our sleep, right? Like lying in bed awake for hours even when it’s clear that we’re not that sleepy. This can actually make our sleep worse. Does that make sense?
This way of speaking is epidemic in clinical work, whether we are speaking to our clients or our colleagues. And yet despite its popularity, there are some significant problems associated with this approach to checking in with our clients (many of which have to do with the fact that most people are not actually using it to check in).
So what is wrong with ‘right’?
What does asking ‘right’ at the end of a factual statement pull for? If you attend any sort of talk or presentation in the next few weeks, notice if the speaker uses this technique and then pay attention to the response. You will almost always see a wave of head-nodding after ‘right’ is tacked on to the end of a sentence. (Particularly if you are in an audience of fellow therapists – we love to nod along!) Why is that? Because ‘right’ encourages you to agree. It essentially plants the idea of agreement into your mind. Now imagine sitting in that same audience and when the speaker says ‘right’, look for the number of people shaking their head in disagreement. It will be incredibly rare. It’s very difficult to disagree when someone says ‘right’, even when we know this statement does not apply to us.
So what does that mean for therapy? It means that when we make a statement like the first one above about the consequences of depression, we’re assuming that our client has the same reaction to feeling depressed as many other people. But maybe that’s not true, maybe the client still engages in regular activities but she is so out of it and withdrawn that people in her life have started to assume that she is angry with them and have backed away from their relationships, isolating her, and leading to increased depression. The outcome may be the same as laying in bed all day, but the behavior is very different. And if I as the therapist don’t stop to check on that, I can end up suggesting an intervention that is counterproductive to the client’s goals.
Perhaps I go for the standard intervention of assigning behavioral activation for homework. I encourage my client to engage in as many activities as she can with an emphasis on mastery and pleasure (perhaps I even throw in another ‘right’ – we usually feel better once we’re up and about, right?) . Now I’ve suggested she engage in the exact behaviors that are already leading to such problems for her. She’ll continue to visit friends and go to work, all the while exhibiting a withdrawn and disinterested attitude that will further alienate her loved ones and continue the cycle of depression. If I had checked in on her actual behavior and developed hypotheses about it’s function, I would have suggested a very different intervention. Instead, I assumed, checked in nominally without actually doing so, and exacerbated the client’s difficulties.
‘Right?’ can lead us to make unhelpful assumptions under the guise of checking in with our clients.
As behavioral and cognitive therapists, we need to understand the specifics of our client’s behavior and then develop conceptualizations that assess what function those behaviors are serving in our clients’ lives (in other words, what is reinforcing those behaviors and how can we develop other types of reinforcers that will reward and therefore increase more effective behaviors?). Checking in with clients about their behaviors and the function those behaviors serve is a good thing! Checking in to make sure clients understand the rationale for completing a homework assignment or are following the psychoeducation we’re providing are also very good things! We just need to make sure we’re doing it in a way that encourages the client to give an honest response that will provide us with useful data, not generic head nods based on social convention.
In addition to ‘right’, there’s another question that therapists commonly use to ‘check in’ with clients that can have many of the same downsides. “Does that make sense?”
This question also pulls for an affirmative response (head nodding or ‘yes’). It can lead us down similar paths of assuming our clients are on the same page that we are, only to find out later that we were reading an entirely different chapter.
So what can you ask to check for understanding or conduct a thorough assessment of your clients’ behaviors, thoughts, emotions, and struggles? The solution (which many of us already know but can still sometimes struggle to implement consistently) is to use open-ended questions. What’s tricky here is that a question like ‘right?’ may feel open-ended because it’s broad and vague. But questions that pull for a yes/no response aren’t open-ended, and ‘right’ and ‘does that make sense’ often function more as verbal tics than as true questions seeking an answer.
Open-ended questions are those that (1) genuinely require an answer, and yet (2) don’t pull for a particular answer.
What happens for you when you get depressed? What are your typical behaviors? [Asking the client for their specific behaviors rather than assuming that they engage in the same behaviors as many other people experiencing depression.]
And what do you think happens for your child when he’s tantruming? Are there any benefits to that behavior for him, in terms of the response from your family, friends, or his teachers? [Assessing the client’s perspective on the function of the behavior. While you might have your own hypotheses, asking the client – rather than stating your hypotheses as fact – can help to elicit additional information that you may not have otherwise known.]
I’ve just reviewed a lot of information about sleep and insomnia – what did you hear me saying? What are you taking away? [Asking the client to share the specifics of what they heard with you rather than asking whether what you said made sense, which pulls for them to say yes regardless of how much they are actually tracking with you.]
Do you have the tendency to lean on ‘right’ and ‘does that make sense’ in place of open-ended questions? (I know that when I’m rushed or stressed, I tend to hear ‘does that make sense’ fall out of my mouth, usually after a long period of one-sided conversation with little input from the client.) If you notice this in your own work, try to pick one of these questions and focus on catching it this week. When you do, try to replace it with an open-ended question and see what you get in response. And, as always, let us know how it works for you in the comments!