Circular Questioning

Circular Questioning
CIRCULAR QUESTIONIN G AND NEUTRALITY ; AN INVESTIGATIO N OF TH E PROCES S RELATIONSHI P Michael J. Schee l Collie W. Conole y ABSTRACT: This stud y investigate d the possibilit y that interventiv e circula r question s violat e the principl e of neutralit y advance d by th e Mila n schoo l as essentia l to th e practic e of systemi c family therapy . A method for categorizin g circula r question s as interventiv e or descrip – tiv e wa s develope d to explor e neutralit y violations . Neutralit y was operationalize d as clien t perception s of therapis t side-takin g and feel – ings of discomfort . Immediatel y after famil y therapy , individua l fam – ily member s viewed videotap e replay s of moment s whe n circula r question s wer e pose d and rate d their perception s of therapis t side – takin g and feeling s of discomfor t for eac h selecte d moment . Finding s indicated a greater tendenc y for non-neutralit y wit h interventiv e questions . Neutralit y was also represente d as multidimensiona l throug h the lac k of correlatio n betwee n side-takin g and discomfor t ratings. KEY WORDS : circular questions ; Mila n famil y therapy ; neutrality . Milan famil y therapy’ s proces s of circula r questionin g and neu – tralit y has hel d a grea t dea l of interes t and centralit y in th e Mila n family therap y literatur e (e.g. , Matthews , 1984 ; Burroughs , 1985 ; Nitzberg , Patten, Spielrnan , & Brown, 1985; Reder , 1985 ; Speed , Michael J. Scheel , PhD , is assistan t professo r in th e Departmen t of Educationa l Psychology , 324 Milto n Bennio n Hall , Universit y of Utah , Salt Lak e City , UT 84112 . Collie W. Conoley , PhD , is professo r in th e Departmen t of Educationa l Psychology , 709 Harringto n Ed. Bldg. , Texa s A&M University , Colleg e Station , TX 77843 . Reprin t re- quest s shoul d be sen t to th e firs t author . 221 Contemporary Family Therapy, 20(2), June 1998 ® 1998 Huma n Science s Press, Inc. CONTEMPORARY FAMILY THERAP Y 1985; Mauksc h & Roesler, 1990) . Other s hav e objecte d to neutrality , proposing that its practic e perpetuate s power differential s in familie s (Avis, 1988; Bograd , 1988 ; Hoffman , 1990). Boscol o and Cecchi n ac- knowledg e that neutralit y is controversia l in it s functio n of non – blam e (Boscolo , Cecchin, Hoffman , & Penn, 1987) . Eve n so, neutralit y is viewe d as essentia l to systemi c practic e (Selvin i Palazzoli , Boscolo, Cecchin, & Prata, 1980) . Whethe r in favo r of o r oppose d to th e prac – tic e of neutralit y in famil y therapy , a clearer understandin g of wha t neutralit y is an d whe n it occur s in th e contex t of systemi c family therapy is needed . Thi s stud y investigate s the relationshi p betwee n type s of circula r question s and th e maintenanc e of clien t perspective s of therapis t neutralit y durin g family therapy . The fundamenta l aims of th e Mila n metho d of famil y therap y are twofold : a) t o provid e the therapis t and famil y a systemi c descriptio n through an efficien t method of informatio n gathering , and b ) t o fee d back to th e famil y contextua l informatio n upon whic h to bas e change . Change develop s throug h disruptio n of dysfunctiona l cycle s of inter – action and sympto m supportin g beliefs (Fleuridas , Nelson , & Rosen- thai , 1986 ; Tomm , 1984). Circula r questionin g is th e Mila n interviewin g metho d use d to gai n descriptiv e assessment s and delive r intervention s throug h ques – tion s to a famil y (Penn , 1982 ; 1985 ; Tomm , 1985; 1987 ; Boscol o et al. , 1987) . The proces s was develope d by th e Mila n Associate s and i s base d on th e wor k of Gregor y Bateson . Circular questionin g was develope d by th e Mila n tea m to connec t individua l family member’ s arc s (pieces ) of understandin g int o circu – lar view s abou t a situatio n withi n a famil y (Selvin i Palazzol i et al. , 1980) . Circula r questionin g is describe d as a Socrati c metho d in whic h the therapis t ask s question s and famil y member s respond . The question s are inquirie s abou t difference s within the family . The ques – tion s are designe d to discove r and revea l systemi c processes . Whe n a family present s an opening , difference s in belief s amon g family mem- ber s are explore d throug h questions . Difference s lead to systemi c hy- pothese s of th e famil y dynamics . Questio n presentatio n is guide d by th e therapist’ s developin g hypotheses (Boscolo et al. , 1987) . Famil y opening s are th e famil y members ‘ beliefs which take the for m of la – bel s or diagnoses . An inten t of th e circula r questionin g proces s is t o expan d these belief s beyon d the meaning s whic h the famil y currentl y holds . For example , durin g this stud y one mothe r was asked , “Wh o do yo u thin k is th e saddes t abou t the fighting? ” Sh e responded , “I don’ t 222 MICHAEL J. SCHEE L AND COLLI E W. CONOLE Y know. I grew up i n a famil y wit h no fighting. ” He r experienc e wit h fightin g was differen t than othe r famil y members ‘ experiences . Thi s informatio n was regarde d as a n opening . The consultatio n tea m hy- pothesize d that becaus e of he r femal e status and famil y of origi n his – tory the mothe r saw hersel f as helples s to d o muc h abou t the fightin g between her thre e sons . The mother’ s openin g was explore d by ask – ing , “Wha t is i t lik e in thi s famil y bein g the onl y female? ” Also , the son s and husban d wer e asked , “Ho w coul d you ge t he r (th e mother ) to lik e bein g upstair s (wher e the fightin g occurs) wit h you more? ” THE VIOLATIO N OF NEUTRALIT Y Neutrality was originall y presente d in th e Mila n metho d as th e basi c therapeuti c stanc e of bein g on everyone’ s and n o one’ s sid e in th e famil y at th e sam e tim e (Selvin i Palazzol i et al. , 1980) . Therapis t neutrality toward the famil y allows the therapis t freedom to wor k withou t defensiveness , scapegoating , or resistanc e by famil y mem- bers , becaus e the therapis t is no t bein g perceive d as takin g sides (Boscol o et al. , 1987) . Neutralit y (Cecchin , 1987 ) als o has bee n de- scribe d as a stat e of curiosit y abou t man y perspective s of th e family’ s problem which allow s exploratio n and inventio n of alternativ e views. When the therapis t violates neutralit y mor e than momentaril y by a n overemphasi s on on e famil y membe r or on e solution , the thera – pist is believe d to los e som e famil y member’ s open communication . Therapeuticall y ope n communicatio n lead s to a mor e systemi c under – standin g and change . As Tom m (1987 ) asserts , the therapis t becomes non-neutra l for a momen t to delive r an intervention . Non-neutralit y exist s becaus e the therapis t sides wit h someon e when a suggestio n occurs, then other s may feel side d against . Interventio n in thi s frame – work is th e proces s of focusin g on on e par t of th e syste m becaus e multipl e foci at on e tim e perhap s canno t occur. Attemptin g chang e via focusin g may leav e certai n member s of th e syste m feelin g excluded , blamed, or upset . For instance , wit h the questio n “Ho w do yo u thin k you r child’ s behavio r would be differen t if yo u an d you r husban d agree d more?, ” the parent s may easil y feel tha t thei r husband-wif e interactio n is be – ing blamed . Anothe r questio n coul d hav e bee n pose d as “Ho w do yo u thin k you r husban d and wif e interactio n would be differen t if you r chil d wer e mor e cooperative? ” Thi s statemen t may no t b e a s upsettin g to th e parents , but mor e upsettin g and blamin g to th e child . 223 CONTEMPORARY FAMIL Y THERAP Y One interventio n seldom , if ever , include s all famil y members ‘ perspectives . If al l perspective s wer e include d the interventio n would be trul y systemic . At th e momen t of interventio n whe n the proces s lose s its systemi c quality , the interventio n suggest s a belief in on e solutio n and on e problem , a more linea r causa l relationshi p (Boscolo et al. , 1987) . The dange r is tha t individual s feel blamed , leadin g to unproductiv e processes. In othe r approache s the unproductiv e pro – cesse s hav e bee n calle d resistanc e or oppositiona l behavior . Throug h multipl e hypothese s that eventuall y includ e all famil y member s (a systemi c relationship) , eac h membe r may hav e a sens e of influencin g the proble m syste m and , mor e importantly , the solutions . Violation of neutralit y is believe d to endange r therapeuti c prog – ress. Familie s may no t retur n if member s wit h mor e powe r in th e syste m feel side d agains t or extremel y uncomfortable . If familie s re- turn afte r violation s of neutrality , som e member s may adop t defen – sive position s whic h preven t the emergenc e of mor e circula r perspec – tives (Boscol o et al. , 1987) . Two indicator s of violate d neutralit y have bee n introduce d in th e Mila n literature . Selvini Palazzol i and associate s (1980 ) propose d that the member’ s perceptio n of th e therapis t taking sides was indica – tiv e of neutrality . Boscolo and colleague s (1987 ) adde d that members ‘ upse t or arouse d feeling s were sign s of violate d neutrality . The feel – ings wer e believe d to b e relate d to non-neutral , mor e linear , questio n interventions . The presen t stud y assesse s neutralit y by clien t report s of therapis t side-takin g and clien t discomfor t associated wit h circula r questions . The clien t report s are solicite d as th e individua l clien t pri – vatel y observe s videotap e re-play s of circula r question s bein g aske d durin g famil y therap y sessions . INTERVENTIV E AND DESCRIPTIV E CATEGORIE S OF CIRCULA R QUESTION S Circular questionin g originall y was describe d as a mean s to in – vestigat e the famil y system withou t violatin g neutralit y (Selvin i Pal – azzol i et al. , 1980 ; Penn , 1982) . Late r writing s (Tomm , 1985; Penn , 1985 ; Fleurida s et al. , 1986 ; Boscol o et al. , 1987 ) propose d that cer- tain kind s of circula r question s are mor e interventiv e tha n others . Interventiv e question s ten d to violat e neutralit y becaus e interventio n is inherentl y non-neutra l (Tomm, 1985; Boscol o et al. , 1987) . Circula r question s hav e becom e the primar y interventio n in th e Mila n metho d 224 MICHAEL J. SCHEE L AND COLLI E W. CONOLE Y of system s therap y (Penn , 1985; Tomm , 1985; 1987 ; Boscol o et al. , 1987) , an evolutio n awa y from deliverin g intervention s throug h pre – scription s at th e en d o f a session . Facilitatin g chang e via circula r question s make s the proces s mor e constructivisti c (Boscolo et al. , 1987) . The functio n of circula r questionin g developed into a proces s of delicatel y balancin g the introductio n of intervention s withi n a famil y intervie w with the maintenanc e of th e therapeuti c stanc e of neu – trality . Becaus e of th e dua l natur e of circula r question s several au- thor s hav e suggeste d typologie s to distinguis h betwee n the interven – tiv e (non-neutral ) and descriptiv e (neutral) . Question s see n as mor e interventiv e are : (a) future-oriented , (b) hypothetical , and (c ) hypoth – esis-revealin g (Boscolo et al. , 1987 ; Penn , 1985 ; Tomm , 1987). Ques – tion s see n as mor e neutra l by askin g for description s of presen t real- ities are : (a) proble m definitio n questions , (b) question s askin g for comparison s between family member s or issues , (c) question s askin g for famil y membe r classifications , and (d ) question s askin g abou t agreemen t (Boscolo et al. , 1987 ; Penn , 1985) . A proble m definitio n questio n suc h as “Wha t is th e proble m in you r famil y right now? ” is descriptive . It ask s the famil y to repor t wha t exist s in th e present . A future-oriente d questio n suc h as “Wha t would it b e lik e in th e famil y in fiv e year s if thing s wer e to continu e as i t i s now? ” is mor e interventive . It ask s the famil y to generat e new meaning s through speculation . Perturbation s in th e existin g meanin g system s are likel y (Boscol o et al. , 1987 ; Penn , 1985) . A hypothesi s revealin g questio n suc h as “Wha t do yo u thin k abou t the ide a that there is a connectio n betwee n you r daughter’ s anorexi c behavio r and you tw o fighting? ” i s als o associate d wit h perturbatio n (Boscolo et al. , 1987 ; Penn , 1985) . Tomm (1987 ) differ s from the previou s author s by differentiatin g upon the basi s of th e therapist’ s intent rathe r than the structur e of th e circula r questions . Tomm (1985 ) point s out tha t all circula r question s hav e the potentia l to trigge r the therapeuti c system’ s reflexiv e process whic h alters famil y meaning s and conse – quentl y promote s change . Whil e Tomm’ s presentatio n is persuasive , the structura l qualitie s of th e circula r question s wer e use d in thi s stud y becaus e of thei r possibl e heuristi c value . HYPOTHESI S OF TH E STUD Y This stud y investigate d the propositio n that interventiv e circula r question s would mor e likel y violat e neutralit y than descriptiv e ques – 225 CONTEMPORARY FAMILY THERAP Y tions. Interventiv e circula r question s wer e future-oriented , hypotheti – cal, an d hypothesis-revealin g questions . Violation s of neutralit y wer e define d as a ) clien t perception s of th e therapis t taking someone’ s sid e in th e family , and b ) clien t reporte d discomfort . This stud y is signifi – cant becaus e it investigate s the theorize d relationshi p betwee n neu – tralit y and type s of circula r questions . Also, the stud y introduce s a procedure for measurin g neutrality from the client’ s viewpoint , and categorizin g circular question s as interventiv e or descriptive . METHODOLOG Y Procedure Thre e familie s received four session s of Mila n systemi c family therapy . Eac h of th e thre e familie s was see n by a differen t therapist for fou r sessions , wit h sessio n lengt h rangin g betwee n 60 an d 9 0 min – utes . A consultatio n tea m assiste d eac h sessio n from behin d a view- ing mirror . The therapis t initiated consultatio n break s and conferre d with the tea m at leas t twic e durin g eac h sessio n regardin g new idea s or feedbac k about wha t had jus t occurre d in session . The consulta – tions wer e to develo p multipl e idea s (hypothesizing ) linkin g togethe r the element s in th e proble m situatio n that help the famil y towar d their goals . Circula r questioning , neutrality , and hypothesizin g wer e verifie d as occurrin g in thi s study . The Mila n Associate s designate d thos e thre e ingredient s as essentia l to conductin g a family intervie w in a systemi c manne r (Selvin i Palazzol i et al. , 1980) . After each famil y sessio n ther e was a 15-minut e brea k followe d by individua l session s wit h eac h famil y membe r lasting about 30 min – utes. Durin g the 15-minut e brea k two experimenter s readie d the video-tape d circular question s from the session . The tw o experiment – ers jointl y selecte d three descriptiv e and thre e interventiv e question s to us e a s stimuli . One interventiv e and on e descriptiv e questio n was selecte d from eac h thir d of th e intervie w in orde r to exer t som e con- tro l ove r the influenc e of whe n a questio n was asked . Question s wit h simila r conten t wer e not used . The individua l interview s consiste d of on e tea m membe r meeting individuall y with a famil y member . Famil y member s separatel y viewed the videotape d circula r question s and reporte d their perception s of therapis t side-takin g and th e leve l of discomfor t for eac h question . An initia l practic e questio n was include d at th e beginnin g of eac h inter – view so th e familie s could becom e accustome d to seein g themselves . The therap y tea m member s wer e blin d to th e purpose s of th e stud y 226 MICHAEL J. SCHEE L AND COLLI E W. CONOLE Y and ha d n o knowledg e of whethe r question s sample d in th e videotap e replay s wer e categorize d as descriptiv e or interventive . The categorizatio n of th e circula r question s underwen t a correc- tion procedure . The in-sessio n categorizatio n of th e circula r question s was correcte d by a se t o f fou r rater s who coul d wor k in a les s pres – sure d manne r after the session s wer e over . Thi s allowe d for a mor e thoughtful , reflective final categorization . Twelv e of th e 7 2 question s sampled change d categorie s as a resul t of rate r judgment . Conse – quently , there was a slightl y unequa l number of descriptiv e and in – terventiv e question s sample d (37 interventiv e and 3 5 descriptive) . Participants Three familie s wer e give n the optio n of receivin g family therap y when they sough t service s at a universit y trainin g clinic . All thre e familie s had mal e and femal e parent s and a t leas t one chil d identifie d as a behaviora l problem . All famil y member s wer e Caucasian . The identifie d children wer e score d by thei r parent s in th e clinica l rang e of th e Achenbac h Chil d Behavio r Checklis t (Achenbac h & Edelbrock, 1983) . All thre e wer e boys , and wer e rate d as uncommunicative , ag- gressive , and delinquent . Non e of th e thre e score d in th e clinica l rang e for schizoid-anxious , somati c complaints , socia l withdrawal , or socia l activitie s subscales . Family A ha d thre e boys , age s 10, 8 , an d 8 wit h the oldes t identi – fied by th e parent s as th e problem . Famil y B ha d on e boy , age 7 , wh o had bee n referre d by th e famil y physician . Famil y C ha d thre e boys , age s 11 , 10 , an d 6 wit h the oldes t referre d by hi s school . The thre e therapist s receive d three year s of trainin g in th e Mila n metho d and wer e experience d family therapists . Two therapist s had a master s degre e and fiv e year s of experienc e as famil y therapists , and one ha d a doctora l degre e and 2 0 year s of experienc e as a famil y ther- apist. The observatio n tea m consiste d of fiv e graduat e student s who had take n a semester-lon g clas s in famil y therap y and fou r two-hou r session s of informatio n and role-playin g specificall y on th e Mila n model . Two experimenter s acte d as conten t selector s durin g the ses – sions . The experimenter s wer e graduat e student s who receive d the sam e trainin g as th e observatio n team , and additiona l trainin g in identifyin g types of circula r questions . The fou r rater s were graduat e students who receive d trainin g in identifyin g type s of circula r ques – tions . 227 Measures Type of circular question. Th e criteri a use d to discriminat e be- twee n the tw o categorie s of circula r question s were : (a) th e conten t of th e circula r questio n and (b ) th e origi n of th e question . If th e conten t of th e questio n was future-oriented , hypothetical , or speculative , re- veale d an hypothesi s of th e therapist , or containe d an embedde d sug – gestion , the n the questio n was classifie d as interventive . All othe r question s wer e considere d descriptive . Descriptiv e question s wer e about the proble m definition , comparing family member s or issues , classification , and agreemen t questions . If th e questio n clearl y origi – nate d fro m a famil y statemen t the questio n was descriptive . If th e origi n of th e questio n cam e from therapists ‘ hypotheses , the questio n was interventive . If th e origi n of th e questio n was fro m a famil y open- ing bu t th e conten t was hypothetica l or hypothesis-revealing , the questio n was classifie d as interventive . An exampl e of a questio n coded interventiv e is: “Wha t woul d hap – pen if yo u tw o ha d a nigh t a week alone? ” It ha s future-oriented / hypothetica l content . The famil y is aske d to speculate , and th e ver b tens e is future . Additionally , the questio n originate d from hypothese s presente d by th e consultatio n team . The question , “Ho w do the y no- tice th e competition? ” was code d as descriptive . It ha s descriptiv e con – tent , originate d from a famil y discussin g competition , and th e ver b tens e is no t future . Reliabilit y for th e identificatio n of categorie s of circula r question s was establishe d at 90 % agreemen t for th e fou r rater s throug h prac – tice . Th e interrate r reliabilit y calculate d after the stud y was a n 85 % agreemen t and a Cohe n Kapp a of .76 . Neutrality measure. Neutralit y was assesse d from two clien t self- reports : the clients ‘ perceptio n of th e therapis t takin g side s (Selvin i Palazzol i et al. , 1980) , and th e clients ‘ leve l of discomfor t with a ques – tion (Boscol o et al. , 1987) . Side-takin g was assesse d throug h the indi – vidua l intervie w wit h a three-poin t anchore d Likert-typ e scale . Eac h paren t was asked . “Fro m you r viewpoint , whil e the counselo r ask s this question , doe s it see m she o r he : (1 ) take s someone’ s side , (2) partiall y takes someone’ s side , or (3 ) take s no one’ s sid e in particu – lar? ” The childre n wer e aske d a simila r questio n wit h les s comple x wording. “While the counselo r asks this question , is h e o r she : (1) o n someone’ s side, (2) a littl e bit o n someone’ s side , or (3 ) no t o n some – one’s side? ” CONTEMPORAR Y FAMIL Y THERAP Y 228 MICHAEL J. SCHEE L AND COLLI E W. CONOLE Y Level of discomfor t was also assesse d during the individua l inter- view. The parent s wer e asked : “Ho w comfortabl e wer e you feelin g af- ter th e counselo r aske d the question ? (1) th e sam e comfor t level as befor e the question , (2) som e discomfort , (3) uncomfortable , (4) muc h les s comfortable , and (5 ) extremel y uncomfortable. ” Childre n wer e asked : “Ho w did yo u fee l afte r the counselo r aske d the question ? (1) the sam e as befor e the question . (2) a littl e bit wors e than befor e the question , (3) wors e tha n before , (4) bad , or (5 ) reall y bad. ” RESULT S A decision was mad e prio r to analysi s to no t conside r response s from childre n unde r the ag e o f 10 . Th e interviewer s reporte d that the younge r childre n did no t appea r to respon d seriously . Som e freel y admitte d the y wer e providin g answer s not relate d to intervie w ite m content . For instance , one youn g participan t reported all th e sam e answer s withou t listenin g to th e interviewer . Anothe r answere d ques – tion s befor e the question s wer e asked . Aggregat e neutralit y score s for eac h questio n wer e tabulate d usin g the followin g procedure : For eac h questio n raw scor e rating s from famil y member s of side-takin g and o f discomfor t were summe d and converte d to z-score s for eac h family . The resultan t side-takin g and discomfor t z-scores for eac h questio n wer e the n summe d to con – stitut e a singl e neutralit y scor e for eac h question . Mean s and stan – dard deviation s of neutralit y score s for interventiv e and descriptiv e question s and t-ratio s comparin g the type s of question s are displaye d in Tabl e 1. An overal l t-ratio resultin g from the combine d response s of th e thre e familie s indicate d a significantl y greater (p<.005 ) tendenc y for violation s of neutralit y wit h interventiv e question s than descriptiv e questions . Tabl e 2 summarize s question s whic h wer e associate d wit h the mos t (-1 o r les s standar d scor e from the mean ) neutra l and leas t (+1 o r greate r standar d scor e from the mean ) neutra l responses . DISCUSSIO N Findings Our finding s were supportiv e of th e theorize d relationshi p be- twee n neutralit y and type s of circula r question s mos t prominentl y 229 CONTEMPORARY FAMILY THERAP Y forwarded by Boscolo , Cecchin , Hoffman , and Per m (1987 ) as wel l as Tomm’ s (1985) hypothesize d lin k betwee n interventivenes s and neu – trality . Specifically , our finding s were as follows . 1. Violation s of neutralit y occurre d mor e ofte n durin g interven – tiv e circula r question s tha n descriptiv e circula r questions . Evidenc e not supportin g the researc h hypothesi s was also present . The non – supportiv e data wer e largel y circula r question s rate d as interventiv e that wer e not viewe d as side-takin g or uncomfortabl e by famil y C members . As researcher s we woul d like to predic t the influenc e of circula r question s upo n neutralit y wit h precision . As clinician s we be – liev e tha t if w e ar e t o err , it i s bette r to b e perceive d as neutra l when we expecte d non-neutrality . We ar e intereste d in creatin g finer distinction s in ou r operationa l definitions of interventiv e and descriptiv e circula r questions . There – fore, we use d the dat a as suggestiv e of a furthe r refinemen t in devel – oping a typolog y of interventiv e and descriptiv e circula r questions . 2. On e area tha t appeare d clea r from the dat a was that Famil y C was comfortabl e with severa l future oriente d circula r question s that we predicte d would be non-neutral . Thes e question s explore d the fu – ture existenc e of th e presentin g problem. However , whe n aske d abou t father feelin g vulnerabl e rather than the presentin g problem about 230 TABL E 1 Means , Standar d Deviations , and T-ratio s of Neutralit y Score s for Interventiv e and Descriptiv e Question s Measure Family A Interventiv e Descriptive Family B Interventiv e Descriptive Famil y C Interventiv e Descriptive Families A, B , & C Interventiv e Descriptive N 11 1 2 13 11 11 1 3 3 5 36 Mean 8 5 -.7 3 .78 -.9 1 .20 -.1 7 .62 -.5 8 SD 1.4 8 1.0 0 2.1 0 .87 1.1 3 1.3 1 1.6 9 1.1 1 T-Ratios t(21 ) = 2.98 t(22 ) = 2.04 t(22 ) = .6 5 t(69 ) = 3.57 P p<.02 5 p<.0 5 p>.10 p<.00 5 MICHAEL J. SCHEE L AND COLLI E W. CONOLE Y TABLE 2 The Mos t and Leas t Neutra l Question s for Al l Thre e Familie s Family A — Violations of Neutrality (Greater than + 1 z-scores) IV: Ho w migh t you ge t peopl e to ac t nic e towar d you i n thi s family ? IV: So wha t woul d you sa y i f I sai d I thin k a proble m this famil y has is tha t the y don’ t hav e enoug h way s to ge t attentio n from one an – other ? IV: Wha t coul d the runnin g awa y mean ? IV: Ho w coul d you tw o (th e parents ) show affection ? IV: Wha t do yo u thin k is goin g to happe n if yo u kee p ignorin g you r mom whe n she say s something ? IV: Ho w migh t you kno w if someon e in th e famil y is goin g to ge t mad ? Family A — Neutral (Less than – 1 z-scores) D: D o yo u thin k mor e fightin g occurs whe n Dad i s gon e ? IV: Wh o is th e saddes t in th e famil y that ther e are fights ? D: Ho w doe s it fee l to b e th e onl y female ? D: Wh o d o yo u lov e more ? D: Wer e the y nic e to yo u whe n you cam e out o f th e basement ? D: Ho w do yo u notic e the competition ? D: Wa s ther e tensio n in th e famil y today? Family B — Violations of Neutrality (Greater than + 1 z-scores) IV: Whe n thing s are goin g wel l betwee n the tw o o f you . how doe s that affec t your parentin g wit h R (the son) ? IV: Doe s the grandmothe r sho w you mor e affectio n now sinc e R (the IF) taugh t Grandm a that? IV: Is i t safe r to no t touc h eve n wit h you r wife ? IV: If someon e would have bee n abl e to hel p you bac k then , how d o yo u thin k thing s things would be differen t today? D What hav e you don e to mak e sure it doesn’ t stop (th e progress) ? IV: Ho w woul d you lik e thing s to b e a yea r from now ? Family B — Neutral (Less than – 1 z-scores) D: Wh o enjoye d the touchin g the most ? D: Wha t kin d of change s hav e you notice d that are differen t tha n before? ‘ D: Ho w ha s th e counselin g helped? IV: If R wasn’ t so active , how woul d things be different ? D: Hav e you notice d any difference s whe n you change d schools ? Family C — Violation s of Neutralit y (greater than + 1 z-scores ) IV: Ho w ar e thing s goin g to b e i n 5 year s dow n the road ? 231 CONTEMPORARY FAMILY THERAP Y the children , a strong non-neutra l respons e was received . We ten – tativel y interpre t this as meanin g that Famil y C ha d talke d and though t abou t the misbehavio r of th e boy s enoug h to develo p a com- fort wit h the discussio n (no t to b e confuse d with a comfor t with the misbehavior) . However, when explorin g the nove l systemi c lin k of fa – ther’ s feelin g of genera l life inadequacies , there were stron g percep – tion s of discomfort . The implication s lea d us t o sugges t that interven – tive question s that ask abou t the presentin g proble m withi n the contex t of th e family’ s presentation , tend to b e les s non-neutra l than question s addressin g allie d issue s or differen t contexts . 3. Thi s stud y contribute s to th e teachin g of Mila n systemi c ther – apy. Trainin g in th e us e o f circula r questionin g is difficul t (Fleurida s e t al. , 1986) . This stud y support s a simpl e taxonom y o f interventiv e and descriptiv e question s on th e empirica l finding o f th e degre e of neutrality . This taxonom y has relevanc e becaus e understandin g the likel y emotiona l effect of interventiv e question s help s the therapis t to guar d agains t an overl y threatenin g atmosphere . Practically , this may allo w the therapis t to investigat e sensitiv e area s of famil y func- TABL E 2 (Continued) IV: Di d yo u (Dad ) giv e it a chanc e to thin k abou t how yo u migh t pre – fer fo r peopl e to sho w you the y car e abou t you? IV: Wha t migh t be mor e preferabl e way s to fee l importan t in thi s family ? IV: If yo u becam e disabled , do yo u thin k the famil y would love you any less ? D: D o yo u eve r feel forgotten ? IV: Ho w ca n yo u hel p her righ t now ? Family C — Neutral (less than — 1 z-scores) IV: Ho w hopefu l are yo u tha t thing s will get better ? IV: Ho w woul d you lik e peopl e in you r famil y to sho w you reall y mat – ter ? IV : Wha t woul d be helpfu l for T (secon d younges t child) ? IV: Wha t woul d be helpfu l in gettin g R’s (younges t child ) need s met ? D: Wha t make s you importan t to th e family , A (the IP) ? D: Wha t do yo u d o t o ge t peopl e to liste n to yo u (th e father) ? D: A ( th e IP ) d o yo u hav e an ide a why T (secon d youngest ) has a har d tim e stayin g involved ? IV-Interventiv e D-Descriptiv e 232 MICHAEL J. SCHEE L AND COLLI E W. CONOLE Y tioning (Tomm , 1987), and kee p clien t familie s from droppin g out be – caus e the therapis t may hav e los t neutrality . Future researc h may also clarif y whethe r interventiv e question s do pertur b family mem- ber s in a manne r that facilitate s productiv e evolution . 4. A n importan t unanticipate d finding wa s th e differenc e be- twee n side-takin g and discomfort . The tw o measure s of neutralit y had almos t no overla p of meanin g (r=.06) . An interpretatio n of th e differenc e between the measure s is tha t neutralit y is multidimensio – nal . In retrospec t it make s sens e that neutralit y is a broa d multi – faceted concept . But i t als o suggest s that the concep t of neutralit y is no t wel l describe d in th e literature . This researc h is helpfu l in indi – catin g ther e may b e differen t types of neutrality . We sugges t that Cec – chin’ s descriptio n of neutralit y as a n attitud e of curiosit y be incorpo – rated int o futur e research . An importan t questio n migh t be, “Ca n curiosit y abou t multipl e possibl e solution s exis t whe n individual s are experiencin g discomfort or perceivin g sidetaking? ” 5. Ther e are clinica l implication s from the findings . Som e ques – tion s wer e mor e associate d wit h perturbatio n of famil y member s tha n others . This indicate s that questio n heuristi c as wel l as questio n con – tex t shoul d be considere d by a therapist . Clinician s shoul d ask them – selve s whethe r the y are balancin g the introductio n of intervention s wit h the gatherin g of meaning s throug h descriptio n from all member s of a family . How muc h does a questio n diverg e from famil y members ‘ existin g realities ? If th e divergenc e is to o grea t famil y member s may demonstrat e resistanc e or fee l too anxiou s to b e differen t than pas t problemati c patterns. If clinician s tip th e scale s too muc h towar d in- tervention , familie s may fee l overwhelme d and misunderstood . On the othe r han d if question s cumulativel y are to o descriptiv e and lac k intervention , a session may b e perceive d as blan d and ineffectiv e by famil y members . Side-takin g throug h question s mus t be balance d among all famil y members . Therapist s shoul d ask themselve s whethe r the outcom e of a sessio n is a n achieve d balanc e for th e dimension s of neutralit y and interventivenes s amon g family members . Eve n in case s in whic h som e famil y member s are clearl y disempowered , the therapis t must be cognizan t of ho w influenc e can b e gaine d from all famil y members . A tool to achiev e influenc e may com e from aware – nes s of th e typ e of questio n bein g posed . A family membe r who previ – ously was no t define d as par t of th e proble m may perceiv e blamin g and reac t defensivel y when interventiv e question s are pose d if th e therapis t has no t firs t sough t that famil y member’ s viewpoin t throug h descriptiv e questions . 233 Limitations There wer e severa l limitation s inheren t in thi s study . One limita – tion concern s the generalizabilit y of result s to othe r familie s with dif – feren t characteristics . The data wer e gathere d from onl y thre e fami – lies, all o f who m were two-paren t intac t familie s from the majorit y culture . A second possibl e limitatio n was ou r applicatio n of th e Mila n model . We attempte d to us e th e Mila n metho d and adher e to th e guideline s of th e proces s as w e understoo d them . Still, our versio n may diffe r fro m other s who us e it . A thir d limitatio n is relate d to th e researc h design . Eac h circula r questio n was treate d as a n indepen – den t even t throug h the researc h methodolog y employed . Othe r factor s suc h as previousl y pose d question s or pas t famil y or therap y event s may hav e als o influence d the measuremen t of neutrality . Thi s proces s researc h contribute d to th e literatur e by usin g real clien t population s to investigat e theorize d principle s of Mila n sys – temi c famil y therapy . We believ e this is a ver y difficul t area to re – searc h becaus e of th e phenomenologica l natur e of th e premise s unde r investigation . The concept s of neutralit y and interventivenes s of cir – cula r question s wer e operationalize d base d upo n the literature . The result s sugges t that the manne r of distinguishin g betwee n interven – tiv e an d descriptiv e question s support s the theor y and shoul d be in – clude d in th e teachin g of circula r questions . We believ e this stud y lay s the groundwor k for futur e studies . REFERENCE S Achenbach, T. M. , & Edelbrock , C. (1983) . Manual for th e child behavior checklist and revised child behavior profile. Burlington , VT: Universit y of Vermont . Avis, J. M. , (1988) . Deepenin g awareness : A private stud y guid e to feminis m and famil y therapy . In L . Braverma n (Ed.), A guide to feminist family therapy (pp. 15-32) . New York : Harringto n Park Press . Bograd , M. (1988) . A feminis t examinatio n of famil y system s models of violenc e against women in th e family . In L . Braverma n (Ed.), A guide to feminist family therapy (pp. 65-78) . New York : Harringto n Park Press . Boscolo , L., Cecchin , G., Hoffman . L., & Penn , P. (1987) . Milan systemic family therapy: Conversations in theory an d practice. Ne w York : Basic Books . Burroughs , C. (1985) . Workin g with familie s of severel y disturbe d children in a da y treatmen t setting. Clinical Social Work Journal, 13(2), 129-139. Cecchin. G. (1987) . Hypothesizing , circularity, and neutralit y revisited: An invitatio n to curiosity . Family Process, 26, 405-413 . Fleuridas , C., Nelson , T. S. , & Rosenthal , D. M . (1986) . The evolutio n of circula r ques- tions: Trainin g famil y therapists . Journal of Marital an d Family Therapy, 12(2), 113-127 . Hoffman , L. (1990) . Constructin g realities: An ar t o f lenses . Family Process, 29, 1-12 . CONTEMPORAR Y FAMILY THERAP Y 234 MICHAEL J. SCHEE L AND COLLI E W. CONOLE Y Matthews, W. (1984) . Ericksonia n and Mila n therapy : An interactio n betwee n circula r questionin g and therapeuti c metaphor . Journal o f Strategic an d Systemic Thera- pies, 3(4), 16-25 . Mauksch , L., & Roesler . T. (1990) . Expandin g the contex t of th e patient’ s explanator y model using circula r questioning . Family Systems Medicine, 8(1), 3-13. Nitzberg , L., Patten , J., Spielman , M., & Brown , R. (1985) . In-patien t hospital systemi c consultation : Providin g tea m systemi c consultatio n in-patient settings where the tea m is par t of th e system . In D . Campbel l & R. Drape r (Eds. ) Applications o f systemic family therapy: Th e Milan approach (pp . 203-212) . New York : Norton . Penn , P. (1982) . Circula r questioning . Family Process, 21, 267-280 . Penn, P. (1985) . Peed-forward : Futur e questions , futur e maps . Family Process, 24, 299 – 310. Reder , P. (1985) . Milan in th e Eas t End : Systemi c therapy with lower-incom e and multi-agenc y families. In D . Campbel l & R. Drape r (Eds.) , Applications of systemic family therapy: Th e Milan approach pp. 97-106) . New York : Norto n Selvin i Palazzoli , M., Boscolo , L, Cecchin , G., & Prata , G. (1980) . Hypothesizing – circu – larity-neutrality . Family Process, 19, 3-1 2 Speed , B. (1985) . The us e o f th e Mila n approac h in se x therapy . In D . Campbel l & R. Drape r (Eds.) . Applications o f systemic family therapy: Th e Milan approach (pp . 119 – 126) . New York : Norton . Tomm, K. (1985) . Circula r interviewing : A multifaceted clinica l tool . In D . Campbel l & R. Drape r (Eds.) . Applications o f systemic family therapy: Th e Milan approach method (pp . 33-45) . New York : Norton . Tomm K. (1987) . Interventiv e interviewing : Part II. Reflexiv e questionin g as a mean s to enabl e self-healing . Family Process, 26, 167-183 . 235 Copyright of Contemporary Family Therapy: An International Journal is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.
Circular Questioning
Principles of Motivational Interviewing Geared to Stages of Change: A Pedagogical Challenge Katherine van Wormer ABSTRACT.This article discusses the significance of motivational in- terviewing as a framework with wide application across the spectrum of social work practice. This article discusses the basic assumptions of the motivational approach and argues that social workers can regard this as a bridge between treatment agencies organized around competing philos- ophies. Suggestions are made for incorporating content across diverse curriculum areas. doi:10.1300/J067v27n01_02[Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail ad- dress: Website: com> © 2007 by The Haworth Press, Inc. All rights reserved.] KEYWORDS.Motivational interviewing, harm reduction, addiction, substance abuse, stages of change INTRODUCTION Social work educators strive to present class content that parallels the treatment needs of agencies while at the same time preparing students to assume leadership positions regarding the introduction of treatment in- novations, especially of those that are evidence based. One area that is often overlooked, perhaps because ofits affiliation with substance abuse Katherine van Wormer, MSSW, PhD, is Professor of Social Work, University of Northern Iowa, 36 Sabin Hall, Cedar Falls, IA 50614 (E-mail: [email protected]). Journal of Teaching in Social Work, Vol. 27(1/2) 2007 Available online at http://jtsw.haworthpress.com © 2007 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J067v27n01_0221 counseling, is the change-inducing strategy generally known as motiva – tional interviewing (MI). An Internet search (as of November, 2004) of “Social Work Abstracts” revealed a mere 11 listings for articles on the subject of MI and 14 on the related subject of harm reduction, compared with 278 listings for MI and 507 for harm reduction onPsycInfo. Evi – dently psychologists have given this treatment modality which is aimed at enhancing client motivation much more emphasis than have social workers. And yet, as most readers of this paper will realize, social work – ers have long practiced many of the precepts that now are incorporated in the MI formulation. In any case, because of its wide applicability of such an approach, especially in situations of short-term treatment for clients in situations that are self-destructive (for example, drug misuse, exposure to family violence), MI is of special relevance to the social work profession. This article makes the case that interventions directed toward client lev- els of motivation are highly consistent with social work’s predominant strengths perspective formulation (see Rapp, 1998; Saleebey, 2002). Sug- gestions are made for incorporating motivational content into courses across the social work curriculum including human behavior in the so- cial environment (HBSE), generalist practice, correctional treatment and counseling. WHAT IS MOTIVATIONAL INTERVIEWING? MI is a non-confrontational model based on the fundamental truth from social psychology that decisions to move toward change are more powerful if they come from within. MI is defined by Miller and Rollnick (2002) as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 25). This approach is client-centered in the sense that most of the state- ments concerning the toll the drinking, gambling and so on are taking is elicited from the client. There is also a focus, however, on the client’s cognitions to help him or her move in the direction of health-seeking be- haviors (Substance Abuse and Mental Health Services Administration, [SAMHSA]1999, TIP 35). MI is the pragmatic approach most closely associated with the harm reduction or public policy model. The focus is on providing empathic counseling and reinforcing the client’s sense of self efficacy or ability to exert some control over his or her life. From this treatment modality, the therapist assesses the level of the client’s motivation for change. Careful 22 JOURNAL OF TEACHING IN SOCIAL WORK to avoid fighting with the client, the motivational worker rolls with the resistance and in so doing, hopes to dispel it. Motivational techniques are geared to help people find their own path to change; feedback is of – fered to the client about what he or she seems to be saying about the need to reduce or eliminate self-destructive behaviors. MI has been a favored treatment modality in substance abuse treat – ment; it also has wide applicability to any area of social work that is cen – tered on the need for behavioral change. The development of MI is credited to the persistent questioning by young Norwegian psycholo – gists and interns of psychologist William Miller as he demonstrated his techniques for enhancing clients’ receptiveness to substance abuse treat – ment and promote their willingness to change (Miller, 1996). Miller’s protégés wanted to know how this was done and what the theory behind it was. The result was a beginning conceptual model that was followed by years of testing and refinements which culminated in the writing of the groundbreaking text, “Motivational Interviewing: Preparing People to Change Addictive Behavior” (Miller & Rollnick, 1991). My first encounter with the principles of motivational work came through an exchange between my university and social work faculty at a large urban university in northeast Britain. “Of what importance is motivation?” I asked myself at the time, my experience having been solely with involuntary clients. “Who comes to treatment voluntarily, anyway?” I wondered. That’s just the point, of course. When treatment methods (total abstinence, urinalysis tests, confrontational presentation of assessment re- sults) are designed to tear down resistance rather than establish rapport, few people sign up for the experience of their own accord. The expense of U.S. mental health care is an additional inhibiting factor. In the United Kingdom, nationalized health care (The National Health Service) and the availability of neighborhood drop-in clinics are conducive to harm reduction strategies–meeting the client where the client is and helping the clients modify their harmful practices at their own pace. Although the contrasts between European pragmatism and U.S. pu- nitiveness persist, especially regarding chemical dependency, many of the aspects of an individually tailored approach to helping are beginning to gain acceptance (Mueser, Noordsky et al., 2003). For social workprac- titioners, this development can only enhance their success in fields such as correctional and addictions work. In its basic formulation and precepts, MI closely parallels the strengths perspective of social work practice (van Wormer and Davis, 2003). The strengths approach, as Saleebey (2002) suggests, is “a versatile practice approach, relying heavily on ingenuity and creativity, the courage and Katherine van Wormer 23 common sense of both clients and their social workers. It is a collaborative process” (p. 1). According to this positive, feedback-oriented framework which builds on clients’ strengths and resources, client resistance and denial are often viewed as healthy, intelligent responses to a situation that might involve unwelcome court mandates and other intrusive prac – tices (Rapp, 1998). As in the strengths formulation, the focuses of MI is on collaboration of counselor and client, as well as on personal choice (see Saleebey, 2002). When the focus on the professional relationship is on promoting healthy lifestyles and on reducing the problems that the client defines as impor – tant rather than on the substance use per se, many clients can be reached who would otherwise stay away (Denning, 2000; Graham, Brett, & Baron, 1994). Central to this approach is the building of a relationship between therapist and client. In working with youth, this relationship is crucial in terms of promoting self-esteem and the confidence to try on new roles. In the MI orientation, the strategy is to help develop and support the client’s belief that he or she can change; this is the principle of self-efficacy men- tioned earlier (SAMHSA, 1999). The motivational, like the strengths approach, meets the client where he or she is at that point in time. The harm reduction practitioner as- sesses the level of the client’s motivation for change, and instead of engaging in a tug of war with the client, “rolls with resistance.” MI tech- niques are geared to help people find their own path to change. The thera- pist provides feedback through additive paraphrasing, a technique that involves selectively disseminating to the client what he or she seems to be saying about the need to reduce or eliminate self-destructive behav- iors (van Wormer and Davis, 2003). Table 1 presents the critical components of MI in a nutshell. These six elements of current motivational approaches have been identified and presented in brief clinical trials (SAMHSA, 1999). They are sum- marized by the acronym FRAMES. WHAT IS THE SCIENTIFIC EVIDENCE FOR THIS APPROACH? In the Substance Abuse Field Most studies to date have been conducted in the treatment of substance abuse disorders (Miller & Rollnick, 2002). A review of the evidence-based 24 JOURNAL OF TEACHING IN SOCIAL WORK literature reveals that motivational techniques are particularly useful as a prelude to other services such as in employee assistance programs where treatment encounters are brief. The most widely cited and ex- haustive study in the literature pertaining to MI is the eight-year-long comparison study directed by the National Institute on Alcohol Abuse and Alcoholism, Project MATCH (1997). Project MATCH involved al- most 2,000 patients in the largest trial of psychotherapies ever under- taken. The goal of this $28 million project was not to measure treatment effectiveness, but, rather, to study which types of treatments worked for which types of people. The three treatment designs chosen for this extensive study were based on the principles of the three most popular treatment designs– conventional Twelve-Step-based treatment, cognitive strategies, and motivational enhancement therapy. All therapy provided was individu- ally rather than group based for more rigorous control of the process. In- dividuals were assigned randomly to the three varieties of treatment. Among the treated subjects, less successful outcomes were associ- ated with male gender, psychiatric problems, and peer group support for drinking. Because there was no control group deprived of treatment, generalizations concerning the efficacy of treatment cannot be made, a fact that has brought this massive project in for considerable criticism (Bower, 1997). What this extensive and long-term study does show, however, is that all three individually delivered treatment approaches are Katherine van Wormer 25 TABLE 1. FRAMES: Critical Elements of Effective Motivational Intervention •Feedback regarding personal risk or impairment is given to the client following assess – ment of substance abuse patterns (or other risk-taking behaviors) and associated problems. • Responsibility for change is placed squarely and explicitly on the client (with respect for the client’s right to make choices for himself or herself). • Advice about changing–reducing or stopping–harmful behavior is clearly given to the client by the clinician in a nonjudgmental manner. • Menus of self-directed change options and treatment alternatives are offered to the client. • Empathic counseling–showing warmth, respect, and understanding–emphasized. • Self-efficacy or optimistic empowerment is engendered in the client to encourage change. Note : This table is based on information in SAMHSA (1999) TIP 35 published by the U.S. Department of Health and Human Services and inspired by the work of Miller and Rollnick. relatively comparable in their results, that treatment that is not abstinence based (motivational enhancement) is as helpful in getting clients to re – duce their alcohol consumption as the more intensive treatment designs. That abstinence could be a long-term but not immediate outcome of this treatment protocol was another significant finding of this mass experiment. The format was this: Treatments were provided over 8- and 9-week periods, with motivational therapy being offered only four times and the other two designs offering 12 sessions. All of the participants showed significant and sustained improvements in the increased percentage of days they remained abstinent and the decreased number of drinks per drinking day. However, treatment researchers noted that outpatients who received the Twelve-Step facilitation program were more likely to remain completely abstinent in the year following treatment than were outpatients who received the other treatments. Individuals high on reli- giosity and those who indicated they were seeking meaning in life gen- erally did better with the Twelve-Step, disease model focus, while clients with high levels of psychopathology did not. Clients low in motivation did best ultimately with the design geared for their level of motivation. An interesting outcome of this study is that insurance companies have come to endorse MI treatments, undoubtedly due to its brevity and therefore cost effectiveness (van Wormer & Davis, 2003). Their en- dorsement, in turn, has bolstered their client-centered approach for use in substance abuse counseling. I believe it has an applicability that goes far beyond the substance abuse field. If the techniques work well with alcoholics reluctant as they are to give up the use of mood altering sub- stances, how much more amenable such techniques might be in other treatment areas–in standard health care and mental health counseling, for example. Empirical Research in Other Areas While the literature is still emerging in areas apart from substance abuse counseling, available evidence suggests that motivational strate- gies hold great promise for promoting healthy behavior change. In their review of the health care literature, Resnicow, DiIorio et al. (2002) found that for nonaddictive behavior, less time may be needed to re- solve client ambivalence; and compliance measures are less tangible for some health-promoting behaviors than, for example, cigarette use. Brief adaptations of MI are often used for such situations of limited contact. 26 JOURNAL OF TEACHING IN SOCIAL WORK One difficulty in the medical field concerns the training of personnel used to giving orders to adopt a new style of relating to patients. Besides, physicians and nurses are often too busy to put the adequate time into training and role plays. Experiments using counselors, psychologists, and social workers, however, have achieved significantly better results compared with standard intervention groups in obtaining diet changes in overweight diabetics, overweight children, and patients at risk of cor – onary heart disease (Resnicow, DiIorno et al., 2002) Promising results have been found in work with schizophrenic patients as well. Participants who attended several motivational sessions showed much improvement in attitudes toward drug treatment and greater insight into their illnessthan did participants in a support counseling group (Kemp, Kirov et al., 1998). More rigorous studies are needed, however, before we can definitely state that MI outshines other means of ensuring medical patient compli- ance. Mueser et al. (2003) conducted a review of systematically con- trolled research into treatments for dually diagnosed patients. What these researchers found was that the programs with the best results were inte- grated (to treat both the substance abuse and the mental disorder), were long term, and were motivation-based. An even greater challenge in terms of employee training and non- compliant participants is found in the criminal justice field. Ginsburg, Mann et al. (2002) pursue the investigation of motivational work in this highly authoritarian milieu. Referring to Project MATCH, these authors indicate that given the success of motivational strategies with alcoholics many of whom were offenders, further research would likely show that MI has application with offender populations in general. Further credence is provided to this supposition in the finding that MI strategies achieved a high level of success in working with clients who initially were angry. Ginsburg, Mann et al. (2002) cite several preliminary studiesshowing that harsh confrontational techniques have less effect in promoting change in offenders than do motivational interventions. Their recommendation for MI with sexual offenders is based on case studies from the United Kingdom which documented that sexual offenders responded well to this approach. It seems self evident that any strategy designed to foster inter- nally motivated behavior change should have more success in offender rehabilitation as opposed to more externally imposedcontrols. A key ad- vantage of MI is its ability to tailor particular intervention strategies to the individual client’s position on the stages-of-change continuum. Let us consider these strategies in some detail. Katherine van Wormer 27 THE STAGES-OF-CHANGE MODEL People are ultimately capable of making an informed choice in their own best interest. The choices they make depend on their readiness to change, i.e., what stage of change they are in at a certain point in time (van Wormer & Davis, 2003). The stages-of-change model, sometimes referred to as the Transtheoretical Model because it relies on several theories of social psychology, was first proposed by Prochaska and DiClemente (1986) for use in helping smokers break their nicotine habit. The model has since been applied and adopted in many addiction treat – ment and other helping settings around the world. DiClemente and Velasquez (2002) describe the series-of-change model as follows: In this model change is viewed as a progression from an initial precontemplation stage,where the person is not currently consid- ering change; tocontemplation,where the individual undertakes a serious evaluation of considerations for or against change; and then topreparation,where planning and commitment are secured. (p. 201) Once the initial stage tasks are accomplished, as DiClemente and Velasquez (2002) further inform us, clients can be expected to takeac- tiontoward change; such action steps, in turn, lead to the final and fifth stage of change,maintenance,in which the person works to maintain long-term change. If the individual falters, however, a sixth stage– relapse or recurrenceof the behavior–may occur. Such backtracking is considered a normal part of the behavior change process. The stages-of-change model is a natural fit with MI and harm reduc- tion practices because of the primary focus on client choice and the em- phasis on helping people progress through the stages at their own pace. Instead of a dualistic, one-size-fits-all framework where there is either complete recovery or total failure, this approach offers the possibility of small steps punctuated by expected set-backs on the road to a resolution of one’s problems. The starting point for the therapist is to determine where the client is, at what level of change. As Boyle (2000) indicates, it is not unusual for involuntary clients to enter treatment at theprecontemplativestage. For the purposes of illustration, let us assume the client is a hard-drinking teenager brought to treatment through a court order. Typical teenage comments at each level of the stages of progression are contained in Table 2. 28 JOURNAL OF TEACHING IN SOCIAL WORK During the initial precontemplation stage of work with the typical teen drug user, the goals for the therapist are to establish rapport, to ask rather than to tell, and to build trust. Eliciting the teen’s definition of the situation, the counselor can reinforce discrepancies between the client’s and others’ perceptions of the problem. During thecontemplationstage, while helping to tip the decision toward reduced drug/alcohol use, the counselor emphasizes the client’s freedom of choice. “No one can make this decision for you” is a typical way to phrase this sentiment. Informa- tion is presented in a neutral, “take-it-or-leave-it” manner. Typical ques- tions are, “What do you get out of drinking?” “What is the down side?” And to elicit strengths, “What makes your family member believe in your ability to do this?” At thepreparationfor change andactionstages questions like, “What do you think will work for you?” help guide the youth forward without pushing him or her too far too fast. Patricia Dunn (2000) finds that the stages of change model is appro- priate for social work because it is compatible with the mission and con- cepts of the profession, is an integrative model, and is grounded in empirical research. Through building a close therapeutic relationship, the counselor can help the client develop a commitment to change. The way motivational theory goes as this: If the therapist can get the client to do something,anything, to get better, this client will have a chance at suc- cess. This is a basic principle of social psychology. Examples of tasks that William Miller (1998) pinpoints as predictors of recovery are going to AA meetings, coming to sessions, completing homework assignments and taking medication (even if a placebo pill). The question, according to Miller, then becomes, “How can I help my clients do something totake Katherine van Wormer 29 TABLE 2. An Ambivalent Teen Progresses Through the Stages Stage of Change Adolescent Comments Precontemplation My parents can’t tell me what to do; I still use, so what if I get high now and then? Contemplation I’m on top of the world when I’m high, but then when I come down, life is a drag. It was better before I got started on these things. Preparation I’m feeling good about setting a date to quit, but who knows? Action Staying clean may be healthy, but it sure makes for a dull life. Maybe I’ll check out one of these groups. Maintenance It’s been a few months; I’m not there yet but I’m hanging out with some new friends. action on their own behalf?” A related principle of social psychology is that in defending a position aloud, as in a debate, we become commit – ted to it. One would predict, from motivational enhancement perspec – tive, that if the therapist elicits defensive statements in the client, the client will become more committed to the status quo and less willing to change. For this reason, explains Miller, confrontational approaches have a poor track record. Research has shown that people are more likely to grow and change in a positive direction on their own than if they get caught up in a battle of wills. In their seven-part professional training videotape series, Miller and Rollnick (1998) provide guidance in the art and science of motivational enhancement. In this series the don’ts are as revealing as the do’s. Ac- cording to this therapy team, the don’ts, or traps for therapists to avoid, are as follows: • A premature focus, such as on one’s addictive behavior • The confrontational/denial round between therapist and client • The labeling trap–forcing the individual to accept a label such as alcoholic or addict • The blaming trap, a fallacy that is especially pronounced in cou- ples counseling To learn more about the specifics of this technique, students can visit the CSAT (Center for Substance Abuse Treatment) Website at www.csat. samhsa.gov. TIP 35, “Enhancing Motivation for Change” can be ordered from this site. Also consult www.motivationalinterview.org for further information. GOODNESS OF FIT WITH THE SOCIAL WORK CURRICULA Clearly, students in substance abuse courses must learn the skills of motivational interviewing, as this is the method increasingly endorsed by insurance companies and substance abuse treatment agencies (van Wormer & Davis, 2003). But social workers in other areas, whether child welfare (parental substance abuse is often a factor), corrections (where the need for decision making in the direction of law abiding behavior is paramount), or mental health agencies (where medical compliance may be a key to good health), will also find a grounding in 30 JOURNAL OF TEACHING IN SOCIAL WORK motivational techniques highly useful. The relevance of motivational training to four other areas of social work education, the core areas of social work, namely, (1) practice, (2) human behavior, (3) research, and (4) policy, are described as follows. Practice Social work practice courses tend to focus on treatment after the fact of personal crisis often involving self destructive behavior rather than on prevention; such courses also tend to focus on individual rather than public health. Yet there is a well established body of literature on effec – tive prevention of behaviors such as teen pregnancy, and reduction of disease risk that should be included in advanced practice courses fo- cused on working with families, children, and adolescents (Williams, Rounds, & Copeland, 2002). Skills development in risk-reducing behav- ior along the lines of learning how to elicit motivation inducing state- ments in clients is invaluable in this regard. Human Behavior in the Social Environment (HBSE) Why people do the things they do and which life events or interven- tions can be turning points in people’s lives are themes of undergraduate and graduate courses in human behavior. An in-depth study of motiva- tion to change is an important aspect of the psychology of human behav- ior, one that is often overlooked in HBSE courses. Yet the connection to human development issues that traditionally comprise the knowledge base of the HBSE curriculum of human motivation is obvious. Research Motivational theory has been an outgrowth of social psychology re- search into decision making. Students, in their critical analysis of evi- dence-based treatment interventions can benefit by exploring the burgeoning research on strategies to elicit motivation. Advanced re- search students can be made aware of the wealth of grant funded oppor- tunities in experimental research in this area. This fact of this demand can be borne out by an Internet search with the substance abuse search engine,www.jointogether.org. This resource provides announcements of funded research opportunities related to substance abuse treatment interventions. Katherine van Wormer 31 Policy How to provide client-based treatment against the backdrop of an under-funded and punitive social welfare system–students of policy will have to tackle that problem. Policy courses should include content on the need for government policies conducive to prevention of disease and to a treatment climate conducive to motivational strategies. Students can be referred towww.statepolicy.org, the Influencing Social Policy Web site, and the Harm Reduction Coalition at . CAUTIONARY NOTE There is some risk that the authorities (government officials, insur- ance companies) will co-opt motivational interviewing techniques and that, in so doing, they will miss the spirit of this client-centered effort. Accordingly, the effort will not be client-centered at all but, in fact, might be construed as a ruse to elicit information from a trusting client. Consider Iowa as a case in point. My observations are drawn from in- formal interviews with authorities at the Iowa Board of Substance Abuse Certification and through conversations with individual counselors. The board of certification requires proficiency in motivational techniques; MI trainings are offered throughout the state for all counselors. The impetus for this apparent paradigm shift, in all probability is related to insurance company reimbursement incentives. Following Project MATCH results that show motivational counseling achieves effectiveness in fewer sessions than does the Twelve-Step or cognitive approach, third party payers logi- cally promote MI strategies as more cost effective. The paradigm shift that I refer to earlier is more apparent than real given the authoritarian structure within much counseling activity that takes place. Treatment compliance is apt to be mandated, often under the threat of imprisonment or loss of driving privileges. Harm reduction philosophy, the guiding model for substance abuse treatment in many European countries, is congruent with a voluntary system in which the clients come and go as they choose and total abstinence is not required. Most treatment in the Untied States, in contrast, is geared toward the court-ordered client. So MI-trained counselors for all their high-powered listening skills and experience in eliciting insightful responses in the cli- ent, are often in the position of wearing two hats, one as a counselor meeting the client where the client is, the other as an employee of the state, county or even correctional establishment. As one counselor put 32 JOURNAL OF TEACHING IN SOCIAL WORK it, “The client opens up and tells you everything and you’re having a great session. The last five minutes you suddenly change your tactics and say, ‘You have a serious problem and will be required to attend so many treatment sessions and you must be drug free the whole time’ and the client gets furious and feels deceived and says something like ‘but you said I didn’t seem to have much of a problem’” (personal interview of April 8, 2004). DiClemente and Velasquez (2002) address this issue indirectly, they caution that to elicit a list of the “cons” in using an addictive substance and then later to use these statements as ammunition against the client defeats the purpose of the exercise (the listing the pros and cons of drug use). They advise that the clinician should trust clients to reach their own conclusions. Until the structure, at least in the substance abuse and correctional areas, is less authoritarian and punitive, motivational strat- egies can only go so far. Such an approach is ideal, however, at mental health centers and private counseling clinics where clients come more or less of their own accord. I have used such strategies with adults in treatment for mental disorders and with teenagers brought into treatment by their parents to good effect. CONCLUSION Social workers in whatever field of practice are change agents, or hope to be. In their individual, group, and family work, the aim is to help people help themselves. Students of social work, therefore, need training in the most psychologically effective methods known to modern science. Motivational enhancement strategies have been shown to be effective in curbing risk taking behaviors, especially related to health and mental health. Motivational techniques are highly effective in helping clients move from a precontemplative stage to an action stage of behavior change. Social work educators can help their students shape appropriate interven- tions to reflect client stages of motivation. HBSE instructors can focus on the human behavior components in MI theory and learn how and why MI works better than harsh confrontation. Courses on health and mental health can focus on the prevention attributes of motivational concepts. Finally, policy courses can consider the structural impediments to insti- tuting client centered programming. In substance abuse and offender situations, however, the American social structure is not always conducive to a treatment regimen centered on the principles of stages-of-change which proceed at the client’s, not the treatment center’s, pace. Katherine van Wormer 33 MI has a tremendous potential in areas in which clients are subjecting themselves or are being subjected by others to harm. I am thinking of the victims of domestic violence or family members of persons with ad – dictions problems or mental illness in need of help to prevent the situa – tion from growing desperate. Because of its versatility, MI techniques can be taught to practitioners at various agencies. This commonality of treatment approach should help bridge the gap between agencies (for example, women’s shelter and substance abuse treatment centers) whose philosophy in the past has clashed due to professional bias and incon – gruities in focus. 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