New PMHNPs: What to Do When Your Patient Answers Every Question With “I Don’t Know”

If you’re a new Psychiatric Nurse Practitioner you’ll eventually have an evaluation or follow-up visit where it feels like you’re doing all the talking.

You ask:

“How have you been feeling?”

“I don’t know.”

“How has your sleep been?”

“I don’t know.”

“Any changes in your appetite?”

“I don’t know.”

“What do you think has been contributing to how you’ve been feeling?”

“I don’t know.”

And eventually, you may start wondering:

How am I supposed to complete an evaluation when my patient won’t give me anything to work with?

First, take a breath.

A patient repeatedly saying “I don’t know” doesn’t necessarily mean they’re being difficult, uninterested, or unwilling to participate. There are several reasons a patient may have difficulty answering questions—and your approach can make a big difference.

Why might a patient keep saying “I don’t know”?

Before assuming the patient is being uncooperative, consider what might be happening underneath the response.

They genuinely don't know

Some patients have difficulty identifying or describing their internal experiences.

They may not have developed the habit of paying attention to their mood, anxiety, sleep, or other symptoms. They may know that they don't feel well but have difficulty putting that experience into words.

For these patients, asking increasingly specific questions may be more helpful than repeating broad ones.

Instead of:

“How has your mood been?”

Try:

“Have you noticed yourself feeling more sad, irritable, frustrated, or about the same?”

You’re giving the patient something concrete to respond to without putting words in their mouth.

They're having difficulty with recall

This is especially important when you're asking about symptoms over a longer period of time.

“Tell me how your sleep has been over the past month” can be surprisingly difficult to answer.

Try anchoring your questions to something more concrete:

“Over the last week, about how many nights would you say you've had trouble falling asleep?”

Or:

“Compared with a month ago, is your sleep better, worse, or about the same?”

Sometimes the problem isn't that the patient doesn't know. It's that the question requires too much mental reconstruction.

They're overwhelmed

An initial psychiatric evaluation, in particuar, can involve a lot of questions, unfamiliar terminology, and personal topics.

Some patients may become overwhelmed or shut down when they feel like they're being asked to explain everything at once.

If you notice this happening, slow down.

As a new grad PMHNP, you may feel tempted to rush through every question simply because it's on your evaluation template.

Instead, try saying:

“We don't have to figure everything out at once. Let's take this one piece at a time.”

That simple statement can reduce some of the pressure the patient is experiencing.

They're guarded

Sometimes “I don't know” really means:

“I don't feel comfortable telling you yet.”

This can happen when discussing trauma, substance use, suicidal thoughts, relationships, psychotic symptoms, or other sensitive subjects.

Rather than immediately pushing for more information, consider acknowledging the difficulty.

You might say:

“That's okay. Some of these questions can be difficult to answer, especially when we're just getting to know each other.”

Creating a sense of safety may ultimately give you more information than repeatedly asking the same question.

Stop asking the same question in a different way

One of the easiest traps for a new Psych NP is repeatedly rephrasing the same open-ended question.

You ask:

“How is your anxiety?”

“I don't know.”

“Have you been feeling anxious?”

“I don't know.”

“Do you feel worried a lot?”

“I guess.”

At this point, you're not necessarily getting more useful information.

Instead, change your approach.

Use specific, observable questions

Rather than asking the patient to define their experience, ask about things you can quantify or observe.

For example:

Instead of:
“Has your depression been better?”

Try:
“How many days this week did you feel down or depressed?”

Instead of:
“How is your anxiety?”

Try:
“How often have you noticed yourself worrying during the day?”

Instead of:
“How's your sleep?”

Try:
“What time are you usually getting to bed, and about how long does it take you to fall asleep?”

Specific questions can make it much easier for a patient to give you usable information.

Give them choices

Multiple-choice questions aren't just useful for exams.

They're also useful during psychiatric evaluations.

If a patient struggles with an open-ended question, give them a few options.

“Would you say your mood has been better, worse, or about the same?”

“Are you having trouble falling asleep, staying asleep, waking up too early, or all three?”

“When you're feeling anxious, is it more physical—like a racing heart and tension—or more of a constant stream of worrying thoughts?”

This doesn't mean you should lead the patient toward a diagnosis.

The goal is to give them a framework for describing their own experience.

Ask about what other people have noticed

Sometimes the patient isn't the best source of information about a particular symptom.

Collateral information can be extremely helpful when appropriate and with the necessary consent or authorization.

For example:

“Has anyone close to you mentioned noticing changes in your behavior?”

“Has your partner noticed anything different about your sleep or mood?”

“What prompted your family to become concerned?”

You may learn that the patient doesn't recognize a change that others have clearly observed.

This can be particularly helpful when evaluating changes in functioning, cognition, mood, behavior, or possible manic or psychotic symptoms.

Ask about functioning

When symptom descriptions aren't giving you much information, functioning can provide another window into what's happening.

Instead of asking only:

“Are you depressed?”

Ask:

“How has this affected your ability to get through your normal day?”

You can explore:

• Work or school

• Hygiene

• Household responsibilities

• Relationships

• Social activities

• Parenting responsibilities

• Exercise

• Eating

• Medication adherence

• Sleep routine

Sometimes a patient can't tell you whether their depression is “better” or “worse,” but they can tell you:

“I haven't showered in four days.”

“I've been calling out of work multiple times a week.”

“I stopped going to the gym.”

“I'm ordering takeout because I can't make myself cook.”

Those details are clinically meaningful.

Don't forget the importance of silence

As a new PMHNP, you may feel uncomfortable when there is silence.

So you fill it. You ask another question. Then another. And suddenly you're talking much more than your patient.

Try giving the patient a little more time.

Ask the question and pause.

You may be surprised by how often a patient eventually begins answering once they have time to think.

Silence can feel much longer to the newbie clinician than it actually is.

“I don't know” can itself be information

Repeatedly saying “I don't know” is not necessarily an absence of information.

It can tell you something about how the patient is approaching the evaluation.

Maybe they're guarded.

Maybe they're overwhelmed.

Maybe they're having difficulty with memory or concentration.

Maybe they have limited insight.

Maybe they're uncomfortable discussing certain topics.

Maybe they're unsure what you're asking.

Or maybe they genuinely haven't thought about the question before.

Instead of viewing “I don't know” as a roadblock, consider it a cue to become curious about why the patient doesn't know.

You might even ask:

“When you say you don't know, is it because it's hard to remember, hard to describe, or you're not really sure what I'm asking?”

That question can sometimes open an entirely different conversation.

You don't have to get every answer today

This is probably one of the most important things for a new PMHNP to remember.

You may leave an initial evaluation knowing that there are still unanswered questions.That's okay.

You don't have to force a patient to disclose everything during one appointment just because your template has another box to complete.

Document what you were able to assess.

Identify what remains unclear. Document that you plan to further explore these areas in the “Plan” section of your note.

Use collateral information when appropriate.

And most importantly, prioritize the information you actually need to make safe clinical decisions.

A psychiatric evaluation isn't a scavenger hunt where you have to collect an answer to every question before the appointment ends.

It's an ongoing clinical process.

A simple framework to remember

When your patient answers everything with “I don't know,” try this sequence:

1. Slow down.
Don't assume the patient is being difficult.

2. Get more specific.
Move from broad questions to concrete, observable details.

3. Offer choices.
Give the patient a framework for responding.

4. Ask about functioning.
Look at what the patient is actually doing day to day.

5. Consider collateral.
When appropriate, find out what others have observed.

6. Allow silence.
Give the patient time to think.

7. Get curious about the “I don't know.”
It may tell you something clinically important.

Explore our resources for more tips for the new PMHNP starting out in practice.