Questioning: a skill for health

I must have driven my parents mad as a child: I’m the eternal 4 year old asking ‘Why’! It’s got me into a lot of trouble over the years when I can’t seem to sit with the status quo, just need to ask the question, understand the reasons things are the way they are – or at least ask why they are the way they are!

In my work, I use Socratic questioning as I work with participants in both group and individual pain management. Socratic questioning is a method of enquiry ‘to challenge accuracy and completeness of thinking in a way that acts to move people towards their ultimate goal.’ It can be used poorly to almost ‘bully’ someone to come around to a specific point of view (ever watched one of those law shows where the lawyer neatly traps the witness into admitting that part of their testimony without the explanation?) – but used well, it can take you and the person on a journey to discover how they have arrived at their point of view.

I came across this interesting paper by Cary Brown, Katrina Bannigan and Joanna Gill, written for occupational therapists about the place of Socratic questioning not simply for therapy but to question the assumptions about health care. They’re arguing from a postmodernist framework, which I won’t really go into today (but watch this space!), in which they suggest that the assumptions that there is One Single Truth, and it’s biomedical, needs to be questioned. Now I won’t argue with that at all! But what I will argue with is throwing the idea of all underlying principles and science (especially empiricism) out along with the biomedical model.

I can see some of my readers rolling their eyes at the philosophy here – but hold on it does make sense!

Brown, Bannigan & Gill argue that the biomedical model of health is incomplete. I totally agree! It doesn’t include all those social and psychological factors that influence whether someone is living well or is unwell. They state ‘A postmodernist perspective of health and well-being underlines that the illness experience is not a linear, cause-and-effect equation’. They go on to say that life experiences and social, cultural, physical and economic contexts influence individual experience – you can’t really work in pain management without appreciating how much these aspects of life influence how one person lives well with pain, while another has great difficulty.

Postmodernism in health has lead to questioning the assumptions of the biomedical model – again this isn’t new, Engel’s biopsychosocial model has been used in pain management for many years (that link is to a 2002 article on the place of interviewing and relationships in heatlh). It’s almost a truism that in nonmedical management of pain, the biopsychosocial model is the one we turn to. I wish I could say that the medical practitioners I work with also recognise that model, but it’s not quite there yet for some of them!

Brown, Bannigan & Gill suggest that questioning is a strategic tool for occupational therapists so they are equipped to deal with the complexities of current healthcare practice. I don’t know where they’ve been practicing, but I can’t think of a time when my practice in pain management hasn’t been complex! But I guess if you’re working in acute orthopaedic rehabilitation, you might find it difficult to argue with the prevailing ‘give em a toilet seat on Day 2 and they can be discharged on Day 4’ attitude!

Anyway, they suggest that Socratic questioning should be used to ‘frame a critical exploration of the relationships between elements of a given issue’.

The six categories of Socratic questioning are:

  1. Clarification – what is the real issue here? what are the parameters, exceptions, inclusions?
  2. Assumption probes – what are the the presuppositions and unquestioned beliefs for treatment/decisions?
  3. Reason and evidence probes – is there a clearly-thought-out rationale fora treatment or approach? What is the evidence for it?
  4. Viewpoints and perspectives – what if we took another viewpoint, what if we had a look from the perspective of a consumer, a purchaser, a referrer?
  5. Implications and consequences probes – a viewpoint may have logical implications that can be forecast. Do these make sense? Are they desirable?
  6. Questions about the question – why did we start asking these questions? Where are they leading to? What does this mean for practice?

The rationale for using Socratic questions with people experiencing pain is to help them take another look at how they are viewing their pain problem – what are their assumptions? what happens if they adopt one action over time? when might one viewpoint hold true and when might another?

By exploring actions and beliefs in this way, we can develop a more robust point of view that can be not only ‘true for me’ (ie constructivist), but also ‘true for others’ (empiricist).  The questioning part seems to me to be essential (well, I would say that, it’s all I ever do!), the finding out why and what’s behind it is one way to help define key issues.  I hope that patients also get trained in how to question.

I also hope that occupational therapists don’t throw out the empiricist approach altogether.  Empiricism simply means ‘can be known by experience’ – in other words, we can test ideas out and see what happens.  I think this is a critical part of case formulation – once we’ve understood the underlying assumptions and relationships between various parts of a person’s presentation, then we may start to directly influence one of those factors – and then watch to see what happens. 

In a very real way, we are experimenting in pain management, because we don’t know the exact mechanisms that are in play so we need to carefully influence one thing at a time to discern the effect – and use Socratic questioning on our own practice to ensure we’re aware of consequences we hadn’t originally thought about.

Brown, C., Bannigan, K., & Gill, J. (2009). Questioning: A critical skill in postmodern health-care service delivery Australian Occupational Therapy Journal, 56 (3), 206-210 DOI: 10.1111/j.1440-1630.2008.00756.x


Now I’m not going to post a lot about Hippocrates himself, but I want to start todays post by quoting something that he is supposed to have said: ‘There are, in fact, two things, science and opinion; the former begets knowledge, the latter ignorance’.

Hippocrates proposed that if a new treatment was to be tried, we should use science to decide whether or not it works rather than relying on somebody’s opinion.

What makes science different? Apart from its reliance on experiments, observations, trials, argument and discussion – and its supposed adherence to objectivity – science continues to question what is accepted and assumed just in case it has got it wrong.

And this is important for us as clinicians – instead of relying on big budgets for advertising, incredible sales talk or persuasion, or even ‘received wisdom handed down the ages’ – we are encouraged, in fact required to maintain a critical eye on what we do, why we do it, and how we do it, to learn from our outcomes, and to endeavour to be objective about what occurs.

Of course this doesn’t happen nearly as wonderfully well as Hippocrates wanted, but it is an aim for us all. It means we need to know something about scientific method or how to systematically investigate our outcomes, and it means we really must know something about how to measure what we do, and some of the confounds that get in the way of being ‘objective’.

There are some hot debates about the place of objectivity in many parts of health care – especially nursing, occupational therapy, social work – areas where individual experience or constructions are important, and where the context of what happens is seen as influencing both the event under observation and the observer.

Actually if you look up constructivism in wikipedia, you are greeted by a whole page of different links (take a look!).
In some ways, hard science, such as empiricism where experiments and facts and statistics have held sway, has been given a bad name in circles where constructivism has been emphasised.  I think you can be both a constructivist and an empiricist – and later this week I’ll show you why.

Why would it matter to us as health care people? Well to me it’s important to know that what I do with a person is less about me personally and all my wonderful charisma, and much more about the methods and skills I have learned. Otherwise I’m concerned that once I’m not here the world will be soooo much less able to manage and I’ll have to live forever doing what I do!!

I may joke about this, but seriously, I want to know what is working in the mix of inputs I provide to someone, so hopefully I can learn to do it more effectively, and have the results last longer.

I’m also keen to know that the effects are not temporary ‘feel good’ effects – and I don’t want to find that the effects are all about natural remission, or ‘regression to the mean’ or reducing distress, when I think it’s something completely different!

If you’re interested in some of the things that do influence treatment effects that aren’t necessarily about the treatment itself, this paper although old, and on a site that has been criticised heavily (check it out for yourself and make your own mind up), has some good information.

More tomorrow!
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