Questions as Interventions - Perceptions of Socratic, Solution Focused, and Diagnostic Questioning Styles.pdf

Journal of Rational-Emotive & Cognitive-Behavior TherapyVolume 17, Number 2, Summer 1999

QUESTIONS AS INTERVENTIONS:PERCEPTIONS OF SOCRATIC,

SOLUTION FOCUSED, ANDDIAGNOSTIC QUESTIONING

STYLES

Wandajune BishopMaimonides Medical Center

Jefferson M. FishSt. John's University

ABSTRACT: A videotaped psychotherapy analogue compared psychologytrainees' (n = 67) and undergraduate non-therapists' (n = 115) perceptionsof three theoretically derived questioning styles: Socratic disputation in Ra-tional Emotive Behavior Therapy (REBT), solution focused questioning (e.g.the "miracle question"), and diagnostic interviewing. Non-therapists ratedREBT and diagnostic styles more highly than psychology trainees. All sub-jects rated solution focused questioning more highly than both other styles,perceiving it as more collaborative and conducive to the client's independentthinking. The constructs of collaborative empiricism and solution focused "co-operation" are discussed in relation to findings. The study also compared psy-chology trainees' and non-therapists' Big Five personality profiles, a topicwhich has not previously been addressed in the literature. Psychology train-ees were higher in Big Five Openness and Agreeableness than non-thera-pists. Openness was negatively associated with ratings for solution focused

This study was based on the first author's Ph.D. dissertation research under the direction of thesecond author. Both authors would like to thank Raymond DiGiuseppe, John Jannes, JeffreyNevid, and Robert Zenhausern, who also served on the dissertation committee, and also BernardGorman of Queens College for his expert statistical consultation. Research was conducted at St.John's University, Maimonides Medical Center, and the Veterans Administration Medical Cen-ters of Manhattan, Brooklyn, and the Bronx. Videotapes were filmed at Three of Us Studios inNew York City by Thomas O'Neill. The authors also extend their thanks to the actors in thevideotapes, Kerry O. Burns and Catherine Brophy.

Address correspondence to Wandajune Bishop, Maimonides Medical Center, 920 48th St.,Brooklyn, NY 11219. Electronic mail may be sent via the Internet to [email protected].

115 © 1999 Human Sciences Press, Inc.

and diagnostic questioning styles, replicating findings of previous analoguestudies, in which undergraduate subjects preferred straightforward approachesto therapy.

INTRODUCTION

The grammatical structure of questions seems to differentiate themfrom statements, which among other things attempt to influence di-rectly, e.g., by offering advice or suggesting causes of problem behav-ior. A moment's reflection, however, suffices to cast doubt upon theinnocence of many of the psychotherapist's questions. One might recallthe Ericksonian offer of (illusory) alternatives: "Would you like to gointo a trance quickly, or slowly?" (Haley, 1976). While earlier psycho-analytic practice tended to exclude questions from therapeutic tech-nique precisely because of their potential to influence (Olinick, 1954),the use of questions has become an indispensable element of all contem-porary psychotherapies. Questions may be used to obtain informationabout the presenting problem, build rapport through encouragement ofself-expression, and influence the client to think in ways that may behelpful (Cormier & Cormier, 1985, Benjamin, 1981; Ivey, 1983). Therecognition of questions as legitimate therapeutic interventions hasshaped the development of divergent schools of psychotherapy, mostnotably the cognitive-behavioral and family systems fields. Yet despitethis growth of interest, little empirical work has addressed how ques-tions in psychotherapy are perceived. Do therapists and clients sharesimilar perceptions of therapists' questions, and do their perceptionsreflect the theoretical assumptions upon which these interventions arebased? The present study sought to further understanding of the roleof questions in psychotherapy process, using a videotaped therapy an-alogue to compare therapists' and naive subjects' perceptions of threetheoretically derived questioning styles: Socratic questioning in REBT,solution focused questions, and diagnostic questions.

Socratic Questioning and Cognitive-BehavioralTherapy

Originally documented in the dialogues of Plato, the Socratic methodhas a long association with the study of philosophy, law, and educationalendeavors. Albert Ellis pioneered the use of the Socratic method inpsychotherapy as a means of helping clients learn to recognize anddispute their irrational beliefs (Ellis, 1971), and the technique has be-

Journal of Rational-Emotive & Cognitive-Behavior Therapy116

come a mainstay of the cognitive-behavioral approach (Beck & Emery,1985; Beck, Rush, Shaw & Emery, 1979). Recently, detailed guidelinesfor using the Socratic method have been developed suitable for workwithin diverse therapeutic frameworks (Overholser, 1993a, 1993b,1994, 1995). The systematic inquiry of Socratic questioning uncoverslogical inconsistencies in clients' thinking (Overholser, 1993a), whileleading questions are used to guide the client's insight and encourageadoption of more rational, generalizable, and empirically-based conclu-sions (Overholser, 1994; Walen, DiGiuseppe, & Dryden, 1992). Clients'maladaptive definitions (e.g., evaluative labels such as "successful") areexamined using inductive reasoning, whereby the therapist prompts theclient to enumerate examples, using them to arrive at criteria for adefinition (Overholser, 1993a). Active participation in Socratic dialogueis thought to enhance learning and promote autonomy, motivating cli-ents to discover answers on their own (Walen, DiGiuseppe, & Dryden,1992; Overholser, 1993a).

Socratic disputation as employed in REBT might be the closest toPlato's classical prototype of any form of Socratic questioning used inpsychotherapy, given its dialectical rigor and direct challenge of irra-tional beliefs. Disputation in REBT should not, however, be concep-tualized as an antagonistic process. Attention to the development ofa strong therapeutic alliance, thorough explanation of the cognitivemodel, and occasional supplying of correct answers (as in Plato) helpmaximize therapeutic gain, and prevent the client from feeling attacked(Walen, DiGiuseppe, & Dryden, 1992). Within a secure therapeuticrelationship, disputation of irrational beliefs communicates a sense ofrespect for the client's commitment to the therapeutic process (Walen,DiGiuseppe, & Dryden, 1992). Theorizing along similar lines, Beckcoined the term collaborative empiricism to describe the ideal cognitivetherapy alliance, in which a spirit of true inquiry and joint effort pre-vails (Beck, Rush, Shaw & Emery, 1979).

Caveats for psychotherapists using the Socratic method are noted inthe literature. Care must be exercised in the choice of leading ques-tions, lest poorly constructed questions bias clients' responses (Over-holser, 1993a). Alternating between Socratic questioning and otherinterventions is suggested to discourage the client's misperception ofthe process as an interrogation (Cormier & Cormier, 1995; Walen, Di-Giuseppe & Dryden, 1992). Clinicians are advised that clients maybecome vexed and resentful if they feel that the therapist is merelytrying to get them to guess at, or admit to, answers which the thera-pist already knows (Overholser 1993a; Walen, DiGiuseppe & Dryden,

117Wandajune Bishop and Jefferson M. Fish

1992). This potential side-effect of the Socratic method was not unknownto its originator, as the reactions of Socrates' respondents reveal: "Pro-tagoras becomes angry, Polus resorts to cheap rhetorical tricks, Calliclesbegins to sulk, Critias loses his self-control, Meno wants to quit" (Sees-kin, 1987, p. 3). Indeed, the historical Socrates' sometimes caustic ironyhas been compared to the counter-transference response of a therapistwho demands that clients translate insight into immediate change(Chessick, 1982)—an irrational stance against which students of REBTare duly cautioned (Walen, DiGiuseppe & Dryden, 1992). For the mod-ern therapist, a client's negative response to disputation signals theneed to retreat from questioning and explore the client's reactions, suchas "awfulizing" about not knowing the answers to questions (Walen,DiGiuseppe & Dryden, 1992; Burns & Auerbach, 1992).

Solution Focused Questions: The "Purposeful"Interview

In the field of family therapy, the development of questioning tech-niques has taken a radically different course from that of cognitivebehavioral therapy. Rather than attempting to restructure individuals'cognitive processes, the family therapist uses questions to probe aswell as redefine the context of whatever problems families present, anemphasis that reflects the influence of Gregory Bateson and the Palo Altogroup of family therapists (Hoffman, 1981). From a Batesonian perspec-tive, complaints are seen as arising from the unique constraints of thefamily system—a complex and ever-changing melange of interactingelements—rather than being "caused" by a single factor (e.g., cognitions)in a straightforward, linear fashion (Keeney, 1983). Because the parame-ters of the family system are so densely interconnected, even a smallchange in their configuration can escalate to potentially great changes(Walter & Peller, 1992).

Solution focused therapy, as developed by de Shazer and his associ-ates at the Brief Family Therapy Center in Milwaukee (de Shazer etal., 1986; de Shazer, 1988; de Shazer, 1991; Walter & Peller, 1992), isarguably the most distinctive in its use of questions of any therapeuticapproach to have descended from the family therapy tradition. LikeHaley's problem-solving therapy (Haley, 1976), solution focused ther-apy may involve individuals, couples, or any subset of family members,making a direct comparison of its techniques with those of traditionalpsychotherapy feasible. The task of solution focused therapy is to bringabout a solution, or resolution to the client's presenting complaint, as


efficiently as possible, capitalizing on the sensitive interconnections ofthe system (whether a family, or an individual in some other context)in order to amplify and sustain changes (de Shazer et al., 1986). Solu-tion focused therapists sometimes refer to their questioning techniqueas "purposeful" interviewing, to emphasize its economy (Lipchik & deShazer, 1986).

In the therapeutic conversation, the solution focused therapist andclient jointly create a perceptual and/or behavioral alternative to theproblem, looking for "exceptions" to how and when the problem occurs.If there are exceptions to the problem, behavioral tasks are designedto elicit them, and therapy terminates when the client can confidentlycontinue alternative behaviors autonomously. If no exceptions arefound that are meaningful to the client, he or she may be asked toimagine what would be different about the future without the problem,whence therapy proceeds to defining goals. At times, the only neededsolution may be to construct a new semantic context for the problem,so that the client no longer views it as problematic (de Shazer et al.1986). Regardless of which approach is used, the focus of the sessionremains on positive aspects of the client's life, with little or no explora-tion of events leading up to present difficulties, the client's history, orother types of information usually seen as essential for diagnosis orcase formulation.

Both the theory and the ethos of solution focused therapy are vividlyexemplified by the characteristic questions asked by the therapist, andby the manner in which questions are introduced. The "miracle ques-tion" provides a framework for clients to describe possible solutions inconcrete terms: "Suppose that one night, while you were asleep, therewas a miracle and this problem was solved. How would you know?What would be different?" (de Shazer, 1988, p. 5). Consistent with thedisavowal of any notion of etiology (Fish, 1995), the miracle question istypically employed in the first session, sometimes in the very first fewexchanges (de Shazer, 1988; 1991).

Non-Interventiue Questions: The Diagnostic Interview

During the same era which witnessed a paradigm shift in the wayquestions are used in therapy, the field of psychodiagnostics has ex-panded greatly, becoming more closely allied with the medical modelof psychiatry in its effort to define and diagnose psychiatric disorders.Numerous interview schedules have been devised, using a decisiontree to guide questioning toward information that will confirm a diag-


nosis (e.g., the Anxiety Disorders Interview Schedule—Revised (ADIS-R), Di Nardo et al., 1985). In the clinical venue, diagnostic interviewsare used for treatment planning and training purposes in settingsranging from college counseling centers to inpatient psychiatric units.Texts and handbooks on the diagnostic interview abound (e.g., Mor-rison, 1995).

At first blush, the questions of the diagnostic interviewer appearunfettered by underlying philosophical or theoretical assumptions, un-like those of the REBT or solution focused therapist. The descriptiveapproach to the classification of mental disorders of The Diagnosticand Statistical Manual-TV (DSM) was expressly designed to facilitateadoption of its diagnostic system by clinicians of widely varying theo-retical orientations (American Psychiatric Association, 1994). So welldoes the DSM meet this objective, that the average clinician may onlyrarely take notice of the medicalized assumptions of the psychodiag-nostic model—distinctions between pathology and health, assessmentand treatment, underlying disease process and observable symptoms—to name but a few.

The most pertinent theoretical assumption of diagnostic interview-ing for our discussion is the distinction between assessment and treat-ment, which is closely tied to the idea of non-interventive or "informa-tion gathering" questions. Presumed to have little or no therapeuticeffect, information gathering questions are used in diverse types oftherapy, including REBT (Walen, DiGiuseppe & Dryden, 1992) and so-lution focused therapy (Lipchik & de Shazer, 1986). In a diagnosticinterview, information gathering questions are likely to be the major-ity, if not the only, kind of questions asked. Though a typical interviewmay not adhere to the decision tree format, if the patient's answer toone question suggests a particular diagnosis, follow-up questions en-sue, e.g., requesting information which has not been spontaneouslydisclosed pertinent to remaining diagnostic criteria. Most practition-ers, viewing the diagnostic interview as an information-gathering pro-cess, would be apt to attribute the interviewee's sense of benefit tononspecific factors, such as therapist warmth or demand characteris-tics of the setting.

Theorists have objected to according clinical priority to assessment,citing the need of clients to obtain a sense of benefit from early therapeu-tic contacts (DiGiuseppe, 1991; Sue & Zane, 1987). Cognitive therapistshave increasingly come to view assessment as an ongoing process thatdevelops in tandem with therapy (DiGiuseppe, 1991; Persons, 1989),while brief therapists collapse the assessment/treatment distinction,


treating each session as potentially the first, last, and only therapeuticencounter (Walter & Peller, 1992; Talmon, 1990). Solution focused thera-pists take the extreme radical position, advocating that the client besteered away from "problem talk" as quickly as possible in the firsttherapeutic contact (I.K. Berg, personal communication, May 30, 1994).Such lack of agreement among seasoned practitioners and theoristsdemonstrates the need for inquiry into how information-gathering isexperienced by clients.

A Theory-Based Comparison of Questioning Styles

Empirical comparison of Socratic, solution focused, and diagnosticquestioning styles is suggested by incisive contrasts between their as-sociated theoretical assumptions.

Psychopathology. The idea of psychopathology, drawn from the medicalmodel, is intrinsic to diagnostic interviewing, which seeks to elucidateand classify presenting complaints. In distinct contrast to this modelREBT defines pathology on a philosophical basis, as beliefs and behav-iors which obstruct rational self-interest. In a more radical departurefrom the stance of traditional psychotherapies, solution focused thera-pists regard "pathology," "etiology" and even "problems" as arbitrarydesignations, equivalent to Wittgenstein's notion of a "language game,"i.e., "a self-contained linguistic system that creates meanings throughnegotiation between therapist and client" (de Shazer, 1991, p. 68). Prob-lem-oriented language games (e.g., discussion of the client's diagnosis)are considered useless or even counterproductive for therapy, since theyconfuse the client as a person with the client's problem (or diagnosticlabel) (Walter & Peller, 1992).

Therapeutic Change. While a unifying theory of therapeutic change isintentionally absent from the taxonomy of the DSM (American Psychi-atric Association, 1994), names and conceptualizations of disorders re-flect a sense of how amenable they are to change, ranging from chronicconditions ("Major Depressive Disorder, Recurrent with MelancholicFeatures") to transient reactions ("Adjustment Disorder with DepressedMood"). In contrast, both treatment models under consideration herepromote well-elaborated and distinct theories of how change occurs.REBT theory describes therapy as didactic and skills-building, viewingchange as an incremental process requiring the "insistent and persis-tent" disputation of irrational beliefs (Ellis, 1971). In solution focused


theory, therapy is a non-didactic endeavor that encourages the client tomake optimal use of existing "solutions." Change is viewed as inevitable,naturally occurring, and not of necessity difficult. These ideas are re-flected in the activities of the solution focused therapist—looking forevidence of pre-therapy change, maintaining focused attention on be-tween session changes, "cheerleading" reports of change—all of whichamplify the feasibility of changing and minimize opportunities for "resis-tance" (Walter & Peller, 1992).

Nature of Questions. Finally, differences between the three question-ing styles are highlighted by their assumptions regarding the nature,purpose and effects of questions. In both REBT and solution focusedtherapy, questions are viewed primarily as therapeutic interventions.Socratic questioning in REBT challenges the client's irrational think-ing, pointing out the implications of faulty logic (Ellis, 1971). Solutionfocused questions seek to activate clients' problem-solving capacities,enlisting their creativity toward the construction of a solution (Walter& Peller, 1992). The diagnostic question, geared toward assessment, ispresented as a straightforward request for information.

The Videotaped Psychotherapy Analogue

The videotaped psychotherapy analogue provides a discerning in-strument for exploring perceptions of psychotherapy process, affordinga much higher degree of control over the independent variable thanwould be possible in a clinical context (Jannes & Fish, 1993). Use ofthe same actors portraying the same characters across conditions con-trols for non-specific factors (e.g. therapist appearance and body lan-guage) known to contribute to therapeutic efficacy (Critelli & Neu-mann, 1984).

Video analogue methodology has been used to draw broad compari-sons between therapy orientations (Cashen, 1979; Hensley, Cashen &Lewis, 1985; Stuehm, Cashen & Johnson, 1977), and with a narrowerfocus, to study theoretically distinct interventions (Jannes & Fish,1993). In the present study, videotapes represented excerpts of ther-apy sessions in which not one question, but a line and style of ques-tioning is developed and pursued to its logical conclusion. This level ofabstraction of the independent variable was selected in the belief thatit would best enhance verisimilitude. Ethnographic interview data ob-tained with families in therapy supports the notion that the therapist's


asking of questions is a memorable aspect of clients' psychotherapyexperience (Newfield, Kuehl, Joanning & Quinn, 1990).

The Big Five personality factors (Neuroticism, Extraversion, Open-ness, Agreeableness, and Conscientiousness) are empirically derived,highly robust, and applicable to both normal and clinical populations(Costa & McCrae, 1992), qualities which lend themselves well to explo-ration of a new area of inquiry (questioning style in therapy). Usingthe five factor model as an interpretive framework, the mixed findingsof previous analogue research appear more coherent. The consistentfinding of a preference for behavior therapy by undergraduate subjects(Cashen, 1979; Stuehm, Cashen & Johnson, 1977; Holen & Kinsey,1975; Hensley, Cashen & Lewis, 1985) may reflect this population'sstanding on Openness. In two such studies, debriefed subjects men-tioned that the behavior therapist "seemed to be getting somethingdone" (Cashen, 1979; Stuehm, Cashen & Johnson, 1977), a pragmatic,conventional view that would be associated with low standing on Open-ness, possibly reflecting the age and education levels of subjects. Mixedfindings regarding gender differences in preference for client centeredversus directive therapy (Tinsley & Harris, 1976; Cashen, 1979) mayreflect the influence of the burgeoning women's movement, attenuatinggender differences on traits associated with Agreeableness (such ascompliance and tender-mindedness) that might influence desire for asense of closeness and sharing in the therapeutic relationship. Finally,the lack of correlation of locus of control with therapeutic preferences(Stuehm, Cashen & Johnson, 1977; Home, Chaney & Dougherty, 1976)may reflect the factorial complexity of this construct, which involvestraits associated with Openness (field independence), Conscientiousness(responsibility) and Agreeableness (compliance).

METHOD

Participants

Participants (unpaid volunteers) were 116 college undergraduatesand 67 clinical or counseling psychology trainees who had completedat least one semester of graduate training. The average age of the non-therapist group was 20, S.D. = 2.98, and the average age of the psy-chology trainee group was 30.7, S.D. = 7.41. There were 57 males and126 females in the sample. In accordance with the American Psychol-ogy Association's guidelines for the ethical treatment of human sub-


jects (American Psychological Association, 1982), informed consentwas obtained from all participants.

Materials

Videotaped Psychotherapy Analogues. Videotaped psychotherapy ana-logues portraying Socratic questions as used in Rational Emotive Be-havior Therapy (REBT), solution focused questions (SFT) and diagnos-tic interview questions (DIQ) were developed based on scripts writtenby the first author and filmed in a professional television studio. Follow-ing the analogue methodology developed by Jannes and Fish (1993),therapist, client, and presenting complaint were held constant for allthree conditions. The presenting complaint, fear of asking a woman for adate, is considered by undergraduates of both sexes to be a common andimportant problem (Jannes & Fish, 1993). Videotape scripts were sub-jected to a rigorous validation procedure including review by experts ineach of the techniques represented, and classification of scripts by expe-rienced clinicians.

Therapeutic Questioning Scale. The Therapeutic Questioning Scale(TQS), is a 13-item scale designed for the study evaluating the extentto which a therapist's questions are perceived as helpful. It containssix positively worded and seven negatively worded items, scored on aseven-point Likert scale. Cronbach's alpha for the TQS is .90.

Preference Ratings. Preference ratings for each condition were elicitedafter all videotapes were presented using the item "If I had a problemsimilar to this client, I would prefer to speak with the therapist in thefirst (second, third) videotape." Participants responded on a 5-pointLikert scale.

The NEO Five-Factor Inventory. The NEO Five-Factor Inventory (NEO-FFI) is a short form of the NEO Personality Inventory (NEO-PI) devel-oped by Costa and McCrae for use in research settings (1992). It consistsof 60 NEO-PI items selected for their high loadings with NEO-PI factors.Coefficient alpha for NEO-FFI scales ranges from .56 to .62. Convergentvalidity for the NEO-FFI has been demonstrated with other measures ofthe five factors (Costa & McCrae, 1992).

Manipulation Checks. Three forced-choice items summarizing uniquecontents of each videotape were used as manipulation checks to deter-mine whether subjects responded randomly to measures.


Wandajune Bishop and Jefferson M. Fish 125

Written Feedback. A form presenting an open-ended request to sub-jects for comments on any aspect of the study was used to collect quali-tative feedback.

Procedure

The experimenter addressed groups of subjects in a classroom set-ting. Subjects viewed the videotaped therapy analogues in one of six(randomly assigned) orders of presentation, completing one copy of theTQS and manipulation checks after viewing each tape. At the end,subjects completed the preference ratings, the NEO-FFI, and providedoptional written feedback.

RESULTS

NEO Five Factor Inventory

Analyses of NEO Five Factor Inventory (NEO-FFI) variables werebased on 182 profiles (one profile was excluded from these analysesdue to several multiply marked or omitted responses; for four otherprofiles containing a missing response on one or more factor scales, theaverage values of other scale items were substituted for the missing

Table 1

Mean NEO-FFI Scale Scores for Psychology Trainees andNon-therapists, and T-tests for Mean Differences

NeuroticismExtraversionOpennessAgreeablenessConscientiousness

PsychologyTrainees<n = 67)

M

21.1828.5534.5233.6332.33

SD

8.605.544.705.937.75

Non-therapistsn = 115)

M

23.1428.7428.6728.9331.05

SD

8.065.665.456.867.23

T-tests for MeanDifferences

MeanDif.

-1.96-0.19

5.854.691.28

t-value

1.54.22

- 7.32***-4.67***-1.12

df

180180180180180

***p < .001

response). Table 1 presents means and standard deviations for eachNEO-FFI factor for psychology trainees and non-therapists. The psy-chology trainee group was significantly higher than the non-therapistgroup in Openness, t = -7.32, p < .001, and Agreeableness, t =- 4.67, p < .001. Using Costa and McCrae's adult norms for the NEO-

FFI (1992), mean scores on Openness of psychology trainees and non-therapists fall at the 95th and 73rd percentiles respectively, whilemean scores on Agreeableness fall at the 57th and 27th percentiles.Pearson product moment correlations were computed between NEO-FFI scale scores and the main measures. A significant correlation wasfound between Openness and TQS ratings for both the SFT condition,r = - .25, p = .001, and the DIQ condition, r = - .26, p < .001. Allother correlations between NEO-FFI variables and the main measureswere low in absolute value (average .05) and none reached significanceat a = .05.

Demographic Variables

Information on the age, years of education and gender was requested ofeach subject. Pearson product moment correlations were calculated be-tween the demographic variables, TQS ratings, and preference ratingsfor non-therapists and psychology trainees. For the psychology traineegroup, a significant correlation was found between male gender andpreference ratings for the SFT condition, r = .28, p = .02. Psychologytrainees also provided information on their therapeutic orientation asfollows: psychodynamic, n = 33, cognitive behavioral, n = 13; ecclectic/integrative, n = 8; other or unspecified, n = 13. Pearson product mo-ment correlations were computed between the therapeutic orientationand the main measures. The only significant correlation obtained wasbetween cognitive behavioral orientation and preference for REBT,r = .38, p < .001.

Therapeutic Questioning Scale (TQS)

Analyses of the main measures were based on 176 protocols (sevenprotocols were excluded from these analyses because they failed ma-nipulation checks). To determine whether gender would influence per-ceptions of questioning style, TQS ratings were analyzed using a threefactor fixed effects analysis of variance with repeated measures on thethird factor. Between subjects factor A was gender, with two levels,male (n = 54) and female (n = 122). Between subjects factor B was


Wandajune Bishop and Jefferson M. Fish

therapist status, with two levels: non-therapist (n = 113) and psychol-ogy trainee (n = 63). Table 2 provides the means and standard devia-tions of TQS ratings for each questioning style by gender. Results ofthe analysis of variance revealed that the main effect for gender wasnot significant, F(1, 172) = .37, p = .54.

TQS ratings were next analyzed using a two factor fixed effects anal-ysis of variance with repeated measures on the second factor. The be-tween subjects factor was therapist status, and had two levels: non-therapist (n = 113) and psychology trainee (n = 63). The means andstandard deviations of TQS ratings for non-therapists and psychologytrainees and the entire sample are given in Table 3.

Results of the analysis of variance revealed a significant main effectfor therapist status, F(l,174) = 31.42, p < .001, with a small value forthe eta squared measure of strength of effect, n2 = .15. There was alsoa significant main effect for questioning style, F(2,348) = 54.81,p < .001, with a modest value for the eta squared measure of strengthof effect, T|2 = .24. The two-way interaction between therapist statusand questioning style was not significant at the desired level, F(2,348)= 2.97, p = .05. Analyses of variance for the contribution of simple

main effects to the significant main effects revealed significant con-trasts between TQS ratings of the non-therapist and psychologytrainee groups for the REBT questioning style, F(l,174) = 10.62,p < .001, the SFT questioning style, F(l,174) = 6.13, p < .05, and theDIQ questioning style, F(l,174) = 28.98, p < .001. There were alsosignificant contrasts between TQS ratings for the different questioning

127

Table 2

Mean TQS Ratings for Three Clinical Questioning Stylesby Gender

Questioning Style

RETSFTDIQ

Females(n = 122)

M

63.1672.0160.53

SD

14.0710.5113.16

Males(n = 54)

M

62.5772.2460.94

SD

14.939.92

11.56

EntireSample

(N = 176)

M

62.9872.0860.66

SD

14.3010.3012.66

Journal of Rational-Emotive & Cognitive-Behavior Therapy

styles within both the non-therapist group, .F(2,348) = 23.21, p < .001,and within the psychology trainee group, F(2, 348) = 32.05, p <.001.Post hoc analyses of pairwise differences between means were con-ducted to follow up the significant simple main effects. For post hoccomparisons involving therapist status, the Tukey statistic for thesignificant difference between means is HSD(120) = 4.95, r = 6,a = .01. Using this value, non-therapists gave significantly higherTQS ratings than did psychology trainees to both the REBT condition(Mean Dif. = 7.14), and the DIQ condition (Mean Dif. = 9.95). Sincethe non-therapist and psychology trainee groups were not equal, theTukey-Kramer modification of the Tukey HSD test was selected forpost hoc comparisons involving questioning style. The modified Tukeystatistic for this group of means is HSD(120) = 5.75, r = 6, a = .01.Using this value, non-therapists gave significantly higher TQS ratingsto SFT than REBT (Mean Dif. = 7.96), as did psychology trainees(Mean Dif. = 11.15). Non-therapists also gave significantly higherTQS ratings to SFT than to DIQ (Mean Dif. = 9.27), as again did psy-chology trainees (Mean Dif. = 15.27).

Preference Ratings

To determine whether gender would influence preferences for ques-tioning styles, preference ratings were analyzed using a three factorfixed effects analysis of variance with repeated measures on the thirdfactor. Between subjects factor A was gender, with two levels, male

128

Table 3

Mean TQS Ratings of Non-therapists, PsychologyTrainees, and Entire Sample

Questioning Style

RETSFTDIQ

Non-therapists(n = 113)

M

65.5373.5964.22

SD

13.829.05

10.82

PsychologyTrainees(n = 63)

M

58.3969.5454.27

SD

14.0911.8913.27

EntireSample

(N = 176)

M

62.9872.0860.66

SD

14.3010.3112.66


(n = 54) and female (n = 122). Between subjects factor B was thera-pist status, with two levels: non-therapist (n = 113) and psychologytrainee (n = 63). Table 4 provides the means and standard deviationsof preference ratings for each questioning style by gender.

The results of the analysis revealed a significant main effect for gen-der, F( 1,172) = 5.37, p < .05, with a small value for strength of effect,n2 = .02. There was also a significant main effect for questioningstyle, F(2,344) = 9.99, p < .001, with a small value for strength of ef-fect, n = .06. There were no significant two- nor three-way interac-tions. Analyses of variance for the contribution of simple main effectsto the significant main effects revealed a significant contrast betweenmales and females for preference ratings of the SFT condition, F(1,174) = 5.04 . p < .05. There were also significant contrasts betweenquestioning styles for males, F(2, 348) = 5.15, p < .01, and females,F(2, 348) = 4.24, p < .05. Post hoc analyses were conducted to followup the significant simple main effects. For comparisons involving ther-apist status, the Tukey statistic for the significant difference betweenmeans is HSD(120) = .33, r = 6, a = .01. Using this value, there wassignificant difference between males' and females' preference ratingsfor SFT condition, with males providing the higher ratings (MeanDif. = .4). For comparisons involving questioning style, the Tukey-Kramer statistic for the significant difference between means isHSD(120) = .74, r = 6, a = .01. Using this value, males gave signifi-cantly higher preference ratings to the SFT condition compared to theDIQ condition (Mean Dif. = .76).

Preference ratings were next analyzed using a two factor fixed ef-

129

Table 4

Mean Preference Ratings for Three Clinical QuestioningStyles by Gender

Questioning Style

RETSFTDIQ

Females

M

2.953.302.82

SD

1.351.121.29

Males

M

3.043.702.94

SD

1.331.021.02

EntireSample

M

2.983.432.86

SD

1.341.101.21

fects analysis of variance with repeated measures on the second factor.The between subject factor was therapist status, and had two levels:non-therapist (n = 113) and psychology trainee (n = 63). Means andstandard deviation of preference ratings for non-therapists and psy-chology trainees are given in table 5.

Examination of the results of the analysis of variance revealeda significant main effect for questioning style, F(2,348) = 9.48,p < .001, with a small value for the eta squared measure of strengtheffect, n2 = .05. Neither the main effect for therapist status nor theinteraction between questioning style and therapist status were signif-icant. Analysis of the variance was computed to explore the contribu-tion of simple main effects to the significant main effect, and revealedthat there was a significant effect for questioning style within both thenon-therapist group, F(2,348) = 4.02, p < .05, and within the psychol-ogy trainee group, F(2,348) = 6.33, p < .01. Post hoc analyses of thepairwise differences between means were conducted follow up thesesignificant simple main effects. The Tukey-Kramer statistic for the sig-nificant difference between means for the questioning style factor isHSD(120) = .71, r = 6, a = .01. Using this value, the only significantcontrast was the higher preference ratings for SFT than RET (MeanDif. = .78) given by the psychology trainee group.

Optional Written Feedback

One hundred subjects responded to the request for written feedback.Two clinical psychologists sorted comments into seven categories: 1)comments relating to the experimental design (e.g., concerning the ad-equacy of the design); 2) negative comments about the therapist's non-specific behaviors in any/all questioning styles (e.g., eye contact andbody posture); 3) comments expressing a sense of interest or benefitfrom participation in the study; 4) comments about the REBT ques-tioning style; 5) comments about the SFT questioning style; 6) com-ments about the DIQ questioning style; and (7) comments about psy-chotherapy that could not be subsumed under the above categories.

Comments regarding the experimental design were offered by 46subjects, and included both praise and criticism for the verisimilitudeof the psychotherapy analogue and expressions of curiosity about theexperimenter's intentions. The proportion of psychology trainees (n= 30) offering comments in this category was significantly greaterthan the proportion of non-therapists (n = 16), x2 = 4.26, p < .05.Comments expressing a sense of benefit from participation in the


study were offered by 21 subjects. The proportion of non-therapistsoffering comments in this category (n = 17) was significantly greaterthan the proportion of psychology trainees (n = 4), x2 = 8.05, p < .01.

Negative comments about the therapist's non-specific behaviors(such insufficient eye contact) were offered by 46 subjects. The fre-quency of this theme in subjects' written feedback (the basis for creat-ing this category) is best explained by the effort of the actress in thevideos to vary the visual portrayal of her character by glancing awayfrom the client, often looking directly at the camera. The proportion ofpsychology trainees (n = 22) offering comments in this category wassignificantly greater than the proportion of non-therapists (n = 4),X2 = 12.46, p< .001.

Comments on any of the three questioning styles or on psychother-apy in general were offered by 45 subjects, most of whom commentedon more than one of the questioning styles. REBT was mentioned 30times in subjects' comments, SFT 21 times, and DIQ 26 times. Foreach of these categories, chi square for the proportion of non-thera-pists vs. psychology trainees was not significant. General commentsabout psychotherapy were offered by 8 subjects (3 non-therapists, 5psychology trainees); since expected/observed frequencies were too low,chi square could not be computed.

DISCUSSION

NEO Five-Factor Inventory

The negative associations found between Openness to Experienceand subjects' ratings on the Therapeutic Questioning Scale for the so-lution focused questioning style (SFT) and the diagnostic questioningstyle (DIQ) were the only significant relationships obtained betweenthe Big Five variables and the main measures. These findings at firstappeared counterintuitive, since use of fantasy and imagination arecentral aspects of Openness (Costa & McCrae, 1992) and of solution-focused technique (Walter & Peller, 1992). Similar to other analoguestudies in which undergraduates preferred behavior therapy as morepragmatic (e.g., Stuehm, Cashen & Johnson, 1977), findings here sug-gest that individuals whose standing on Openness is relatively low(i.e., who have a more conventional outlook) may value interventionsgrounded in practicality and common sense, such as finding solutions toproblems (SFT), or finding out about problems in order to solve them


(DIQ). This interpretation is strengthened by written comments subjectsmade about the solution focused therapy analogue, e.g., "The first session[SFT] worked best for the client because she was able to guide himtowards a practical solution."

An area of inquiry addressed by the present study which has notpreviously appeared in the literature concerned differences betweentherapists' and non-therapists' Big Five personality profiles. In thepresent sample, the psychology trainee group was found to be higher inOpenness and higher in Agreeableness than the non-therapist group.Given that Openness has been found to be correlated with both educationand measured intelligence (Costa & McCrae, 1992), the Openness find-ing likely reflects the psychology trainees' greater interest in and apti-tude for intellectual pursuits compared to non-therapist undergradu-ates, and possibly greater Openness to Feeling, a facet of Openness(Costa & McCrae, 1992) one might expect to find elevated among psycho-therapists. In the case of Agreeableness, while there was a significantdifference between the two groups, the psychology trainees scored onlyslightly above average compared to adult norms (57th percentile), whilethe non-therapist group scored below average (27th percentile), perhapsreflecting an unanticipated source of bias such as regional differences infive factor personality profiles.

Therapeutic Questioning Scale

Ratings on the Therapeutic Questioning Scale (TQS) were clearlyaffected by questioning style, with solution focused questioning (SFT)rated higher than diagnostic interviewing (DIQ) and higher than So-cratic questioning in Rational Emotive Behavior Therapy (REBT) byboth groups. A recurring theme in subjects' comments about the ques-tioning styles was how well (or poorly) the therapist in each conditionfacilitated the client's participation in therapy and active/independentlearning, mentioned four times with reference to REBT, five timeswith reference to SFT, and once with reference to DIQ. This aspect ofpsychotherapeutic process is reflected in TQS Item #1 ("The client andtherapist are figuring things out together") and theoretically tied tothe idea of collaborative empiricism in cognitive therapy (Beck et al.,1979). Collaborative empiricism refers to the spirit of true inquiry andjoint effort by therapist and client, thought to be intrinsic to the cogni-tive behavioral approach and the basis for a productive working alli-ance (Beck & Emery, 1985). The higher TQS ratings subjects gave tothe solution focused questioning style in part may reflect that, of the


therapy analogues used in this study, the solution focused analogueoffered the most convincing portrayal of a collaborative relationshipbetween therapist and client. Though the solution focused therapistwas not shown pursuing a joint inquiry in the philosophical sense, sheand the client were depicted "figuring out" the solution to a problemtogether in a cooperative and mutual process. By contrast, the REBTanalogue took pains to portray the deconstructive aspect of the So-cratic method, in which the therapist's assertive, challenging question-ing style alternates with didactic interventions that frankly displayher expert knowledge.

While overall ratings on the TQS were most strongly affected bydifferences between questioning styles, therapist status also had aneffect on ratings. Non-therapists provided higher overall TQS ratingsthan psychology trainees for the REBT questioning style, perhaps re-flecting their predominantly psychodynamic orientation. Non-thera-pists also provided higher TQS ratings than psychology trainees forthe diagnostic questioning style (DIQ), an unexpected finding in lightof contentions that diagnostic questioning is alienating to clients andpossibly a major cause of premature termination (DiGiuseppe 1991;Sue & Zane, 1987). This finding is suggestive that at least in the con-text of a psychotherapy analogue, the expectation of benefit from con-tact with a therapist outweighs the imagined discomfort of being theobject of diagnostic inquiry. Alternatively, the lower ratings for the di-agnostic interview condition provided by psychology trainees may re-flect that they accurately perceived this condition as an assessment,e.g. "I suppose I am not clear as to the purpose of comparing the thirdvideo [DIQ], because it was not really a therapy session. . . . Compar-ing an intervention strategy with a structured assessment of the pa-rameters of the difficulties seems like mixing 'apples and oranges.'"

Preference Ratings

Preference ratings were affected by gender, though the observed ef-fect size was small. Male subjects gave higher preference ratings tothe SFT therapist compared to the DIQ therapist, also giving signifi-cantly higher ratings to the SFT therapist than did women. This patternof findings may reflect that the presenting problem (asking a woman out)was more salient for males, enhancing the pragmatic value of a solutionfocused approach. The small correlation between preference for REBTand male gender might be similarly explained. Alternatively, the find-ings regarding gender and preference for the solution focused therapist


suggest that a solution focused approach, which is apparently non-direc-tive and more receptive to client input, may be more consonant with amale client's expectation that he will have a dominant role in the thera-peutic discourse, as in any other conversational interaction with a female(Tannen, 1993).

Preference ratings like TQS ratings were affected by questioningstyle, with the solution focused therapist again being most preferred,though the effect size was small. Preference ratings were not affectedby either therapist status (therapist/non-therapist) nor by the combi-nation of therapist status and questioning style. Post hoc analyses re-vealed that psychology trainees preferred the solution focused thera-pist over the REBT therapist, following the pattern of TQS findings.However, average preference ratings given by both groups for the ther-apist in any of the three questioning styles deviated only slightly fromthe value for "not sure," suggesting that preferences were basedon more subjective aspects of the therapy analogue than questioningstyle.

Written Feedback

A substantial proportion of the sample (55%) responded to the re-quest for written feedback on any aspect of the study. As would beexpected, a greater proportion of psychology trainees than non-thera-pists commented on the experimental design and on the non-specificbehaviors (e.g. mannerisms, body language) of the analogue therapist,concerns to which their graduate level training in psychology wouldhave sensitized them. A greater proportion of non-therapists expresseda sense of benefit from participating in the study, perhaps reflectingthat experimental stimuli were more novel to them and therefore moreinteresting. These findings merely provide validation of the distinctive-ness of the subject groups.

Overall, comments on the three questioning styles supported themain findings of the study, as well as reflecting theoretical assump-tions on which the questioning styles were based. The most frequentreason subjects gave for liking the solution focused condition was thatit enhanced the client's autonomy and participation in therapy, e.g.,"The client was given a lot of time to speak and think for himself,""The therapist let the client try to figure out the problem on his own,""The client gained confidence and insight on his own." These percep-tions reflect the strongly-held position of solution focused therapiststhat clients have what they need to solve problems, while the therapist


takes the client's lead in determining what changes are desired andhow change should come about (de Shazer et al. 1986; Walter & Peller,1992). Other comments on the solution focused condition alluded tothe advantage of maintaining a positive focus, another core solutionfocused concept (Walter & Peller, 1992), e.g., "[SFT] helped him imag-ine what it would be like to have [his] problem solved and that wouldhelp him solve it."

Two subjects offered negative comments about the SFT conditionthat reflected criticisms of the solution focused model found in the lit-erature. E.g., one non-therapist subject wrote "I strongly disliked thefirst [SFT] and second [DIQ] sessions because they didn't deal with theroot of the patient's problem!"—demonstrating awareness of the solu-tion focused therapist's lack of emphasis on or interest in the etiologyof problems (Fish, 1995; Fish, 1996). Another non-therapist found theinterventions of both the solution focused therapist and the diagnosticinterviewer "not as professional, helpful, or successful" as those of theREBT therapist. These comments recall criticisms that solution fo-cused therapists may be guilty of ignoring clients' conceptualizationsof problems when they deviate too far from solution focused assump-tions (Efron & Veenendaal, 1993; Friedman 1993; Nylund & Corsiglia,1994). Subjects' comments here suggest that the non-expert stance ofthe solution focused therapist and the lack of obvious theory-based in-terventions may not appear credible nor effective to clients who seektherapy primarily expecting expert professional intervention ratherthan support.

A number of non-therapist subjects commented that the REBT con-dition was the most effective type of therapy portrayed, perhaps con-struing the didactic component of REBT as advice giving. E.g., "I par-ticularly liked the second [REBT] therapy session as the therapist tookon a more instructive directive mode of communication," "[REBT] wasthe best advice and help that was given to the patient. male [sic]."Obtaining a concrete sense of benefit from the initial therapy contacthas been theorized to be crucial in preventing premature termination(Sue & Zane, 1987). These comments suggest that for some clients,providing a sense of immediate benefit may indeed be one of the ad-vantages of beginning with an active, directive approach.

An opposing theme in subjects' comments about the REBT conditioncentered around objections to the manner of the REBT therapist: "Thefirst part of the therapy seemed more harsh, but yet, also made himrealize that he may have over exaggerated his feelings," "Although thetechniques were accurately represented, I thought the therapist moved


too quickly—asked too many questions without letting the patient talk. . . my ratings would have been more positive if the therapist had notbeen as 'pushy.'" Such comments readily bring to mind the many in-junctions to students of cognitive therapy not to slight the therapeuticrelationship out of eagerness to implement technique (e.g., Beck &Emery, 1985; Walen, DiGiuseppe, & Dryden, 1992).

Limitations of the Present Study

The influence of non-specific therapist characteristics presents aproblematic confound for the present comparison of therapeutic ques-tioning styles. While every effort was taken to ensure that the char-acterization of therapist and client remained consistent across thevideos, one can only hazard a guess as to the possible interactionsbetween therapist non-specifics and perceptions of questioning style. Itmay be that distant or objectionable non-verbal behavior on the thera-pist's part would have enhanced the unsettling effects of Socratic ques-tioning, thus exerting a differential impact on perceptions of the threeconditions.

It might be argued that the favorable ratings enjoyed by the solutionfocused analog in the present study partly reflect its status as a rela-tive newcomer among schools of psychotherapy. Previous analoguestudies have often found that newer therapies were most appealing tosubjects (e.g., Stuehm, Cashen & Johnson, 1977), which may reflectboth the effects of experimenter bias as well as enhanced expectanciesgenerated by "new and improved" treatments. Given the nature of thepresenting problem employed here (dating anxiety), whether similarresults would be observed with more clinical problems and populationsremains open to question. Likewise, while every effort was made toenhance the validity of the psychotherapy analogue, the relationshipbetween subjects' responses to analogue stimuli and their responses toactual therapy is an area that would benefit from further investigationso that more definite conclusions regarding generalizability might bedrawn.

Directions for Future Research

The differences observed in this study between therapists' and non-therapists' standing on the personality factors of Agreeableness andOpenness to Experience encourage a more ambitious investigation oftherapists' Big Five personality profiles. Miller (1990) has written poi-


gnantly of the developmental conditions which may provoke the thera-pist's intellectual giftedness and sensitivity to others' needs—qualitiesthat may be related to the constructs of Openness and Agreeableness.A cluster analysis of therapists' five factor personality profiles, andcorrelations of factors with more traditional and qualitative measureswould further understanding in this area, as well as explore conver-gences between the Five Factor Model and more dynamic conceptual-izations of personality, as Block (1995) has urged.

The present study represents one of the few empirical treatments ofsolution focused therapy, reflecting the recent development of this ther-apeutic approach, as well as its origins in the contemporary philosophy oflanguage, an area which lies outside the traditional domain of empiri-cally-based psychology. While present findings suggest that therapists'and non-therapists' perceptions of solution focused interventions re-flect their underlying theoretical assumptions, whether solution fo-cused strategies lead to any significant advantage in therapy outcomeremains to be demonstrated.

Among the most intriguing theoretical areas pertinent to the pres-ent study are the constructs of collaborative empiricism as understoodin cognitive therapy and the solution focused idea of cooperation. Ithas been argued in the cognitive therapy literature that an inherenttension exists between the ideal of collaborative empiricism and therole of the therapist as an expert, particularly as an expert questioner(Young, Beck & Weinberger, 1993). Recommendations have been is-sued for de-emphasizing the therapist's expert status, especially withpopulations such as substance abusers and mandated clients, who mayfear and react defensively toward experts (Beck, Wright, Newman &Liese, 1993). Similarly, Overholser (1995) has argued that disavowal ofknowledge, known as Socratic ignorance in the philosophy tradition, is acritical element of the use of the Socratic method in psychotherapy.Disavowal of knowledge is manifested in the therapist's tendency to viewmost information (including theories of psychotherapy) as tentative be-liefs, hypothetical constructs, or personal opinions, rather than objectivefacts. Such a stance constrains the therapist from an overly protectiverole, modeling an emotionally neutral approach to problems and thwart-ing the oppositional client's reactive defiance (Overholser, 1995). In con-trast to REBT and most traditional approaches to therapy, the solutionfocused model eschews the notion of resistance as counterproductive tochange. Instead, all client behavior is reframed as essentially coopera-tive and communicative in the therapeutic context—if the client appearsto balk at interventions, it is because the therapist has failed to compre-


hend the client's expert view of his or her problems and goals (Walter &Peller, 1992). While this stance may appear misguided or contrived totraditionalists, the findings of the present study might cause one toreconsider whether collaboration can be fully optimized when the client'sresistance and need for instruction are presumed.

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