If the heading of the article slowed you down a little and made you think about what the question is really asking, that’s exactly what I hoped. If you haven’t answered it yet, reflect on it now – what would your colleagues think? In answering this question, even to yourself, you’re likely being pushed to consider something from a different perspective than you usually might have. In turn, this is pushing you to search for new information or new ways of considering an old question.
In this article I want to outline three key aspects of a great clinical interview in the lifestyle medicine context.
You don’t need specialised training to be able to conduct an interview in this way – just a curiosity about your patients or clients and an understanding of how to formulate questions that push them to really think. At the end, I’ll outline a simple template which allows you to formulate pretty much an infinite number of questions.
So let’s make a start.
I’ll be using the generic terms “practitioner” and “client” throughout…
The key to great clinical interviews is in how you think about them – do you see them as a data gathering exercise?
Well, in part that’s helpful, but more importantly, a clinical interview is the cornerstone of the therapeutic alliance between practitioner and client. Whatever a client’s presentation, they are frequently anxious about themselves and their situation and therefore tuned to signs of judgment from practitioners. We’re all taught to be “non-judgmental” in training but how do you actually do that?
The way you ask questions is a central part of this.
Very often, practitioners ask closed questions – do you get 30 minutes of exercise every day? Do you eat 6 serves of vegetables every day? Combined with tone of voice and body language, questions like this can sound judgmental to a client and from the outset the therapeutic alliance may be impacted.
Consider now if you were to ask instead: “Which friends do you most like to exercise with? What do you mostly do? What would [friend X] say is your best asset in exercise?”
Questions phrased this way do several things.
- They turn the practitioner into a curious bystander rather than an “expert” (which has profound implications for motivation).
- They push the client to think about their situation in ways they likely don’t anticipate.
- They yield much more useful data than a closed question.
- And they encourage our clients to be curious about their own behaviour.
You might be thinking that this is all great if clients exercise at all. But what if they reply “I don’t do any exercise”? What’s your inclination here? Educate about how vital it is? Remind them of their elevated HBA1C or blood pressure? What if you were to respond “Oh – how did that come about?” or “I’m curious – what led to you not exercising?”
Again, you’re having a conversation with your client they’re not likely anticipating and which they really need to search their minds to engage in. Your client is also far more likely to perceive you as someone who is interested in what they do and why (their desire for this interaction) rather than simply telling them what they should do (their fear).
Secondly, as I’ve hinted at above, the best questions evoke thoughtful, searching and unrehearsed responses.
Think for a moment about all they ways in which we engage in rehearsed speech through the day:
“How was your weekend?”
“Yeah – good. Did the kids’ sport on Saturday then just relaxed”
“Hi honey, I’m home”
“How was your day?”
“Two kilos of chicken thigh fillet please”
“Just over okay??”
“Yeah – no worries, thanks”
No thinking needed. These conversations and exchanges still serve a useful purpose – a lot of the time they are the “oil” of social interaction. But we want clinical interviews to be much more than a simple exchange of data that doesn’t require the client to think very much about their replies.
Now it might feel odd to ask a question like this (and I’m not suggesting that it would be useful here), but imagine you were to say to a colleague on Monday morning:
“What would your wife say was the thing you most enjoyed about the weekend?”
The first thing that happens is that your colleague has to think about the question. The second is they start empathizing (because they’re thinking about what someone else might think) and the third is they likely deliver you unrehearsed and novel information. As a bonus, they will likely also perceive you as someone who is genuinely interested rather than just “going through the motions”.
Imagine that, for whatever reason, the next consultation with a particular client will be the only time you see them and the only chance you have to help them make a difference.
You’d want to do everything you could to make that consult have as much impact and opportunity for change as possible. That’s the framework we should use for all of our client consultations.
If you adopt that way of thinking, the logical consequence is that your “intake interview” or “clinical interview” is an intervention in itself, not just an information gathering session. This perspective ensures that we see every interaction as an opportunity for intervention and avoid the (artificial) distinction between “assessment” and “intervention”.
I have often had clients return to a second appointment saying “I’ve been thinking about that question you asked me” – evidence that as practitioners, we can have a powerful impact from our first meeting with a client.
So to summarise, three key features of a useful clinical interview are that:
1) It places the practitioner in the role of curious enquirer rather than expert and maximizes the likelihood of client generated motivation
2) It sends clients on a search for information that they don’t readily have at their mind’s “fingertips”
3) It sees every interaction with a client as an intervention and can lead clients to be curious about their own behavior and reflect in novel ways about themselves
So…how to have such conversations?
I’ll describe below some straightforward principles. If you’d like to learn about the origins of this style of questioning, then the reference is at the end of this article1.
Firstly, make all your questions open – start them with: Who, what, when, where, why, how?
- “Who would most like to see you lose weight and be more active?”
- “How easy would it be on a scale of 0-10, to start eating one more vegetable serve per day?”
- “What would be the hardest aspect of managing your weight more closely?”
Second, vary the tense of your questions – ask your clients about the past and future and invite them to make comparisons.
- “When in the past have you had success in increasing the amount of exercise you do?”
- “How challenging was it for you to stop buying and drinking soft drink?”
- “If you are successful in your goal to reach 100kg, what personal characteristic will have helped you most?”
Finally, introduce relationship to questions.
Relationships are a significant source of support for all people who are desiring to make personal change. Helping clients tap into this will likely add to their arsenal of resources.
- “Who in your family would be most amazed that you’d decided to eat more vegetables?”
- “What will your sister say when she learns you’ve decided to make some lifestyle changes?”
- “How do you imagine your wife will react when you tell her you’ve lost 10kg in the last month?”
The art of great questioning comes from being able to combine two or three of these principles in one question.
If you read these and think they sound “stilted” or “unnatural”, there are likely two reasons for that – you’re not in the habit of asking questions like that and you’re also not in the habit of being asked questions like that!
That’s what makes them a powerful intervention!
Simon Matthews is a Registered Psychologist and Member of the Australian Psychological Society.