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by Martha Stark, MD / Faculty, Harvard Medical School



Decades ago, I was taught the medical model of asking questions to ferret out the truth – the medical model of plying the patient with questions that would be important for the patient to think about and answer – so that, ultimately, she would have more insight into the inner workings of her mind and the impact of her toxic past on her present.


I would therefore ask the patient somewhat heady questions like – “This sense you have of being judged by your friend – is that perhaps a familiar feeling from way back?” – instead of empathic statements like – “…so painful – this feeling of being always judged” (and then letting the patient associate perhaps to early-on experiences of having been judged).


Heady questions like – “How did you feel when your father kept calling you a loser?” – instead of “…devastating and absolutely enraging when your father kept calling you a loser.”


Unfortunately, somewhat heady questions run the risk of eliciting somewhat heady answers – more heady than heartfelt / more cognitive than experiential.


For the most part, therefore, I do not simply ask questions or suggest, rather lamely, that the patient say more. 


… because, over the course of the years, I have come to appreciate – counter to what I had been taught – that the work we do – whether crisis intervention, short-term intensive, or long-term in-depth – will generally be more effective and more authentic when, moment by moment, we shift the focus from ourselves and the probing questions that we might have to the patient – to what she’s experiencing and what she would seem to be wanting us to know.


For the most part, therefore, I let the patient lead – and I follow.


I take my cues from the patient – listening always with compassion and never judgment – with both my head and my heart – to everything the patient is telling me – no matter how seemingly irrelevant it might be – whether details about the television programs she most enjoys or the anxiety she has about an upcoming exam or the specific ingredients she adds to her favorite recipe or obsessive ruminations about a love interest of hers.


Based upon what the patient is sharing with me, I will offer empathic statements that highlight “what she is actually feeling” and “about what” – statements that often end with an implied dot-dot-dot – whereby I am signaling that I am very open to having my rendering of things edited, corrected, or revised in order to make it a more accurate reflection of what the patient is actually saying.


Examples of empathic statements: “so hard to know where to begin when everything feels so overwhelming,” “so uncomfortable to be here when you’re not sure the therapy is really helping anyway,” “so upsetting to be feeling so out of control.”


Interestingly, the empathic statements that I offer to “highlight affect and associated theme” often (although they need not) start with the word “so” – “so tired of thinking about whether you should stay with her or go,” “so much despair about ever being able to find a true soulmate,” “so afraid that you will disappoint people,” “so concerned that you yourself will be disappointed,” “so worried about what I might be thinking.”


In offering the patient empathic statements, I am of course giving her something – rather than asking of her that she give me something (namely, answers to my questions).

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