MIDLAND, GA — There is a sentence I said out loud on a podcast last week that I have not been able to put down since. My co-host and I were arguing about cancer staging — about what happens when a person tells you they are ill and the next thing out of your mouth is a request for a number. Jeff Conklin made the practical case, which is a good one: when somebody says they are sick, you want to know how bad it is, and a stage answers that faster than any amount of talking will.
I conceded the point and then said the thing I keep chewing on:
It's also a way of avoiding the actual talking about what's going on with the person. It avoids having to open that discussion, which I'm not sure a lot of people really want to get into. Sounds supportive, but no — maybe not.
I want to make an argument here that goes further than I went on the air, because I think it lands on our profession rather than on worried relatives.
The question that requests a number sounds like engagement and functions like an exit. And we have built most of a clinical intake out of it.
The chart on the wall was designed for children
The best moment in that episode was not mine. Jeff brought up the pain scale — the little laminated row of faces taped up in every examination room in America.
You always go, well, right this second, it's not hurting at all. But what does this mean? Is it eight? I'm passed out on the floor? Seven? I'm crying and throwing up? I'm right between those two smiley faces.
I answered without noticing I was making his argument for him. I used those charts. I used them in play therapy, with children who did not yet have the vocabulary for an internal state and needed something to point at. That is what the instrument is for. That is who it was built for.
It has since migrated up the age range and into adult medicine and adult behavioral health, and it is now asked to carry meaning it was never designed to hold. We hand a grown adult a picture of a face and ask them to identify with it, and then we chart the number they pick as though it described their week.
I am not arguing against measurement. I have spent my career in a field that fought hard for measurable outcomes and I do not want to give that back. I am arguing about sequence. A scale administered after a conversation is data. A scale administered instead of a conversation is an exit that we have made reimbursable.
What a real opener costs
The alternative in that episode came from Jeff and it took six seconds:
Say, so how's it going? Try to open the door for them. And if they want to go, fine. And if they don't want to go, fine.
Four words and a posture. It signals availability. It carries no obligation. It contains nothing the other person has to manage on your behalf. And — this is the part that makes it clinical rather than merely polite — it leaves the next move with them.
I said on the record that I would much rather let the person decide for themselves, and I meant it as praise for Jeff's approach. Reviewing the transcript, I think it is closer to an indictment of my own field's habits.
Consider what we actually do in the first fifteen minutes with a new client. A packet. A screener. A symptom inventory. A severity scale. A checklist of risk items delivered in the flat voice we all learn to use so as not to alarm anybody. Every one of those instruments is defensible in isolation, and I have defended them, and I have taught graduate students to administer them properly.
But look at what the sequence teaches. It teaches, in the first quarter hour of a relationship, that in this room the clinician sets the agenda, the categories are already chosen, and the client's job is to locate themselves inside a structure somebody else built. Then we spend the following six sessions trying to establish an alliance and wondering why the client is guarded.
We opened by taking the controls. We should not be surprised when they are slow to hand anything else over.
The honest part
Jeff said something in that conversation that I think every supervisor should have printed and taped inside a cabinet door. He was describing why you do not push, and then he interrupted himself:
You're not the curious one trying to get an answer to something. And by the way, you might really want to know.
You might really want to know. There it is.
Our curiosity is not a defect. It is most of why we entered this work. But curiosity dressed as concern is the single most common way a well-meaning clinician takes a session back from the person it belongs to, and it is nearly invisible from the inside because it feels like caring. It has all the phenomenology of caring. It is caring — pointed the wrong direction.
The test I have started using on myself is crude and it works. Could this question be honestly answered in one word, and would I be all right with that? If the answer is no — if "fine" would leave me unsatisfied and reaching for a follow-up — then I did not open a door. I asked for something.
What I am actually calling for
Not the abolition of instruments. Three smaller things.
One: audit your openers. Take the first five minutes of your intake, written out, and mark every item that requests something. Most of us will be startled by the ratio. Then ask which of those items has to come first, and whether "first" is a clinical judgment or an administrative one. Usually it is administrative, and usually it can move.
Two: teach the sequence, not just the tool. We train supervisees thoroughly in the administration of measures and almost not at all in the question of when a measure closes something. That is a curriculum gap, not a personal failing, and it is fixable inside a single semester.
Three: name the number for what it is. When a client or a family brings you a stage, a score, a percentile, treat it as two things arriving together — a piece of information and a request for something to hold onto. Answer only the first and they will go looking for the second on the internet, where nobody is going to ask them how it's going.
Forty-plus years in, I opened that episode by admitting I did not know how to start a conversation I was going to have to start. I have decided not to be embarrassed about that. The techniques we have are good. The instruments are mostly good. What we have quietly stopped practicing is the part that comes before all of it: asking a question small enough that the other person is still holding the answer.
Sounds supportive. Make sure it is.
Michael Baltimore Ph.D. is Publisher and Editor-in-Chief of MIC LEDGER, a counselor educator, and a clinical supervisor in Midland, Georgia. He co-hosts Mike & Jeff: Off the Record with Jeff Conklin Ph.D. Episode 32, "Team Human," is the source of the quotations above.