Collaborative Therapy with Multi-Stressed Families, Second Edition (The Guilford Family Therapy Series)

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Collaborative Therapy with Multi-Stressed Families

The Guilford Family Therapy Series Michael P. Nichols, Series Editor Recent Volumes Collaborative Therapy with Multi-Stressed Families, Second Edition William C. Madsen Working with Families of the Poor, Second Edition Patricia Minuchin, Jorge Colapinto, and Salvador Minuchin Couple Therapy with Gay Men David E. Greenan and Gil Tunnell Beyond Technique in Solution-Focused Therapy: Working with Emotions and the Therapeutic Relationship Eve Lipchik Emotionally Focused Couple Therapy with Trauma Survivors: Strengthening Attachment Bonds Susan M. Johnson Narrative Means to Sober Ends: Treating Addiction and Its Aftermath Jonathan Diamond Couple Therapy for Infertility Ronny Diamond, David Kezur, Mimi Meyers, Constance N. Scharf, and Margot Weinshel Short-Term Couple Therapy James M. Donovan, Editor Treating the Tough Adolescent: A Family-Based, Step-by-Step Guide Scott P. Sells The Adolescent in Family Therapy: Breaking the Cycle of Conflict and Control Joseph A. Micucci Latino Families in Therapy: A Guide to Multicultural Practice Celia Jaes Falicov

Collaborative Therapy with Multi-Stressed Families Second Edition

WILLIAM C. MADSEN

THE GUILFORD PRESS New York London

© 2007 The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012 www.guilford.com All rights reserved Except as indicated, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number:

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LIMITED PHOTOCOPY LICENSE These materials are intended for use only by qualified mental health professionals. The Publisher grants to individual purchasers of this book nonassignable permission to reproduce the appendices. This license is limited to you, the individual purchaser, for use with your own clients and patients. It does not extend to additional clinicians or practice settings, nor does purchase by an institution constitute a site license. This license does not grant the right to reproduce these materials for resale, redistribution, or any other purposes (including but not limited to books, pamphlets, articles, videoor audiotapes, and handouts or slides for lectures or workshops). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications. Library of Congress Cataloging-in-Publication Data Madsen, William C., 1954– Collaborative therapy with multi-stressed families / William C. Madsen. — 2nd ed. p. ; cm. — (The Guilford family therapy series) Includes bibliographical references and index. ISBN-13: 978-1-59385-434-8 (pbk. : alk. paper) ISBN-10: 1-59385-434-X (pbk. : alk. paper) ISBN-13: 978-1-59385-435-5 (hardcover : alk. paper) ISBN-10: 1-59385-435-8 (hardcover : alk. paper) 1. Family psychotherapy. 2. Family counseling. 3. Problem families. I. Title. II. Series. [DNLM: 1. Family Therapy. 2. Counseling. 3. Family—psychology. WM 430.5.F2 M183c 2006] RC488.5.M332 2006 616.89’156—dc22 2006034702

About the Author

William C. Madsen, PhD, is the Director of the Training Program in Collaborative and Narrative Therapies at the Family Institute of Cambridge and the Director of the Family-Centered Services Project, an organizational change initiative dedicated to helping state organizations and community agencies develop more respectful and responsive ways of interacting with clients and families. Over the past 25 years, he has developed and administered many innovative programs, and currently provides training and consultation regarding collaborative approaches to therapy and the development of institutional cultures that support family-centered work.

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Acknowledgments

These acknowledgments, like the book revision itself, both overlap with the first edition and contain significant new additions. Many colleagues, clients, and community agencies made important contributions to the first edition. These contributions live on in this revision, and for that I am extremely grateful. My acknowledgments here primarily focus on those who have made particular contributions to this edition, though some of the original contributions so suffuse these pages that they require repeated mention. Many people have profoundly influenced my work over the years, both directly, through conversations and workshops, and indirectly, through books, articles, and videotapes. Rather than acknowledge all of them, I would like to focus on a few whose ideas have especially influenced the development of this book. Michael White and David Epston’s ways of being with clients have radically transformed my work. Their work offers ways of thinking and practicing that have helped me bring the best elements of myself into my work. I continue to be inspired by the clarity and continual evolution of the ideas of Karl Tomm and Lynn Hoffman. Evan Imber-Black’s original commitment to publicsector families and efforts to expand our conceptual analysis to include the larger helping system have long influenced my work. And the repeated emphasis throughout this book on envisioning possibilities sits on the shoulders of Insoo Kim Berg, David Cooperrider, and Michael Durrant. Many of the families described in this book find themselves embedded in complicated, provocative situations, and I have been very vii

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Acknowledgments

moved by the ability of Marcia Sheinberg, Peter Fraenkel, Virginia Goldner, Alan Jenkins, and Andrew Turnell to handle this complexity in such compassionate ways. Many other great minds and spirits have made more immediate contributions to this book. I want to thank my editor at The Guilford Press, Jim Nageotte, who originally approached me with the idea of writing a second edition, as well as series editor Michael Nichols for his generously blunt comments that helped tighten this book’s conceptual framework and made its expression more accessible. David Epston and Vicki Dickerson are two dear colleagues who were immensely supportive of me as I pondered the possibility of taking on a second edition, and without their strong encouragement I would never have begun this project. Numerous friends and colleagues offered helpful comments about this edition. In particular, I want to thank Sallyann Roth for her help in thinking beyond polarized binaries and Bill Lax for his omnipresent intellectual and emotional support throughout this process. Over the past 10 years, I have been extremely fortunate to draw on a national professional community of support that has enriched my work and life. Among others previously mentioned, I want to express my appreciation to Janet Adams-Westcott, Gene Combs, Barry Duncan, Melissa Elliot, Jill Freedman, Ken Hardy, and Rick Maisel for their obvious and sometimes more subtle contributions to the development of this book. Closer to home, I want to acknowledge the importance of my colleagues at the Family Institute of Cambridge and the Public Conversations Project, particularly Corky Becker, Dawn Belkin Martinez, Laura Chasin, Phil Decter, David Gibbs, Sallyann Roth, and Kaethe Weingarten, who have all been influential in shaping this book. Throughout both editions of this book, I have attempted to translate somewhat esoteric concepts into readily accessible language. Those efforts have been enhanced by my contact with individuals and agencies through numerous trainings and consultations. The lessons I have learned in this process prove that this business of helping others is truly a two-way street. I particularly want to thank members of the Family Institute of Cambridge 2005–2006 Narrative Therapy Program for their help in making this book more reader-friendly. Finally, I want to acknowledge and thank my own family. My partner, Meg Bond, and our children, Arlyn Madsen-Bond and Erik Madsen-Bond, have both tolerated my obsession with this book and simultaneously refused to let it pull me too far away from them. They have kept me anchored in the “real” world and helped me appreciate its wonder. Meg’s support, encouragement, and thoughtful criticism have been invaluable. Her presence permeates this book, and without that

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presence, this book would not exist. The process of witnessing Arlyn and Erik grow into the people they are becoming has been the richest experience of my life. This book is dedicated to those individuals and families who have shared aspects of their lives and allowed the inclusion of their stories in order to help the helping profession. Many of these families have not fared well within traditional service systems, and their willingness to share their experiences and, we hope, inspire our profession to rise to a higher level represents a grace and generosity that I find inspiring. I hope that we can honor that gift by building a professional culture more thoroughly grounded in possibilities, collaboration, and accountability.

Contents

Introduction: Reflective Practice in Frenzied Times

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Chapter 1.

Working with Multi-Stressed Families: Recognizing the Importance of Relational Stance

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Chapter 2.

What We See Is What We Get: Reexamining Our Assessment Process

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Chapter 3.

Collaboration Is a Two-Way Street: Engaging Reluctant Families

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Chapter 4.

Developing a Proactive Vision to Guide Clinical Work: Collaborative Therapy Contracts

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Chapter 5.

Collaborative Inquiry: An Anthropological Approach to “Intervening” with Families

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Chapter 6.

Examining the Relationship between Clients and the Problems in Their Lives

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Chapter 7.

Helping Clients Shift Their Relationship to Problems and Develop Preferred Lives

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Chapter 8.

Developing Communities to Support New Lives

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Chapter 9.

Solidifying New Lives through Therapeutic Documents

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Chapter 10.

Sustaining a Collaborative Practice in the “Real” World

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Appendix A.

One Example of a Strength-Based Assessment Outline

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Appendix B.

Questions to Assess Externalized Problems Rather Than Families

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Appendix C.

Considerations in Collaborative Therapy Contracts

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Appendix D. An Interview Outline to Consolidate

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Alternative Stories

Appendix E.

Coauthoring Termination/Consolidation Summaries with Clients

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References

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Index

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Introduction Reflective Practice in Frenzied Times

This book describes a way of working with families in difficult clinical situations. It examines contexts in which overextended workers in underresourced organizations with continually shifting mandates attempt to help families beset by overwhelming problems and crises. It critically examines many of the assumptions that traditionally organize our work with “difficult” families; highlights the importance of the stance, attitude, or emotional posture we take in relation to families; and outlines conceptual models and clinical practices that help us ground our work in a spirit of respect, connection, curiosity and hope. The book offers a clinical framework that can reinvigorate our work with families who have not responded to more traditional approaches. It outlines four conceptual developments that provide a foundation for this framework and illustrates that framework using multiple clinical examples. This Introduction briefly takes up some broader questions about the rationale for working with families, introduces the four conceptual developments, and highlights developments and challenges to implementing a collaborative approach since the publication of the first edition of this book.1 As a starting point, consider the following vignette. Kire, a relatively new family therapist, was waiting for a family that was late for an appointment. While waiting, he decided to check messages and heard the following series of messages about this family: 1

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COLLABORATIVE THERAPY WITH MULTI-STRESSED FAMILIES Beep—Hello, Kire. This is Mrs. Smith from Corwin Elementary School again. Lateesha is still acting out. She was suspended today, and I’m not sure how much longer we are going to be able to tolerate her behavior. I hope you will talk to her about this. I referred her to you because I heard you were especially good with children of this kind. Please call me as soon as possible. Beep—Hello, Kire. This is Mandy from the Department of Children’s Services. I’m afraid I wasn’t able to get an extension for funding for Lateesha and her family past four more sessions. I wish I could tell you something different, but I hope you’re able to accomplish something with this family in that time. Lord knows they need it. Beep—Hey, Kire. Look I’m really sorry but I have to cancel our supervision today because I have to go to the Quality Assurance meeting to discuss the new forms. I know you had a family that you really wanted to talk about. Maybe we can meet later in the week. Beep—Hi, Kire. This is Becca, Lateesha’s mom. We’re going to be a little late. Lateesha got suspended from school again, and I got called in from work to pick her up. We had a huge fight in the car on the way home, and she jumped out and ran away. Anyway, I tracked her down and we’re headed over to your office now, but she’s refusing to talk to me and I don’t know what to do. We’ll be there shortly, and I hope you have some ideas about what to do with her ’cause I’m at my wit’s end. Beep—End of messages.

As Kire hung up, he found himself thinking, “Oh great, what the heck do I do now?” Does this sound familiar? Have you ever found yourself pondering a similar question? There’s a lot of force behind that question. Therapists working with “difficult” families can put substantial pressure on themselves to be helpful. Parents can look to us, as clinicians, for answers while simultaneously distrusting our ideas. Other helpers, desperate for change, can impose unrealistic demands. Funders continually push for better outcomes with fewer resources in less time. And new advertisements for drug companies and cutting-edge treatment protocols tantalize clinicians with the possibility that there might be magic answers to our difficult questions. The question “What the heck do I do now?” has become all too familiar. I don’t want to minimize the importance of this question. When Lateesha and her mother come into Kire’s office, it is important that he has some clarity about his intentions in responding to them. His interactions with them may have powerful effects on their relationship and

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their future. However, despite the insistence of this question and the pressure to come up with a great answer by yesterday, I want to suggest the usefulness of slowing down a bit. Our response to the question “What the heck do I do now?” can be enriched if we have first considered other important questions like: • Why are we meeting with families, anyway? • What is our purpose in meeting with families? • How are we relationally positioned in our conversations with families? • How are we thinking about families and problems in those conversations? • And finally, what are we saying and doing (and not saying and not doing) in those conversations? These questions are taken up throughout this book. My intention is not to provide simple answers to these complex questions. In fact, the spirit of this book is characterized more by the posing of questions than by the provision of answers. Here I offer some thoughts in relation to these questions to contextualize the thinking that organizes this book and invite readers to reflect on some of their own thoughts and questions. I begin with a brief examination of why it is helpful to meet with families and then consider a metaphor that captures an overarching purpose to guide clinical interactions.

WHY INVOLVE FAMILIES? As we consider the question of why to involve families, the ways in which we respond to that question have powerful effects on how we approach our work and on the relationships we develop with clients. One response to this question would be that we meet with families because they are part of the problem in people’s lives. Wynne, Shields, and Sirkin (1992, p. 13) summarize this perspective thus: “The hypothesis that family systems are causative in generating or maintaining symptoms provided much of the impetus for starting the field of family therapy.” One of the important origins of family therapy grew out of research on the etiology of schizophrenia. The thrust of most early family formulations was to better understand and spell out the roots and persistence of pathology. Although there has been a gradual shift from identifying pathology to eliciting family resourcefulness, there is a historical trail littered with fault-finding concepts like schizophrenogenic mothers, enmeshment, and function of the symptom. The legacy of those

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concepts continues to affect our thinking today. These ways of thinking about families position helpers in particular relationships with them. Seeing families as part of the problem can invite judgment, suspicion, and criticism. As Chapter 1 highlights, the relational stance we hold with clients profoundly shapes the way in which our work with them unfolds. David Epston (1999, p. 140) has described his own commitment to “meet people with compassion rather than suspicion.” Another response to this question would be that we meet with families because they are the most powerful solution in people’s lives. Although this is an admirable claim, it can sometimes violate our experience of the families we work with. When families are captured by bitterness, frustration, or utter despair, it may be hard to see them as part of a solution. In addition, when families’ lives are characterized by neglect and abuse, the claim that they are the most powerful solution in people’s lives can be seen as going beyond romanticizing families to becoming a downright dangerous assertion. My own response to this question requires a rethinking of what we mean by “family.” I think “family therapy” is perhaps an inadvertent phrase. Although families have always appeared in many different forms, diverse family forms are much more apparent today. Despite the reification of the family, often referring to some romanticized entity lost from the good old days, it is hard to know exactly what we mean in referring to “the family.” Anderson, Goolishian, and Winderman (1986) have proposed the concept of the “problem-determined system,” referring to whoever is involved with or talking about the problem. I think we can usefully expand our conceptualization of the family as those important others who might serve as a resource or community of support in a person’s life. In this way, family can include immediate family, extended family, family of origin, family of choice, friends, neighbors, and other important members of a family’s network. We can also think more broadly and include “evoked presences” such as instant-messaging friends we’ve never met, important people who have passed on, even literary or imaginary characters. With this expanded definition of the family in mind, we can think about involving families in clinical work because they are potentially the most powerful resource in people’s lives. Much of the work I describe here begins with an assumption that important people in someone’s life have intentions to be a resourceful community. Although that assumption can be a challenging one to hold at times, I believe it is useful. We can begin with this assumption and then set about proving it to ourselves. This assumption positions us in particular relationships with clients and has effects on our relationships and on our clients’ experience of themselves in the context of such relationships.

Introduction

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WHAT IS OUR PURPOSE IN MEETING WITH FAMILIES? Clearly, responses to this question are varied and context specific. However, one metaphor I have found useful to frame an overarching purpose in our work is a story metaphor. Much has been written about stories and narratives from a wide range of perspectives. In an attempt to keep this book interesting, I draw on the movie The Wizard of Oz to highlight three aspects of a story metaphor: (1) stories shape experience, (2) individual stories are embedded in and shaped by broader family and cultural narratives, and (3) interactions invite the enactment of particular stories.

Stories Shape Experience Our experience of life and self are profoundly influenced by the stories we tell as well as the stories told about us. Jerome Bruner (1990) suggests that human beings organize their experiences in the form of stories. Narratives or life stories provide frameworks for ordering and interpreting our experiences in the world. At any point, there are multiple stories available to us, and no single story can adequately capture the broad range of our experience. As a result, there are always events that fall outside any one story. However, over time particular narratives are drawn upon as an organizing framework and become the dominant stories of our lives. Narratives organize our field of experience, promoting selective attention to particular events and experiences, and selective inattention to other events and experiences. These resulting dominant stories are double-edged swords. They make our world coherent and yet, in the words of White and Epston (1990, p. 11), “prune from experience those events that do not fit with the dominant evolving stories that we and others have about us.” In this way, much of our lived experience goes unstoried, is obscured, and phenomenologically does not exist. Particular narratives can become problematic when they constrain us from noticing or attending to experiences that might otherwise be quite useful to us. We can see an example of this process in the Scarecrow in The Wizard of Oz. His refrain “Oh, I’m a failure because I haven’t got a brain” reflects a life story that organizes his experience of self. Scarecrow’s experience of events in his life is filtered through this life story of failure. That story highlights information that reinforces the view of self as a failure and disqualifies information inconsistent with this view. Scarecrow, who could sing and dance, would be regarded in some quarters as quite accomplished. In fact, throughout the story, he is extremely competent. In one scene, Dorothy and Scarecrow are walking down the Yellow

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Brick Road and stop to get apples. Unbeknownst to them, the apple trees are alive and become irate at the thought of having their apples picked. Scarecrow, in a stroke of creative genius (and an early example of a strategic intervention), goads the trees into throwing their apples at him, and then he and Dorothy have lunch. Scarecrow is also the one who develops a plan to get into the witch’s castle to rescue Dorothy. And yet Scarecrow doesn’t perceive his own competence or his accomplishments. The life story of “Oh, I’m a failure because I haven’t got a brain” precludes recognition of events that fall outside it. This life story becomes problematic because of the limiting effects it has on Scarecrow’s life. Scarecrow’s life story is similar to the types of stories that come to organize the lives of many clients. Often, the life stories of families coming for services have pervasive themes of incompetence, inadequacy, and shame. These stories “prune from experience” those events that do not fit within their dominant story, and shape what they “see” and believe about themselves. So, too, our understanding of our own lives is shaped by life stories or narratives. However, these limiting stories are not simply individual stories. They are embedded in and profoundly shaped by broader cultural narratives that organize our sense of self and our relation to the world.

Individual Stories Are Shaped by Broader Cultural Narratives Scarecrow’s life story is a good example of an individual life story that is embedded within a broader cultural story. Given a certain dearth of historical information, it is difficult to examine the ways in which Scarecrow’s life story may be embedded in family-of-origin narratives. However, we can identify broader cultural expectations that support his life story of failure. Scarecrow complains that he is a failure at his job because he “can’t even scare a crow.” The idea that he should be accomplished in his profession and that he should be able to intimidate those subordinate to him (e.g., crows) can be seen as expectations that cause him considerable distress. These specifications (ideas about who he should be) are supported in our culture (and perhaps in Oz) by broader societal ideas of how men should be. Scarecrow’s life story of failure may exist within a broader gender discourse (e.g., “Real men scare crows”). His life story of failure may also exist within a broader cultural valuation of success, accomplishment, and achievement, in which one’s worth as a scarecrow (or a human being) is often measured by one’s performance in a work role. In this way, performance in one’s job can become a broader statement about one’s adequacy in life. Placing individual stories within a historical and cultural context provides a better appreciation of the power and influence of that context.

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So, what is the relevance of this broader context to therapy? Therapy can become a place where clients have an opportunity to reflect on the stories that shape their lives and decide whether these stories really suit them. It is useful in this reflection process to examine the degree to which the stories that organize clients’ lives are in turn shaped by broader cultural stories. Viewing individual narratives within the broader constraining context of cultural ideas has the potential to significantly reduce self-stigmatization. It shifts the onus of blame from the individual to constraining cultural ideas and highlights personal agency (and accompanying responsibility) in challenging those cultural expectations. Our work can then help clients examine the limiting effects of broader sociopolitical stories on them and begin to develop and enact life stories that offer more choices and possibilities.

Interactions Invite the Enactment of Stories In our interactions with others, we perform or enact our life stories and invite others to participate in them. Our interactions with others are interpreted through life stories and consolidate existing life stories. However, interactions that fall outside existing life stories and are different enough to be notable may challenge current life stories. As helpers, we are often invited to participate in the enactment of existing family narratives, and the way in which we respond to that invitation can have a profound effect. In fact, we may be invited simultaneously into several possible family narratives. We can respond by noting the range of possible narratives into which we have been invited and selecting which ones we’ll respond to and in what ways. Interactions between families and helpers can inadvertently invite the enactment of pathologizing and constraining life stories. Our interactions with clients can also invite the enactment of liberating and empowering life stories. Returning to The Wizard of Oz, we can think about Scarecrow, Tin Man, Cowardly Lion, Dorothy, and Toto as a nontraditional family receiving help from a Wizard of a therapist. Do you remember their first encounter with him? He appears in a billowing cloud of smoke and fire, proclaiming, “I am Oz, the great and powerful. Who are you?” Dorothy responds, “I am Dorothy, the small and meek.” As the family members begin to tell their story, the Wizard interrupts them. He knows why they have come (perhaps from their intake sheet). He is in charge and defines the turf. As each family member stutters and tries to respond, Cowardly Lion sums it up by fainting. As you reflect on this interaction between the “therapist” and the family, how would you describe it? How are the family members experiencing themselves in the process? What story are they enacting? Would you describe it as an empowering story that opens up new possibilities?

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Now fast-forward to the family’s next meeting with the Wizard. The session again begins with the same power dynamic, but this time the family is stronger and more defiant. Toto pulls aside the curtain, and the Wizard is forced to come out from behind his socially sanctioned role. There is a profound shift in their interactions. Initially, the family members are angry that he is not the all-knowing Wizard they had believed him to be. Dorothy asserts, “Oh, you’re a very bad man.” The Wizard, stepping out of his expert role, replies, “No, I’m a very good man. I’m just a bad Wizard.” As he shifts his position, there is a profound shift in the family. The Wizard acknowledges and highlights its members’ competence. He says to the Scarecrow, “[Great thinkers] think deep thoughts and with no more brains than you have! But they have one thing you haven’t got—a diploma.” He gives him a diploma to acknowledge and honor his competency. For the first time in the story, Scarecrow perceives his competence, exclaiming, “Oh joy, rapture, I have a brain!” In this second meeting, the Wizard elicits the family’s expertise and recasts it in a new light. In the interaction, Scarecrow and other family members experience themselves quite differently. This new experience begins to enlarge their previous story. The development of this richer story has probably also been profoundly affected by events outside the session, such as their success in dealing with the Wicked Witch. Scarecrow’s broader emerging story brings into experience his resourcefulness. Although this lighthearted example captures many important points, there is one important distinction to be drawn here. The Wizard is in a sense pointing out Scarecrow’s resources and offering him a new story. From the perspective outlined in this book, the goal is not to point out strengths and resources or offer a new and improved story for clients, but rather to draw on events that fall outside the dominant story to elicit and elaborate broader possible stories through which experience can be filtered, and then engage clients in an examination of the possibilities inherent in expanding the range of stories that shape their lives. This shift from “pointing out strengths” to eliciting richer stories and supporting previously obscured experiences is examined repeatedly throughout this book. For now, take note that every interaction has the potential to invite the enactment of particular stories. As a result, every interaction is an intervention. With this in mind, several points become evident: • It is important to address not just presenting problems, but also the organizing life stories within which they are embedded. • It is important to focus on the process of service delivery as well as its content. • It is important to understand clients’ experience of our interactions with them.

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• It is important to use ourselves in ways that minimize the enactment of constraining life stories and invite the enactment of empowering life stories. The next section introduces four conceptual developments that can be useful in guiding us in our interactions with clients.

FOUR CONCEPTUAL DEVELOPMENTS THAT CAN REORGANIZE OUR WORK WITH FAMILIES This section briefly introduces several phrases that will be used throughout this book and the four conceptual developments that form the foundation of this approach. The developments introduced here are subsequently elaborated throughout the book: 1. Recognizing the importance of our relational stance with families. 2. Viewing clients as being in a relationship with the problems in their lives. 3. Developing a proactive vision to guide our work with clients. 4. Engaging in collaborative inquiry.

Recognizing the Importance of Our Relational Stance with Clients A collaborative approach to our work reflects a focus on the attitude or 2 stance we take in relation to clients. That stance is the foundation for all subsequent clinical work. This book examines what I have come to call a relational stance of an appreciative ally. The phrase “relational stance” refers to the way in which we approach clients. We can choose how we position ourselves in relation to others. We can position ourselves in ways that strengthen respect, connection, curiosity, and hope in the therapeutic relationship. We can also position ourselves in ways that inadvertently pull us toward judgment, disconnection, and disapproval. The stance we take in relation to clients has profound effects on the relationship and is shaped by the values and conceptual assumptions with which we enter. The phrase “appreciative ally” refers to a stance that allows clients to experience us as being “on their side.” This stance requires a continual search for elements of competence, connection, and hope in our work with families. Those elements help us to better anchor ourselves in this type of relationship. This stance has both pragmatic and aesthetic benefits. The work with families is more efficient and effective when anchored in this relational stance, and it better reflects how many of us

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generally prefer to be with people in the world. Chapter 1 further examines our relational stance with clients.

Viewing Clients as Being in a Relationship with Problems in Their Lives The phrase “multi-stressed families” reflects an attempt to view family members as separate from and more than the problems in their lives. The clients in this book have been described in many ways. Some of the adjectives typically attached to them include highly resistant, noncompliant, dysfunctional, high-risk, chaotic, disorganized, and multiproblem. At times, families behave in ways that make labels of this type extremely compelling. At the same time, the labels organize how we view families and what we attend to in our interactions with them. As a result, these labels have a tendency to become self-fulfilling prophecies. When we view families only through such pejorative labels, we strip away the richness of their lives and demean the integrity of our work. This book proposes an alternative to the traditional description of “multi-problem families.” If we are going to refer to families in difficult situations with some kind of label, a more appropriate one might be “multi-stressed families.” This phrase better captures the stresses and pressures that operate on these families. “Multi-stressed” recognizes the difficult realities of their lives, yet also orients us to the capacities, abilities, and know-how that families can access to address those stresses.3 In order to support this conceptual development of viewing people as being in a relationship with problems, this book draws on the narrative therapy concept of externalizing (White & Epston, 1990). Externalizing conversations frame problems as external to clients. When we think about a person as having a problem or being a problem we run the risk of conflating that person’s identity with the problem (e.g., “I have depression” or “I am a depressed person”). This can imply that change requires the alteration of one’s very being and can invite despair, shame, and/or defensiveness. Thinking about people as distinct from problems, and yet in an ongoing and changeable relationship with them, opens possibilities for renegotiating that relationship. As clients perceive themselves in a relationship with a problem (rather than having or being a problem), they often experience a sense of relief, a bit of distance from the problem, and a greater ability to address the problem. Externalizing conversations are an attempt to reorganize our thinking in ways that counter shame and blame, minimize defensiveness, and promote client agency (individuals’ capacity to act on their own behalf in relation to problems). This conceptual development is further introduced in Chapter 2 and then explored in depth in Chapter 6.

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Developing a Proactive Vision to Guide Our Work with Clients The third conceptual development reflects a focus on possibilities and preferred ways of being. Often therapy is framed in terms of problems that need to be addressed. There is an understandable focus on what needs to be changed. However, this orientation may have the inadvertent effect of contributing to a continued focus on a problem. Such a focus may not help a client or family develop a sense that things could be different. As David Waters and Edith Lawrence (1993) put it, “One of the great deficits of most therapy is the lack of a proactive vision of what people need to move towards instead of a sense of what they need to move away from” (p. 9). Michael Durrant (1993) suggests that we shift from focusing on what needs to change to focusing on what that changed state will look like; in other words, focusing on the nonproblematic future. When we begin with a focus on clients’ preferred directions in life, we establish a positive momentum that builds connection and minimizes “resistance.” Chapter 4 explores this in more detail.

Engaging in Collaborative Inquiry If, as clinicians, we begin by helping clients to develop a proactive vision to guide our work together and view clients in an ongoing and changeable relationship with problems that pull them away from preferred directions in life, we can reconceptualize our clinical efforts as a process of collaborative inquiry in which we focus on where people would like to be headed in their lives, the challenges that stand in their way, and how they can address those challenges. Rather than simply offering our professional expertise to help clients struggling with these questions, we can view the expertise we hold as the ability to ask questions that elicit, elaborate, and acknowledge the family abilities, skills, and know-how that were previously obscured. I am referring to this as collaborative inquiry to suggest a partnership in which we are tapping the resourcefulness of both client and clinician. This process is not a simple conveyance of professional expertise to clients, nor a simple eliciting of client ideas. Rather, it seeks to develop shared knowledge in the context of therapeutic conversations. Chapter 5 examines collaborative inquiry in detail. These four conceptual developments (recognizing the importance of our relational stance with clients, viewing clients as being in a relationship with the problems in their lives, developing a proactive vision to guide our work with clients, and engaging in collaborative inquiry) form the basis for this book and are woven throughout the rest of the text.

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The next section introduces some of the more recent developments and challenges in the field that pertain to clinicians’ embracing a collaborative approach to therapeutic work.

RECENT DEVELOPMENTS AND CHALLENGES Since the publication of the first edition of this book in 1999, collaborative approaches have gained momentum and been increasingly embraced by many practitioners and agencies. There has been significant excitement about the types of ideas and practices outlined here and in similar books and articles. Families have responded well to the development of more respectful and responsive ways of interacting with them, and many agencies have found that services based on a collaborative stance are both effective and cost-efficient. This second edition updates and elaborates newer developments in working with multi-stressed families and also tries to make previous concepts more accessible and relevant. At the same time that there is growing enthusiasm for these ideas and practices, many clinicians have also experienced increased challenges in pursuing them within agency contexts. Among the challenges that will be important to address are: • The delegitimizing effects of dominant taken-for-granted professional values, assumptions, and practices on clinicians who operate in nontraditional ways. • The dilemma of attempting to develop strengths-based, culturally curious, collaborative relationships while responding to documentation requirements and reimbursement structures that promote a search for client deficits, obscure client wisdom, and encourage a hierarchical, instrumental approach to clients. • The paradox of inviting reflection on clinical practice in the organizational turmoil that characterizes underfunded agencies and leaves workers complaining that they have “no time to think” and are “working too hard to work smart.” These challenges and ways of addressing them are addressed throughout this book, with a particular focus on them in Chapter 10. NOTES 1. Throughout this book I interchangeably use the terms “therapist,” “clinician,” “helper,” “worker,” “counselor,” and “practitioner.” This book is

Introduction

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intended for a wide audience, and there are many terms we can use to describe our roles. Although there are important differences in job titles and responsibilities, I believe one unifying theme is a broader job description of “therapeutic agent” (or people who hope to have therapeutic effects through their conversations and interactions with others). This is the basic concept I am attempting to convey in the use of these different terms. 2. In my use of the phrase “collaborative approach,” I am referring to a combination of theoretical ideas and practices from narrative, solution-focused, and collaborative language systems therapies. Certainly, these are not the only therapeutic approaches that could be clustered under this rubric. They are simply those that have strong current influence in my work. 3. We could conceivably use the phrase “multi-problem families” to refer to families encountering multiple problems in their lives and still think of the families as distinct from those problems. However, the phrase as traditionally used has such a strong connotation of locating problems within families and collapsing families’ identities into their problems that I prefer the phrase “multi-stressed families.” This phrase tends to orient us to the external stresses impinging on families and better supports a separation between people and the problems in their lives.

CHAPTER 1

Working with Multi-Stressed Families Recognizing the Importance of Relational Stance

Most people who have worked in community agencies are probably familiar with situations such as those described in the following three 1 stories. A particular client, Linda, is notorious among the staff of a local mental health clinic. Mere mention of her name elicits a collective groan. She is a single parent of three children, none of whom know their different fathers. Linda came from an abusive, alcoholic family and grew up in multiple foster homes. She has an extensive drug history, wildly fluctuating mood swings, and an explosive temper. She routinely calls in crisis, and members of the crisis team refer to her as a “frequent flyer.” Numerous clinic staff members are alarmed about her parenting and view her as a “help-rejecting, hostile borderline in denial.” After a recent incident in which Linda ended up screaming obscenities at her son’s therapist in the waiting room, the staff is debating whether to demand an apology for her behavior or ban her from the clinic. Edgar is a 16-year-old, large, menacing-looking boy with suicidal ideation, impulse control problems, and sexually provocative behavior. He has had multiple hospitalizations, and his parents have been begging protective services for an out-of-home placement. The family has been assigned a young home-based worker who is intimidated by Edgar and yet is supposed to help his parents develop better parenting strategies. The worker is profoundly worried that something will happen to Edgar’s younger sister and doesn’t know 15

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where to turn. Her supervisor is on maternity leave and the temporary program director has had difficulty finding time to meet with her in supervision. When the director does meet with her and asks what she is trying to accomplish with the family, she replies, “I have no idea. I’m trying not to think about this case too much.” Crystal never seems to catch a break. She has an estranged daughter and two sons with recurring health crises. Her life has been an endless progression of tragedy and trauma. She was sexually abused by her four older brothers, two of whom died in accidents as teens. Six months ago, her live-in boyfriend shot himself. She recently lost her job and is impoverished and socially isolated. She accepted the referral for family therapy with the same fatalistic resignation that has permeated her life. Her therapist discusses her in a case presentation meeting and notices a pervasive gloom as team members begin to dissociate. That night, the therapist tries talk to her husband about the difficulty of listening to so many painful stories in her work. He responds by shaking his head and saying, “God bless you, honey. I don’t know how you do it.” Strangely, she doesn’t feel comforted.

RELATIONAL DIFFICULTIES IN THERAPY The preceding stories highlight some of the relational difficulties that can develop between clients and helpers and the effects that these difficulties can have on clinicians’ work with multi-stressed families. Let’s examine these difficulties.

Loss of Connection Clinical situations like those just described can be emotional roller coasters. Our reactions to them can run the gamut from judgment to fear to despair to resignation. The ways in which we make sense of and handle these reactions shape our interactions with clients and may threaten our clinical connection. The mutual frustration that grows out of conflictual situations, such as that generated by Linda’s interactions with the mental health clinic, can fracture relationships and lead to further adversarial interactions that polarize and escalate anger and blame. Difficult clinical situations can also provoke concern and fear, as evidenced in Edgar’s situation, and make it difficult to develop open, appreciative relationships. Finally, the relentless trauma and sorrow in lives such as Crystal’s can become too painful to bear. As we seek to protect ourselves from overwhelming despair, avoidance becomes an appealing coping strategy. Each of these situations presents a danger of losing our connection with

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clients. This danger is exacerbated as funding cuts lead to fewer available resources for families at risk. As the pace of work increases, there is more stress and less time and space to acknowledge our challenging emotional responses to families and to reflect on how to engage them. We, the clinicians, and families become increasingly reactive to or avoidant of each other, and our helping efforts become stuck.

Loss of Competence The overwhelming nature of problems confronting multi-stressed families and the inadequate patchwork of available services can also pull us into feelings of incompetence. We can feel scared, inadequate, and unable to safely express those feelings. In hearing stories such as Crystal’s, we can be captured by tragedy and victimization and lose sight of client resourcefulness. As we work hard to help families make changes in their lives, we can reflect on the apparent lack of progress and begin to question our own competence. Improvements seem so minimal, especially when compared with those shown in videotapes of magical interventions by the “masters” of family therapy. We can blame ourselves, clients, or the system, but we become profoundly attuned to what is not working. In addition, we are constantly subjected to pressures to do more with fewer resources. Managed care wants a 30% increase in functioning in 40% less time, agency mandates shift without notice, and paperwork eats up more and more hours. Amid all this, we can end up wondering why we ever got into the field in the first place, lose sight of our own abilities, and have difficulty seeing competence in clients.

Loss of Direction Folksinger Steve Goodman’s song “The I Don’t Know Where I’m Going but I’m Going Nowhere in a Hurry Blues” captures another feeling that can often accompany work with multi-stressed families. Often we don’t even know where to start. We feel overwhelmed by the multitude of problems and our own emotional reactions. Every time we think we have a focus, a new crisis hits and we end up feeling as though we’re starting from scratch. In response, we can become frustrated with clients and blame them for the crises, referring to them with such phrases as “crisis prone.” Or we can drift into resignation, going through the motions of talking with clients and wondering when the session is going to end. In either case, any thought of actual change becomes a distant possibility.

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Loss of Hope The magnitude of problems confronting families can at times become overwhelming. As we listen to the relentless tragedy and trauma in Crystal’s life, it is easy to become caught in despair and resignation. Reflection on the system’s apparent inability to adequately respond to clients like Edgar and his family only exacerbates these feelings. We can be dismayed by the task of trying to help people in unbearable situations and wonder about our own audacity in taking on this work. We can lose hope that things can be different and begin to search for ways to protect ourselves from both the wrenching pain in clients’ lives and our own sense of impotence. The loss of hope makes it extremely difficult to continue doing this work.

Loss of Balance In an attempt to deal with these dangers of losing connection, competence, direction, and hope, and to provide better services to families, numerous calls have arisen for strengths-based, collaborative approaches. Although this book reflects such a shift, a loss of balance can accompany these efforts. We can enter families’ lives romanticizing the strengths we credit them with and ignoring or minimizing the limitations, difficulties, and pain that also exist in their lives. In the process, we may avoid difficult but important conversations with families. This lack of balance may leave family members feeling that we don’t understand the severity of the difficulties in their lives, or it may direct us away from taking real risk factors into account. If we focus only on family strengths, we risk missing situations in which children are being abused, women are being battered, or individuals are doing substantial harm to themselves. Isn’t this a cheerful beginning? Aren’t you glad you picked up this book? I wanted to start here to acknowledge that this work has many potential dangers. It is hard work and ripe for cynicism, despair, and resignation. Yet working with families such as these can also be challenging, stimulating, and rewarding. This book describes a way of thinking about and working with families that have not been well served by mental health, social service, and medical systems. It attempts to do so in a way that acknowledges the difficulties that can accompany this work and yet emphasizes the potential reward and personal gain for therapists working with them. Having considered some potential dangers of working with multi-stressed families, let’s begin to examine a way of approaching clients that can help us avoid these dangers and stay connected to our hopes and values. The following story introduces the foundation of this approach.

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A LESSON IN HUBRIS A number of years ago, I took a job in a large agency to help staff members providing home-based therapy develop their family therapy skills. I was greeted enthusiastically by workers who welcomed my expertise in family therapy, and I entered with a certain degree of hubris. I had a lot of family therapy experience and believed the staff would benefit from it. Although many of the front-line staff members were experienced homebased workers, they were not “technically proficient” therapists. They had neither an articulated conceptual framework nor a set of techniques from which to draw. And yet they were very successful with families who had not responded to previous services. This was puzzling. It challenged much of what I had learned as a family therapist. These people knew little about family therapy and yet were doing great work with families. How was I to make sense of this? As I talked to both staff members and families, I was struck by consistent themes. The staff members, by and large, didn’t see the families with which they worked as “resistant” or “pathological.” Rather than view family members as some strange or dysfunctional “others,” they described them as “regular folks.” Some might describe these staff members as inexperienced or naive, but they preferred to think of themselves as “experienced optimists.” The family members, in describing their experience of receiving services, repeatedly said things like “The workers were so respectful; I know we gave them a hard time, but they just kept coming back,” “They were the first professionals who really listened to me,” “They treated my kid like a normal kid, not a mental case,” and “I liked talking to them because no matter how hopeless I felt, they always believed I could do better.”

ATTITUDE AS THE FOUNDATION OF CLINICAL WORK As I pondered the apparent paradox of staff without formal training doing effective work with families once considered unreachable, I became convinced that the foundation of clinical effectiveness lies in the basic stance we hold in regard to clients and the way we position ourselves in relation to them. I think this is particularly true with families we designate as “difficult.” Our most important clinical quality is the attitude, stance, or emotional posture we take in relation to clients. That stance is the foundation for all subsequent clinical work. Although this assertion is a simple and perhaps commonsensical one, I believe it has profound implications and represents a significant change from how most of the mental health system currently operates.

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Throughout the history of psychotherapy, numerous authors from a wide range of theoretical perspectives have highlighted the importance of the therapeutic relationship (e.g., Aponte, 1992; Duncan, Miller, & Sparks, 2004; Nichols, 1995; Rogers, 1957, 1961; Sullivan, 1953; and Yalom, 2002, to name a few). In conversations with families about their experience of helpful services, the consistently emerging themes have revolved around how families felt they were treated by helpers. Clients have repeatedly emphasized the importance of interactions characterized by respect, connection, curiosity, and hope. For the past 40 years, this point has been consistently echoed by the common factors literature in psychotherapy outcome studies. This extensive collection of literature has examined differential contributions to psychotherapy outcome and concluded that 40% of therapy outcome is attributable to client factors (those things clients are doing in their lives outside of therapy), 30% is attributable to common factors (relationship factors such as empathy, respect, warmth, and genuineness), 15% is attributable to the provision of hope and the expectation of change (which I contend could be another relationship factor), and 15% is attributable to technique (what clinicians do in therapy) (Asay & Lambert, 1999; Dore & Alexander, 1996; Hubble, Duncan, & Miller, 1999; Lambert, 1992; Lambert & Bergin, 1994; Patterson, 1984). The research findings encourage some powerful realignments in how we approach clinical practice. If client factors are the single most powerful contributor to psychotherapy outcome, it behooves us to find ways to draw upon and enhance client resourcefulness. If relationship factors and the construction of hope are considered together, the relational stance we hold with clients becomes particularly important. Research on the power of the alliance reflects more than 1,000 findings (Duncan et al., 2004). A positive alliance is one of the best predictors of outcome (Horvath & Symonds, 1991). Families are more likely to put a therapist’s suggestions into practice when family members perceive the therapist as understanding them and caring about them (Kuehl, Newfield, & Joanning, 1990). In fact, clients’ perceptions of therapists’ attitudes better predict successful therapy outcome than do therapists’ perceptions (Bachelor, 1991; Free, Green, Grace, Chernus, & Whitman, 1985). The hope that therapists bring to therapeutic interactions also contributes to change. Successful therapists hold greater hope for clients (Frank, 1982), and efforts to heighten client hope may be as genuinely therapeutic as specific techniques (Connor-Greene, 1993; Lambert, 1992). Increasingly, the field of mental health is recognizing the importance of the stance or attitude with which clinicians approach families. One example of this is Blow and Sprenkle’s (2001) call for more attention to

The Importance of Relational Stance

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common factors in marriage and family therapy training. However, the development of therapist attitudes still receives minimal attention in professional education and training, and the current organizational context of mental health and social services along with an increasing focus on evidence-based practice can pull for an instrumental focus on interventions and technique. This instrumental focus (according to literature just cited) accounts for a minimal portion of outcome and can lead to a situation in which clients experience helpers as experts acting on them rather than allies working with them. That stance may provoke a response from clients who resent the experience of being “acted upon.” That response may be interpreted by professionals as “resistance” or “noncompliance,” leading helpers to either pathologize or try to counter that response. The resulting behavioral sequence between clients and clinicians contributes to therapeutic “stuckness.” In an era of cost containment and the search for more efficient techniques, the field may be losing sight of the simple fact that respect, connection, curiosity, and hope are cost-effective. Throughout this book, the phrase “relational stance” is used to refer to the ways in which we approach clients. This phrase has also been described as a philosophical stance (Anderson, 1997), an emotional posture (Griffith & Griffith, 1992, 1994), a conceptual posture (Tomm, 1995), and a position (Elliot, 1998; Winslade, Crocket, & Monk, 1997). Each of these descriptions emphasizes a “way of being in relationship with our fellow human beings, including how we think about, talk with, act with, and respond to them” (Anderson, 1997, p. 94). Whereas this way of being has been in the background of collaborative approaches to therapy (an umbrella term referring to narrative, solution-focused, and collaborative language systems therapies), I want to move it to the foreground in order to evaluate our ways of thinking and acting in terms of their potential to support this way of being with clients. This emphasis on the importance of our relational stance does not diminish the importance of therapeutic techniques. Our conceptual models (how we think) and clinical practices (how we act) position us in particular relationships with families and profoundly influence families’ experiences of themselves in that interaction. With this in mind, we can evaluate our conceptual models and clinical practices by examining the kinds of therapeutic relationships they encourage and the effects of those relationships on clients’ experience of self in their interactions with us as helpers. The relational stance we hold reflects a choice, and there are various options. We can let the pull of problems and difficult situations, as well as the conceptual models and clinical practices we happen to utilize, position us with clients. We can also consciously choose how we would prefer to position ourselves with clients and draw from conceptual models and clinical practices that help to keep us anchored in that

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relational stance. The ways in which we think and act help us to embody the spirit or stance that is the foundation of our work.

BECOMING AN APPRECIATIVE ALLY My preferred relational stance with families can be described as one of an “appreciative ally” (Madsen, 1999a). This description refers to a stance in which we position ourselves in alliance with clients and in which clients experience us as “in their corner” or “on their side.” Drawing on more politicized language, this stance could be described as standing in solidarity with clients as they resist the influence of the problems in their lives. Appreciation is an integral part of this stance. We can begin with a focus on what is working in clients’ lives and seek to support and elaborate on that. We can continually search for elements of competence, connection, and hope in our work with families. Those elements help us better anchor ourselves in this type of relationship. This stance has both pragmatic and aesthetic benefits. The work with families is more efficient and effective when anchored in this relational stance, and it better reflects how many of us generally prefer to be with people in the world. A relational stance of an appreciative ally is characterized by a spirit of respect, connection, curiosity, and hope. Although we could think of these as inherent personality characteristics, I find it more useful to view them as ways of being in the world that we actively attempt to bring forward in our interactions with clients. This conceptualization draws from social constructionist approaches to psychology that view the “self” as something we construct in social interaction with others rather than an inherent essence. This shifts the focus from “who” we are with clients to “how” we are with clients. I prefer this focus because it opens more possibilities for us in how we position ourselves with clients. If the qualities of this relational stance are personal characteristics, we are in a position of either having them or not (e.g., she is empathic, he is judgmental) and then we’re stuck with that situation. If we consider our relational stance to be a way in which we deliberately choose to position ourselves with clients, it opens up space for us to create very different relationships with clients. We can begin with an appreciation for the honor of being invited into people’s lives, attempt to enter into their experience, and acknowledge and validate their pain and joy in the world. We can take the time to get to know clients as best we can and actively look for ways to connect with them. We can emphasize our similarities with clients and view them as regular human beings struggling with problems in some of the

The Importance of Relational Stance

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same ways we all do. We can look beyond the problems in people’s lives and develop ways of thinking about them that sparks our interest in getting to know them more. And we can hold onto an unshakeable faith that people can do better in their lives and that they have the resources to address the difficulties in their lives. At times, our most profound work can be aimed at keeping hope alive in the darkest of times. This is not naive romanticism, but rather experienced optimism. Holding a stance of an appreciative ally does not mean that we uncritically accept everything clients do or that we ignore our own strongly held values and positions. It is important to acknowledge negative emotional reactions to clients whose actions we find intolerable. Implicitly invalidating those reactions can be shaming of us as clinicians. At the same time, in working with clients who shock, offend, infuriate, or sadden me, I have repeatedly found that significant work begins only after I have been able to find something (however small) that I can appreciate and respect about them. That kernel of appreciation and respect is the foundation for an alliance and subsequent work. Valuing a stance of an appreciative ally also does not limit us in taking a stand on important issues. There are times when we may decide to confront clients about the effects of their actions on others and times when we may decide to act in ways that will be experienced by clients as “not being on their side” (e.g., arranging involuntary hospitalization for someone who is considering suicide or filing a child abuse report on a parent). The important issue in taking a stand in situations like this is not whether we do so, but how we do so. A useful approach is offered by Sallyann Roth (1999, 2006a), who raises four questions that can guide difficult conversations: • • • •

Am I speaking my truth with integrity? Does my speaking move the relationship forward? Is it more, rather than less, likely to be heard by the other? Do I like what I’ve said and how I’ve said it?

I think these are useful guidelines that can help professionals to have difficult conversations with clients from a relational stance of an appreciative ally. This focus on process is both an aesthetic and pragmatic decision. As Alan Jenkins (1996, p. 122), who works primarily with abusive men, put it this way: I remain convinced that I cannot assist a man to give up patterns of abusive behavior by abusing him in return. I cannot assist a person to respect

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COLLABORATIVE THERAPY WITH MULTI-STRESSED FAMILIES others’ personal boundaries by violating his own. Respectful therapy involves a process of knocking on doors and waiting to be invited in, rather than breaking them down, barging in, and then expecting to be welcomed with open arms.

It’s important to acknowledge that holding a stance of an appreciative ally with clients is often easier said than done. The clinical situations described in this book are complex and difficult. The stresses that families face can be overwhelming, and their behavior can be outrageous. And the ways in which we are encouraged by many conceptual models to make sense of and respond to problematic client behavior often exacerbate the problem. In an attempt to provide some direction for the development of a relational stance of an appreciative ally, the rest of this chapter examines four commitments that underlie it: striving for cultural curiosity and honoring family expertise, believing in the possibility of change and building on family and community resourcefulness, working in partnership and fitting services to families rather than families to services, and engaging in empowering processes and making our work more accountable to clients. These commitments are framed as active verbs to highlight the point that we are attempting to intentionally conduct ourselves in particular ways in therapeutic relationships.

STRIVING FOR CULTURAL CURIOSITY AND HONORING FAMILY EXPERTISE Our understanding of challenging clinical interactions can be constructively viewed through a metaphor of a cross-cultural negotiation. I’ll illustrate this metaphor with a story. A number of years ago, when I was training family practice and pediatric residents in a large public hospital, I heard a story of a woman who came to the hospital to have a baby. The delivery went without complications until the physician who delivered the baby congratulated the mother, exclaiming, “You have a beautiful baby boy. In fact, he is one of the most beautiful babies I’ve ever seen.” Rather than joining the physician in his appreciation of her son, the mother became apprehensive and retorted, “No, it’s an ugly baby.” The physician was perplexed and sought to reassure the mother that her new son was perfectly healthy, quite normal, and very beautiful. However, the more he attempted to reassure her, the more upset she grew. She became agitated and began crying, “Get out of here. Leave me alone. He is an ugly baby; ugly, ugly baby.” The physician wondered about the

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mother’s emotional state. He thought she might have an attachment problem and became concerned for the baby’s well-being. He decided to separate them in order to give the mother time to calm down. However, the attempted separation backfired and resulted in the mother desperately clinging to the baby and trying to hide him under the bedsheets. At this point, the physician retreated to consider his options. He thought the woman might be psychotic and potentially abusive. He considered a psychiatric consultation and wondered about contacting protective services. He was puzzled and alarmed. This is a perplexing situation until one puts it into a particular context. The mother was a Southeast Asian woman who believed in the existence of dabs, or evil spirits, that can steal away the souls of beautiful babies. Within this prevailing cultural belief, she believed it was important to camouflage the beauty of her baby. From this perspective, the mother’s actions become protective and caring, whereas the physician’s proclamations of the baby’s beauty potentially put the baby at risk. This story highlights an unfortunate cultural mismatch. A cross-cultural metaphor can be useful when applied to the therapeutic process. We can view both families and helpers as distinct cultures with particular beliefs and preferred styles of interacting, embedded in a wide range of taken-for-granted assumptions. Therapy can be seen as a cross-cultural negotiation in which the two cultures interact in a mutually influencing relationship (Harkaway & Madsen, 1989; Madsen, 1992). In this negotiation, the beliefs and interactions of a client or family may be more understandable through their perspective than ours. In the previous example, the mother’s emotional outburst makes sense in her cultural context. She is not a “crazy” person but a concerned and protective mother who is pursuing her only option in the face of the physician’s apparent disregard for her baby’s welfare. Similarly, the physician’s actions make more sense within his cultural context. In this situation, the difficulties that developed did not stem from a crazy mother or a neglectful physician but grew out of a cross-cultural exchange that went awry. It is important to note that this cross-cultural exchange does not occur on a level playing field. In this exchange, the physician and his culture take a dominant position and are much more visible in the interaction. The mother and her culture occupy a more marginalized position and can be easily overlooked or rendered invisible. As Jean Baker Miller (1976) has pointed out, people in a subordinate position usually know significantly more about people in a dominant position because they have to. Although a cross-cultural metaphor has been most commonly applied at a macro-level to refer to broader ethnic or sociological

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differences, it is also useful with any family we encounter. To encourage our consideration of each family as a distinct culture, we can refer to individual clients or families as “micro-cultures.” In thinking about particular families as micro-cultures, it is important to enter into their lives with an attitude of curiosity, seeking to learn about them while developing a keen sensitivity to the influence of broader macro-cultures. The concept of micro-cultures can be particularly applicable with families who seem most like us. Because they seem like us, we can fall into the mistake of thinking we know who they are, that we (metaphorically) speak the same language, and that their taken-for-granted assumptions are the same as ours. It is important to remind ourselves that we need to figure how the world looks from their perspective. Viewing each family as a foreign micro-culture encourages an attitude of cultural curiosity in which we actively try to elicit a family’s particular meaning rather than assume we already know it or that it is the same as ours. To fully understand the complexity of each family, it is useful to approach it as a unique culture and to learn as much as possible about that culture. Some of this learning can be accomplished by asking family members to teach us about them. It can be useful to think about entering each family as an anthropologist looking to elicit client meaning rather than looking to assign professional meaning. Such an endeavor can be supported by entering with a stance of “not knowing” (Anderson, 1995, 1997, 2005; Anderson & Goolishian, 1988, 1992). I have come to refer to this as an attitude of cultural curiosity. Just as anthropologists (or, more accurately, ethnographers) immerse themselves in a foreign culture in order to learn about it, therapy from an anthropological stance can begin with immersing ourselves in a family’s phenomenological reality in order to fully understand its members’ experience. Within family therapy, a cultural metaphor has been proposed as an alternative to the prevailing systems metaphor, with the idea that families may be more usefully viewed as cultures than systems (Pare, 1995, 1996). Clifford Geertz (1973), a prominent cultural anthropologist, differentiates between thin and thick description in considering an anthropologist’s task. Thin description refers to those portrayals of other cultures that are arrived at through categories derived by the anthropologist (e.g., the aforementioned physician viewing the Southeast Asian mother’s response to his declaration of her baby’s beauty as evidence of dysfunction). Thick description is arrived at through interpretations that are anchored in the other culture’s own categories of understanding (e.g., searching for the cultural belief within which the mother’s actions make sense). Clinically, thin descriptions attempt to fit clients to professional categories, whereas thick descriptions attempt to understand people within their own experience. Geertz is critical of thin description. He

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regards any descriptions of an action that “attempt to cast what it says in terms other than its own as a travesty—as the anthropologist’s severest term of moral abuse, ethnocentric” (Geertz, 1973, p. 24). Ethnocentrism is the emotional attitude that one’s culture is superior to others. At times, we in the therapeutic community can fall into therapeucentrism, referring to the tendency to privilege our categories of understanding clients’ lives above others. We can mistake our categories for objective facts rather than interpretive frameworks that we developed to support our work. We can become oblivious to clients’ perspectives, either assuming they are the same as ours or simply placing more stock in our own values and beliefs. Therapeucentrism inadvertently suppresses the reality of different perspectives. In the process, valuable information is lost and we risk cross-cultural negotiations that are experienced by others as dishonoring them. An example of therapeucentrism is reflected in the story of Linda, the client described at the beginning of this chapter. Linda was viewed by the clinic staff as a “help-rejecting, hostile borderline in denial” (a potentially very thin description). She had many questions about what was happening in her son’s individual therapy and was quite insistent on getting them answered. Her son’s therapist viewed her demands to be more involved in that therapy as evidence of enmeshment and poor boundaries. He responded by working harder to keep her out of the therapy in order to protect the confidentiality of that relationship. If we draw on a cross-cultural metaphor and seek to understand the context in which Linda’s actions might make sense, we discover that Linda had a long history of physical and sexual abuse in various foster homes, as well as emotional abuse by previous helpers. Within that context, her demand to know what a stranger whom she doesn’t trust is doing all alone with her son in a locked room makes perfect sense. Her fury at the therapist when he tells her he can’t tell her what is going on and implies that she should not be asking that question takes on a whole different light in this context. When we enter into clients’ lives without an attempt to develop a rich understanding of the texture of their lives, we risk being experienced by them as arrogant, patronizing, or oblivious. Clients may respond to us by acquiescing (e.g., Linda could simply comply with the therapist’s demand that she not question his rules and thus feel abused by authority yet again), rebelling (e.g., Linda could refuse to comply with a rule of confidentiality that she fears puts her son at risk), or a mixture of both (Linda could loudly protest and also experience herself as disempowered and pathetic). Each response has powerful effects on the story she will tell about herself and her interactions with helpers. Viewing Linda’s actions within the context of her experiences, values,

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and beliefs helps us develop a more compassionate view of her actions and interact with her in more constructive ways. Although an anthropological approach can be useful, it is often difficult to remain curious when we observe events that challenge our own values and beliefs. The following questions may provide some help in this process: • In what context might this behavior make sense? • What might be a positive intent behind the behavior I find frustrating? • How can I come to respect and appreciate that positive intent even if I don’t condone the behavior? • What do I not know about the members of this family that might change my opinion of them? • What could I learn from this family? If we view each family as a distinct micro-culture and regard clients as the experts on their experience, our role moves beyond intervening with families to bring about particular outcomes. We can become curious inquirers dedicated to bringing forth family abilities, skills, and know-how.2 Rather than imparting professional knowledge, we can jointly develop new ideas that draw on both local client knowledge and our professional experiences and understandings. In this process, we move into learning with clients (Hoffman, 1992). As we invite clients to teach us about their competence, connection, and hope, they begin to experience themselves in important new ways. The art and skill of this process lies in how we organize our questions to elicit information. In the process, new ideas emerge and clients experience themselves in a different, richer fashion.

BELIEVING IN THE POSSIBILITY OF CHANGE AND BUILDING ON FAMILY AND COMMUNITY RESOURCEFULNESS As we enter family cultures, what we look for profoundly shapes what we see and how we experience that culture. What we see shapes how we act, and how we act reinforces what we see. We can enter families with a focus on deficit and dysfunction, and it will affect our interactions with them and the possibilities that emerge. We can also enter with a focus on possibilities and resourcefulness. We are always faced with a fundamental choice that guides all subsequent action. That choice involves whether we are attending primarily to what is and could be or to what isn’t and should be.3 Historically, the field of mental health has been strongly influenced by a deficit model. A deficit model assumes certain knowable norms for

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family organization and interaction. Whatever deviates from those norms is assumed to be defective. Services then focus on fixing that which is in need of repair, inadvertently reinforcing a focus on dysfunction. This process puts helpers in a position of identifying what is missing or broken in families and attempting to address that. In contrast, a resource model of family functioning assumes the following: A family is continually generating its own norms in an interacting context of history, culture, ethnicity, social class, politics, interpersonal relationships and individual quirks. The therapist searches for strengths, and attempts to remain respectfully curious and open to difference. Diversity is welcomed. Therapy is seen as that which facilitates the family’s creative capacity to solve problems, to effect healing, to generate development and to gain new knowledge, first with the therapist and then without the therapist. (Imber-Black, 1986, p. 149)

Increasingly, the field of family therapy has embraced a belief in possibilities and a commitment to building on family resourcefulness. All families have the capacity to grow, learn, and change and often have significant untapped abilities, skills, and knowledge that can be useful in their lives. A resource model does not ignore difficulties, but prefers to focus on expanding competence. A deficit model and a resource model can be thought of as stories or narratives held by practitioners that organize what is seen. Our stories about families shape our view of them and promote selective attention to some factors and selective inattention to others. What we see and attend to shapes how we act with others. Professional stories about Linda, the woman described earlier, provide an example of this. Clinic staff viewed Linda as a “help-rejecting, hostile borderline in denial.” That story promoted attention to her “borderline” nature, her interpersonal difficulties, and her incompetence as a parent. It became a self-fulfilling prophecy and influenced the staff’s interactions with her. Linda was expected to be out of control and yet was also asked to publicly apologize for her behavior. Her interactions with staff members in turn confirmed their story about her (as well as her story about them), leading to a situation that was extremely frustrating for everyone involved. Linda was later referred to another clinic for family therapy and had a different experience. Two therapists working together met with various members of Linda’s family. Having heard about Linda’s previous experience with professional helpers, they made a deliberate choice to approach her quite differently. They viewed Linda as a trauma survivor whose whole childhood had been a fight to stay alive. They saw her as overwhelmed at times by shame and humiliation and viewed her substance use as a way to cope with that shame. They were impressed with

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her commitment to quit drugs for her children and risk confronting shame. Knowing that Linda was fiercely protective of her children and had a long history of bad experiences with professionals, they structured an initial meeting as an opportunity for Linda to interview them to see whether she would be willing to entrust her family’s “intimate life” to their care. Subsequently, they drew on Linda as a consultant for ongoing work with her children. Linda’s relationship with these therapists had its ups and downs. She was volatile and often challenged them. They appreciated Linda’s strong feelings and saw her as someone who gave them opportunities to practice sitting with clients experiencing intense affect. Linda’s trust grew slowly but surely, and as she came to believe that the therapists’ faith in her was real, she became less reactive and more resourceful. These therapists actively tried to develop a different story about Linda, and the resulting interactions held much more promise. To summarize here, what we look for shapes what we see. What we see shapes how we act with others. And how we act with others shapes what is possible to occur. This juxtaposition of Linda’s experiences with helpers is not a comparison of a “good” team and a “bad” team. I invite readers to view it as a story about the interpersonal effects of our conceptual frameworks. I am encouraging critical reflection on our conceptual models, not critiquing individuals influenced by those models. Moreover, in juxtaposing a narrative of pathology and a narrative of resourcefulness, it is important to avoid a polarization in which clients are seen as simply dysfunctional or resourceful. There were significant difficulties in Linda’s life. However, the ways in which we make sense of those difficulties have powerful effects. A deficit model often situates client lives in a tragic story. There is a focus on what is missing and what has been lost. A tragic story can have significant appeal. There is a certain drama that accompanies it. However, it can also obscure possibilities for clients. A resource model often situates client lives in a heroic story that acknowledges the tragedies in their lives but also emphasizes their courage in confronting multiple stresses. A heroic story can pull for a appreciative connection with clients without losing sight of life’s challenges. A deficit model is a strong organizing assumption in our field and is supported by a number of factors. One of the most pressing is the immediate context of our work. Mark Karpel (1986) points out that clients typically go to therapists because they (or someone) feel something is wrong. They arrive unhappy in some way, and the purpose of therapy can easily be seen as trying to understand what is “wrong” and do something about it. Because we are being asked on a daily basis to “fix” something that is wrong, it makes sense that we have developed a language for this endeavor. By the time clients get to therapy, the problems

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that bring them have often become entrenched and occupy significant space in their lives. In the words of Michael White and David Epston (1990), clients’ lives have become “problem-saturated.” Michael Durrant (1993) suggests that helpers’ views of clients are often derived from inadequate or skewed data. We see people when things are not going well, and such a skewed sample easily leads us to see the world in terms of dysfunction, pathology, and deficit. A couple I saw put it this way: “You know, you really see us at our worst.” We could view this statement as a minimization of their situation or as a sobering comment on the limited views we get of people in a clinical setting. Our immediate work context often promotes selective attention to problems and inattention to resourcefulness. Our work is also shaped by professional assumptions that strongly support adherence to a deficit model. The field of mental health has a long tradition of attempting to identify, categorize, and describe pathology. This is reflected in the diagnostic categories available to us, the assessment questions required by licensing regulations, and the documentation requirements for continued funding. Our field is much more organized around what is wrong with people than what is right with them. Much of our adherence to a deficit model can be traced to the evolution of a medical model as the dominant metaphor for understanding problems in living. The medical model was developed to address physical maladies. It seeks to describe symptoms, group them into syndromes, and understand their etiology in order to develop cures. It has proved extremely useful in the treatment of acute and infectious diseases. For example, from 1900 to 1980, the development of antibiotics and improved immunological measures brought most infectious diseases under control (Burish & Bradley, 1983). However, this stunning success in addressing acute physical maladies has not translated well into addressing chronic physical illnesses (which have replaced infectious disease as the most prevalent form of sickness in the United States) and is even less applicable as a metaphor for problems in daily living. The application of a medical model to social functioning has encouraged us to view human life through a lens of disease, with a strong focus on presumed pathology within the individual. In the process, the broader context of social interaction and meaning is obscured. The family as a social context is essentially ignored except as the locus and source of trauma (which can position counselors and families in an adversarial relationship). And the influence of broader social, economic, and cultural factors disappears almost entirely. As a result, what began as a major triumph in one arena (infectious and acute physical illnesses) has become quite limiting in the field of mental health. The problem here is not the medical model, but our continued unquestioned adherence to it.

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Much of family therapy has also replicated this search for pathology. Attempts to view individual clients within a family context have often shifted from labeling the patient as the problem to labeling the family as the problem. Family therapy began with research on the etiology of schizophrenia, and the thrust of most early family formulations was to better understand and spell out the roots and persistence of pathology. Increasingly, there has been a gradual shift from identifying pathology to eliciting resourcefulness; however, there is still a historical trail littered with fault-finding concepts such as schizophrenogenic mothers, enmeshment, and function of the symptom. The legacy of those concepts continues to affect our thinking. Finally, as a participant in a workshop I once led, put it: “Competence is quiet; it tends to be overlooked in the noise and clatter of problems.” I like that quote. I have two children. When they are getting along well, it’s easy for me to not notice (despite my best intentions to pay attention to those times and remark on them). However, when they are fighting, it’s impossible to not notice. Is that true in your life? In your own clinical supervision, do you talk more about the aspects of your work that are going well or the problems you encounter? If you drive to work, are you more likely to notice when traffic flows smoothly or creeps at a snail’s pace? Are you more likely to write a letter to your congressional representative when he or she does something you like or when he or she does something you dislike? We are all steeped in a culture that promotes attention to complaints and problems. Competence is quiet. The trick is to listen carefully for it.

Advantages of a Belief in Possibilities and Resourcefulness When we begin with a focus on resourcefulness, we are less likely to provoke resistance. I assume that for most of us that it is easier to introduce ourselves to strangers by talking about what we do well than by leading with our deepest, most shameful secrets, and this holds true for clients as well. When exploring problems, building a foundation of competence provides a reminder that families are resourceful as well as struggling with difficulties. Eliciting resourcefulness evokes a sense of competence and pride that provides a stronger foundation from which to derive solutions to problems. Focusing only on problems can be demoralizing. Recognizing resourcefulness invites hope and opens possibilities. A belief in possibilities and resourcefulness also provides an organizing focus for our work. Waters and Lawrence (1993) point out that many therapy models offer elaborate schemas for investigating what’s wrong with a person but little for what’s functional or effective. We are likely to study people’s difficulties ad absurdum but altogether ignore

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their assets. The development of a proactive vision offers a map for moving forward in life. When we begin therapy with an exploration of resourcefulness, we are better positioned to help clients draw on their resources to address problems. In addition, a focus on client resourcefulness adds to the accumulated wisdom brought to clinical situations. Clifford Geertz (1973) draws a distinction between expert and local knowledge. Expert knowledge includes those bodies of professional knowledge that have been written, published, and given credence in our society. Local knowledge is that wisdom that grows out of people’s daily lives and experiences. A focus on resourcefulness encourages us to elicit clients’ local knowledge. In the example described earlier, the second team’s consultations with Linda about their work with her son resulted in a number of creative ideas that they would never have developed on their own. In addition, as clients and workers share knowledge, new ideas are collectively developed. As the second therapy team and Linda discussed her family’s situation, they synergistically generated new ideas for helping her son that far exceeded the usefulness of prior attempts by either party. Finally, a belief in possibilities and resourcefulness has the potential to enrich our clinical work. If you think back to the two Lindas described previously, would you rather work with a help-rejecting, hostile borderline in denial or a trauma survivor who is intensely committed to her children and yet wary about whether she can trust helpers? When we focus on client resourcefulness, clients become more intriguing human beings. They become easier to respect and appreciate. We begin to realize that we may also learn something from them. It offers the potential for this work to become something that is quite remarkable. I am not romanticizing clients’ lives here. Let me reiterate that a belief in resourcefulness need not minimize the difficulties that exist in people’s lives. It is important to avoid a dichotomous way of thinking in which clients are seen as either dysfunctional or simply resourceful. We need to acknowledge both the abilities of families and the difficulties they confront. However, beginning with a strong appreciation of family competence serves as an important foundation for helping them address the problems that enter their lives.

WORKING IN PARTNERSHIP AND FITTING SERVICES TO FAMILIES If we believe that families are the experts in their lives and often have more competence than we realize, our work together can become a collaborative process that draws on the abilities, skills, and knowledge of

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both parties. Therapy proceeds much better when based on a collaborative partnership in which the nature of the relationship is jointly determined. Research studies have suggested that the degree of client collaboration and client participation may well be the best predictors of successful treatment outcome (Hartley, 1985; Orlinsky, Grawe, & Parks, 1994; Stiles, Shapiro, & Elliot, 1986). If collaboration is jointly defined, cooperation becomes a two-way street and helpers as well as families can be noncooperative. As clinicians, with our culturally conferred status and professional privilege, we are typically in a position to determine the prevailing definition of therapeutic relationships. However, we benefit from attending to how clients experience these relationships. Partnership is an interactional process. Inasmuch as helpers hold a leadership position in the relationship, a collaborative partnership begins with our finding ways to cooperate with clients and make our work relevant to them, rather than simply expecting them to cooperate with us. Collaboration also involves honoring the expertise of all involved parties. Clients are the best experts on their experience. When that expertise is acknowledged, they are better able to draw on it. Clinicians have expertise in creating contexts that help clients to envision possibilities and draw on their resourcefulness to address the problems that stand between them and preferred lives. In my own work, I find that I can be more helpful to families when I stay grounded in my area of expertise (supporting them in their life journey). I often become less useful when I stray into their areas of expertise (determining the direction of that journey).4 A collaborative partnership is enhanced when we come across as regular human beings rather than distant professionals with clients. In daily practice, this connection is supported by talking in a conversational way rather than conducting interviews, checking our use of jargon, and attempting to match clients’ language. The process of connection is facilitated by emphasizing our similarities with clients while acknowledging and becoming curious about our differences. The connection we make with clients is influenced by our assumptions about our place in their lives. In community agencies clients are often assigned to workers, with little choice in the process. We can fall into assuming that because they are “our” clients, we have a right to enter their lives and ask personal questions. We need to be careful about such assumptions. A conceptual device that can help us stay grounded in collaborative partnership is to refer to clients in our heads as “the people we work for” and to see our presence in their lives as a privilege that needs to be earned. In collaborative relationships, there are attempts to acknowledge and minimize the power differential between clients and therapists. As

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therapists, even though we may not experience it at times, we are in a privileged position in our relationship with clients. Therapy typically occurs in our space, at a time we largely set, and in a structure we largely determine. We diagnose clients and keep the official record of our work in our charts. And we are paid for being in the relationship (albeit not much at times). Clients are culturally defined as being in need of help, are expected to disclose potentially embarrassing aspects of their life (even though they may choose not to), and are more likely to feel vulnerable in the interaction. Although attempts to flatten hierarchy in the relationship have beneficial effects, it is important to acknowledge that given the structural power differential in therapy, it is impossible to have a totally egalitarian relationship. It would be a mystification to pretend that the relationship is an equal one, and it runs the risk of obscuring the responsibilities that accompany our privileged position. A metaphor that can support collaborative partnership is the idea of working on family turf (Madsen, 1999a). This metaphor can be considered both literally and metaphorically. The development of home-based therapy serves as a concrete example of the shift from professional turf to family turf. Home-based therapy emerged as an effective alternative for clients who have not been well served by more traditional programs services and falls within a broader approach to service delivery called “family-centered services.” Family-centered programs typically include short-term intensive services that are delivered primarily in clients’ homes, a focus on the whole family as the client, 24-hour availability so that services are delivered according to the family’s schedule rather than the provider’s schedule, a strong focus on integrating concrete services as well as traditionally defined “clinical” services in an attempt to respond to a broad range of family needs, and the active involvement of families in determining their own treatment plans (Berg, 1994; Berg & Kelly, 2000; Berry, 1992; Hartman, 1992; Kaplan & Girard, 1994; Kinney, Haapala, & Booth, 1991; Sandau-Beckler, Salcido, & Ronneau, 1993). Other examples of family-centered approaches to service delivery include wraparound services and family group conferencing. Wraparound services involve flexible, strength-based formal and informal services being wrapped around a family in the context of their own community, based on individualized plans in which families have a strong voice. (Swartz, 2004; VanDenBerg & Grealish, 1996). Family group conferencing consists of structured processes for family members (with significant advance preparation and available information and resources) to take the lead in devising plans to ensure a child’s welfare and safety while professionals hold more of a supporting role (Hardin, Cole, Mickens, & Lancour, 1996; Mirsky, 2003a, 2003b, 2003c).

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Family-centered services have resulted in a radical reorientation of services. Many home-based workers have been profoundly affected by the context of working in clients’ homes rather than professional offices and have come to view both their work and relationships with clients in quite different ways. There is something profoundly different about doing therapy in clients’ homes (family turf) rather than in our offices (professional turf). The context of home-based work structures the therapeutic relationship in a distinct way. For example, think about how it is different when the therapist shows up out of breath, late for an appointment after hitting bad traffic, and the family is wondering what the “real” meaning of the lateness might be. The power hierarchy is significantly flattened in home-based therapy. Whereas an office-based therapist might announce to the family that he or she is going behind the mirror to consult with the team, a home-based therapist is much more likely to encounter family “team members” (such as the chatty next-door neighbor or the teenager’s boisterous friends) who drop by unannounced and join the session or bring it to a close. The context of home-based therapy also makes it difficult to hold a disengaged expert stance. For example, consider the effect of any of the following situations on the therapeutic relationship: At the end of a session, you have to ask family members if you can use their bathroom, which unfortunately doesn’t have a door. Immediately after a difficult session, you return to ask the family’s assistance in jumping your car battery because you inadvertently left your lights on. Family members suggest that their 13-year-old boy walk you to the subway stop because they don’t think you’d be safe walking there by yourself. The context of home-based therapy exposes our own vulnerabilities and offers opportunities to come across as a regular human being (as well as highlighting family resourcefulness in responding to trying circumstances). For many of us as home-based therapists, collaboration is a daily practice rather than an abstract idea. Conversations occur over coffee around a kitchen table or in a living room surrounded by family photos. We are guests rather than experts and need to conduct ourselves differently. Finally, in home-based therapy, the therapist is much closer to the family’s lived experience. For example, a therapist is told, “You might not want to sit by that window. A bullet came through there last week.” The

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family goes on to describe how the police have been inadvertently bursting into the wrong apartments recently as part of a crackdown on drugs in the projects, and one of the family members jokingly says, “If they kick in our door tonight, do you think they’ll believe you’re our therapist?” As the therapist has difficulty holding his train of thought while staring at the door, he suddenly feels in his gut what the family experiences on a daily basis. He begins to wonder what they draw on to cope with their living situation. In this way, the context of home-based work offers helpers an intuitive grasp of client experience that is less accessible in other contexts and supports the development of an appreciation for our clients’ wisdom and expertise. This immersion in family experience is a significant aspect of the power of home-based treatment. In my experience with family-centered services, families often express the sentiment, “You folks were the first helpers who really understood us.” These contextual elements that flatten hierarchies, humanize our interactions with clients, and invite us more directly into an appreciation of family experience all contribute to a collaborative partnership. The commitment to working in partnership is reflected in attempts to work on family turf by making ourselves relevant to families and fitting services to them. This can be reflected in the design of all services, ranging from user-friendly waiting rooms and intake procedures, to family involvement in clinical discussions, to being accountable to clients for how meetings are conducted. (Ideas for developing institutional structures that support collaborative partnership are discussed further in Chapter 10.)

Advantages of Collaborative Partnership The advantages of collaborative partnership for clients can best be described by clients. The following exchange comes from an interview I did with two women from Parents Helping Parents (a self-help parent group) about their experiences in receiving mental health services. Here they talk about the importance of partnership between helpers and parents. KAREN: I think what you’re talking about is what I call breaking down the barriers and equalizing the relationship between professionals and parents. When you’re sitting in a therapist’s office and the therapist is sitting across from you in his or her professional attire and you’re the person with the problems and you’re feeling very ashamed about yourself in the first place, there’s a definite hierarchy. It feels like this person sitting across from me has his or her life

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all together and I’m a mess, even though rationally we know that’s not true. But that’s what it feels like, and to have somebody be able to meet you on an equal footing and connect as a human being— well, it just changes everything. BILL: How does that change things? If helpers connect with you as human beings rather than as the experts, how does that change things? KAREN: I think it decreases the feelings of shame and helplessness. To me, it gets rid of the feeling of I’ll never be able to live up to where this person is or I’ll never be able to get it as together because no matter what I do, I’m always going to be one step below. NAOMI: I think what happens in that situation for me, when professionals are more human, is I’m more prone to being honest and to really be who I am. A lot of times, I carry around this image of myself. You know, how I’m supposed to behave, and what a good parent is, and I’m always doing, doing, doing. And the bottom line is I’m always feeling less than, like I’m not up to par. My image of professionals is that they’re smart, they’re put together, they’re just all that I would like to be, and when I see that they’re human and have their own struggles, I learn from that. I learn that I’m okay. I learn that we’re all in this together. Nobody is perfect and so I’m more honest. KAREN: I think there’s a huge difference in focusing on what a person needs help with in a way that makes them feel less than others because they have problems, and in a way that makes them feel human because they have strengths and weaknesses, which we all do. Clearly, conducting therapy on family turf, humanizing the relationship, and acting in partnership have powerful effects for these women. This way of working also holds potential risks and powerful opportunities for us as therapists. There is a certain amount of vulnerability when we step out from behind our professional roles. We run the risk of not knowing ahead of time how to respond to clients, of feeling that we are on the spot, and of having to acknowledge our own uncertainties. We also run the risk of more deeply connecting to clients’ painful experiences, as well as experiencing our own feelings that are triggered in the process. These risks are also opportunities. The development of collaborative partnership has the potential to become a transformative process for us as well as for clients. We have opportunities to make powerful connections, to be profoundly moved, and to learn important lessons about ourselves, others, and life.

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ENGAGING IN EMPOWERING PROCESSES AND MAKING OUR WORK MORE ACCOUNTABLE TO CLIENTS As we seek to work in partnership with clients, our efforts may support them in building the lives they prefer and at times may inadvertently constrain them in those efforts. This section focuses on empowering and disempowering processes, highlighting some of the ways in which professional actions may inadvertently undermine clients and examining ways to make our work more accountable to the clients we serve. The phrase “empowering processes” is used to refer to ways of thinking and acting that acknowledge, support, and amplify people’s participation and influence in developing the lives they prefer. “Disempowering processes” refers to ways of thinking and acting that may disqualify, constrain, or supplant people’s participation and influence in their lives. The focus on empowering processes rather than empowerment is deliberate. It orients us to professional actions and their effects on clients. As we interact with clients, our actions have certain effects on them. Our actions may have empowering effects, they may have inadvertently disempowering effects, and they may have mixed effects. For example, consider the different consequences for a mother’s sense of competence with her son when a male therapist sets limits on her son’s rowdy behavior in a family therapy session and when he helps her to set limits. In addition, the way in which he chooses to attempt to help her may have differential effects. The therapist may draw upon her past successes with her son and the wisdom she holds about him to help her develop more effective ways of dealing with him, or he may offer suggestions from a parenting training manual that, although effective, disqualify her knowledge and violate her preferred ways of being with her son. Every interaction with clients invites particular experiences of self and the enactment of particular stories. These interactions may have positive, negative, or mixed effects. It is useful to draw a distinction between the intent behind our actions and the effects of those actions. Helpers generally attempt to act in empowering ways, but their actions may have inadvertent disempowering effects on clients. For example, a team holds a case conference and includes parents in an attempt to be family centered. In one of these meetings, the therapist begins a description of her work with the family by glancing at the mother and then saying to the team, “I began working with this case when DSS filed a C & P and the son was placed in an ASU to assess suicidality and whether he had an Axis II diagnosis.” The therapist continues while everyone, except the mother, nods knowingly. What impact do you think this experience might have on this mother? How might it be for her to be referred to as “this case,”

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followed by a string of unintelligible acronyms? If you were in her shoes, how would you feel about being in a room and hearing your life described in unfamiliar words to a group of strangers, believing that you were the only one who didn’t have a clue about what was being said? The mother who related this incident to me described her reaction: “I thought we were coming to the meeting to all talk about my son’s future, and when the therapist started, I realized that there was no place for me in the room. I felt really stupid and really pissed at my son for getting me into that situation.” No one in the meeting had intended to negatively affect this mother. The way in which they spoke is fairly common practice in “case discussions.” However, that manner of speaking had a devastating impact on this mother’s participation and sense of influence in both the meeting and her life at that moment (and potentially on her son’s well-being when she returned home). I find it useful to draw a distinction between common clinical practices and the helpers engaged in them. The ways of speaking in the team meeting were not originated by the professionals who attended. Speaking in jargon is a common, taken-for-granted professional practice that can capture all professionals. I believe that helpers engaging in professional practices have positive intentions, and that sometimes those practices have inadvertently negative effects. The best judges of the effects of professional actions are those on the receiving end of them. It is important not to lose sight of the good intentions behind our actions. However, it is also important to be accountable for the effects of our actions on clients that occur despite our best intentions. Our actions with clients are shaped by taken-for-granted assumptions about our role and what it means to be a “professional.” There are a number of ways in which we, as therapists, are encouraged to view our job as acting on clients to change them or to repair damage. Many traditional clinical approaches are influenced by a medical model that positions professional helpers as “experts” who assess clients, develop treatment plans, and implement a series of interventions designed to bring clients more in line with “appropriate functioning.” There is a privileging of professional knowledge and an invitation into professional certainty that is often reflected in attempts to assign professional meaning rather than elicit client meaning. This is reflected in the ways in which assessments are often conducted (who asks the questions and writes the assessment), and “cases” are often presented (with the subtle encouragement to deliver formulations with objectivity, professional distance, and confidence). It is important to reflect on the effects of these taken-forgranted practices and be aware of the ways in which they can have disempowering effects and supplant client functioning. This inadvertent supplanting of client functioning is supported on many fronts. It is supported by the specialized expert knowledge we are

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taught about development, functioning, and pathology. This has the potential to encourage clients to defer to our knowledge and lose sight of their own. It is supported by professional titles (e.g., “the Doctor will see you now”) and by the semimystical aura of therapy (e.g., the idea that we know and can interpret what is really going on for people). Finally, it is supported by professional language that positions helpers and clients in particular relationships. For example, we have “service providers” and “service recipients,” “case managers” and “cases.” Language used in this way can construct clients as the objects of professional intervention rather than subjects in their own right with intentions, hopes, dreams, and agency. Our inadvertent supplanting of client functioning may also be encouraged by our good intentions and the organizational pressures we face. Many of us come to mental health and social services out of a strong desire to help others. As we stand a little bit outside clients’ lives and view their pain and distress, it may appear to us that there are some obvious solutions that would alleviate this distress. There is a strong pull to fix things. This “fix-it” mentality also receives significant support from the current push for evidence-based treatment approaches and the search for replicable procedures for specific conditions that will save time and money. Clinicians in community agencies are under incredible pressure to produce and document quantifiable changes in client functioning in a shorter and shorter amount of time. As therapy increasingly takes on an assembly-line ethos, we are encouraged into an instrumental orientation that transforms human beings into billable hours. Our conceptualization of our role also influences how we think about and draw on clients’ broader communities. All too often, we are aware of the professional resources available to clients but ignore the power of their natural networks. We make a point of coordinating our work with other helpers but neglect to learn about important neighbors, self-help groups, and faith and community organizations. We are only a temporary presence in clients’ lives, whereas these community resources are embedded in the fabric of their lives. One concept that can help us remember our place in clients’ lives is a distinction between primary relationships (consisting of an individual’s relationships with family and household members, kin, friends, neighbors, associates and acquaintances, and community members) and secondary relationships (consisting of relationships with representatives of social institutions, which include mental health, social service, and health care workers) (Kliman & Trimble, 1983). It is important that we remain secondary and do not inadvertently undermine clients’ primary relationships. Within a commitment to empowering processes, our job is to support, not supplant the knowledge and functioning of clients and their existing communities.

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Making Our Work More Accountable to Clients Our attempts to position ourselves as allies who actively support clients in building preferred lives can be guided by a series of questions to examine the effects of our actions on them: • How might this client be experiencing our interaction right now? • How might they be experiencing themselves in our interaction? • Would they say our interaction is more or less likely to highlight their abilities, skills, and wisdom? • Would they say our interaction is more or less likely to acknowledge, support, and amplify their participation and influence in life? The questions provide a way for us to continually reflect on the effects of our actions on clients. They are rooted in an assumption that the best judges of the effects of our actions are the people most affected by them; that is, those human beings who come to be called “clients.” We can minimize inadvertent disempowering processes by actively inviting clients’ feedback about their experience of our actions and evaluating our work in terms of the degree to which our actions are experienced by clients as respectful, connecting, empowering, and hopeful. One way to do this is through accountability structures. Accountability structures are attempts to amplify the voices of those who have less power in interactions and ensure that those with more power have opportunities to receive feedback about inadvertent negative effects of their actions as well as opportunities (and consequent responsibilities) to acknowledge and address those effects (Hall, 1996; Waldegrave, Tamasese, Tuhaka, & Campbell, 2003). Often, accountability is seen as a unidirectional flow in which those in hierarchically subordinate positions are accountable to those in positions of more power or responsibility (e.g., workers are accountable to supervisors). However, accountability in this context refers to partnership accountability in which parties are mutually accountable to each other, with a particular emphasis on amplifying voices less likely to be heard. We can make our work accountable to clients by routinely inviting their feedback on the effects of our actions in ways that convey a commitment to take that feedback seriously and act on it. We can do this at the end of sessions by checking with clients how the work is going from their perspective and how we can together make it a more useful experience. We can also develop institutional structures to address this so that the maintenance of accountable practices becomes an institutional responsibility rather than an individual inclination. We can include

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clients in clinical discussions and solicit their feedback about the process. When clients are unable to attend such meetings, we can include “client voices” in clinical discussions through having someone listen to the discussion as the client being presented, and then being interviewed about his or her experience of the discussion (Anderson, 1997; Madsen, 1996, 2004). Finally, we can develop clear structures and processes for involving clients in organizational decisions that affect our efforts to help them. Additional ways to make our work more accountable to clients are discussed throughout this book. We can also make our work more accountable to the clients we serve by engaging in practices of “transparency.” David Epston introduced this term to refer to the process of sharing our organizing thoughts and assumptions with clients (White, 1993). The process of clearly identifying the experiences, ideas, and intentions that guide our questions, thoughts, and suggestions helps clients become more aware of the rationale for our actions and participate on a more equal footing in therapeutic interactions. Examples of transparency in the course of therapy sessions include questions like “Would you be interested my thinking behind this question and why I’m asking it?” or “I’m thinking about pursuing this line of questioning—how would that be for you?” I’ve often thought of this process as conducting therapy with subtitles that show our thinking. This both brings clients into the process and helps us to get “on the same page” so that work can proceed in a collaborative fashion. As we check with clients at the end of sessions, we can also offer them opportunities to better understand (if they desire) the rationale behind particular questions or comments made during the session (Madigan, 1993; Nylund & Thomas, 1997). In this way, they can leave with a clear sense of the intentions and hopes behind our clinical practices rather than wondering what we “really meant” by a particular statement or question. Accountability structures and therapist transparency are both means of demystifying our thinking and anchoring it in a specific context rather than contributing to the belief that professional thoughts arise out of some distant “truths” that are inaccessible to clients. These practices help develop a context in which clients are better able to decide for themselves how they might want to respond to our efforts and become more active participants in important aspects of their lives.

SUMMARY This chapter has highlighted the importance of the relational stance we adopt with clients. That stance is the foundation for our clinical work. A

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stance of an appreciative ally is characterized by the active cultivation of respect, connection, curiosity, and hope. Four commitments that support the development of an allied stance include striving for cultural curiosity and honoring family expertise, believing in possibilities and building on family and community resourcefulness, working in partnership and fitting services to families, and engaging in empowering processes and making our work accountable to clients. These commitments help us to maintain this type of relational stance. Our relational stance reflects “how we are” with clients. It underlies and informs our conceptual models or “how we think” about clients, as well as our clinical practices or “what we do” with clients. Our conceptual models and clinical practices help us embody a particular relational stance. Graphically, it can be illustrated in the following way: CLINICAL PRACTICES “HOW WE ACT” CONCEPTUAL MODELS “HOW WE THINK” RELATIONAL STANCE “HOW WE ARE”

The rest of this book explores ways of thinking about and working with multi-stressed families that help position therapists as appreciative 5 allies. The next three chapters outline conceptual models that are useful in thinking about families, problems, and therapy. The subsequent five chapters outline clinical practices that grow out of these conceptual models and support a relational stance of an appreciative ally. The final chapter examines possibilities for weaving a spirit of respect, connection, curiosity, and hope into the fabric of organizational cultures. NOTES 1. The names of clients discussed in this book and the details of their lives have been changed in order to protect their confidentiality. 2. In this book, I refer to abilities, skills, and know-how (or knowledge or wisdom) frequently. In this context, I am using know-how to refer to concrete “hands-on” knowledge or wisdom about life that has been gained in the context of living life. This knowledge is often developed in a social context and shared among people. 3. It is important to emphasize the word “primarily” here. This is not a choice of attending to possibilities or problems, resourcefulness or difficulties,

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safety or risk. Clearly, it is important to appreciate both. However, where we put our primary focus will influence what we see, how we act, and what possibilities emerge. 4. Child protective work is a notable exception to this distinction. In this context, workers have a goal of ensuring a situation is safe enough for children to remain in or return to their home. In that case, their expertise and responsibility also involves making judgments to ensure children’s safety. Nonetheless, collaborative partnerships can significantly enhance protective work. A great resource for further pursuing this possibility is Turnell and Edwards’s (1999) Signs of Safety: A Solution and Safety Oriented Approach to Child Protection Casework. 5. I do not in any way want to imply that the conceptual models and clinical practices described in this book are the only ones that invite the enactment of the relational stance I’m proposing. They are simply ones that I have found particularly useful.

CHAPTER 2

What We See Is What We Get Reexamining Our Assessment Process

In most agencies the need for assessments is taken as a fact of life. Many programs separate out a distinct assessment phase of treatment. However, the process of conducting an assessment can also be a profound intervention. Consider Jeffrey, a 14-year-old boy who has been hospitalized 12 times in the last 3 years. Today, at his most recent psychiatric admission, an intake worker is collecting his previous hospitalization history. As the worker methodically asks him about the details of precipitant, course of treatment, and discharge plan for each hospitalization, she notices Jeffrey growing more and more despondent. The intake worker is only collecting information, not “intervening,” and yet is it any wonder that by the time Jeffrey describes his 11th unsuccessful hospitalization, his sense of self has shrunk to a microscopic level? The questions we ask in assessments not only elicit information, they also generate experience. The process of answering assessment questions shapes clients’ experience of self and powerfully affects how subsequent work will unfold. This chapter critically examines the effects of our clinical assumptions on clients and the process of therapy. It offers a conceptual map for thinking about family difficulties in nonblaming, nonshaming ways and outlines a collaborative assessment process that promotes particular attention to family resourcefulness. 46

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EXAMINING THE EFFECTS OF OUR ASSUMPTIONS In the first chapter, Linda (the client discussed in some detail) encountered two different mental health teams. The first team saw her as a helprejecting borderline with inappropriate boundaries. The second team saw her as a survivor of serious abuse who was desperate for help but wary due to a long history of negative experiences with helpers. As we reflect on Linda’s interactions with the two different teams, several important points emerge. What we look for shapes what we see. Different observers notice different things in a situation. Perception is not a passive process of observation but an active drawing of distinctions (Tomm, 1992). Our distinctions promote selective attention to particular events and selective inattention to others. Our distinctions organize our experience of what we are observing. As therapists, the distinctions we draw are profoundly organized by our conceptual models, our own history, the institutional contexts in which we work, and broader cultural assumptions that shape our interpretation of the world. The different views of Linda and the problems in her life were shaped by the context of the respective teams’ interactions with her, as well as the clinical orientations within which those interactions were interpreted. The members of the first team operated within a medically oriented outpatient clinic, in which Linda felt very uncomfortable. Their work was based on an assumption that treatment must begin with a thorough diagnostic assessment, which encouraged a more formal, distant way of interacting with her. Members of the second team saw Linda in her own home (in which she felt more comfortable) and primarily organized their work around an assumption that therapy must begin with a compassionate connection. The combination of her increased comfort and their commitment to build a connection led to the development of a different relationship and a different view of her. Our assumptions about clients influence our responses to them and position us in particular relationships with them. Our reactions to clients are often communicated in subtle ways and, in turn, invite particular responses from clients. Over time, these mutual responses can develop into repetitive interactional patterns. For example, based on previous interactions, the members of the first team anticipated outbursts from Linda and described themselves as stiffening up when seeing her. Linda, in turn, perceived these team members as critical of her and viewed them as “uptight and judgmental.” She responded with suspicious defensiveness, and an interaction developed that was characterized by mutual mistrust, blaming, and antagonism. As the interaction became more polarized, the parties became more entrenched in their negative views of each other.

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Members of the second team, whose perspective emphasized Linda’s resilience and commitment to her children, had a different reaction to her. They admired her persistence in continuing to seek help despite previous negative experiences and wanted to help her have a different experience in her interactions with them. In turn, Linda felt understood and validated by the members of the second team and responded more “appropriately” with them. Although she had a fiery temper and reacted strongly to perceived slights, she also recovered, and the interactions between the second team and Linda were largely characterized by mutual appreciation. Their respective views of each other led to more constructive interactions, and those interactions reinforced their respective views of each other. Our clinical assumptions have strong effects on our views of clients, on their views of us, and on our developing relationships. If we accept this premise, it makes sense that we need to be conscious about how we choose to view clients, understand problems, and organize our work. The questions we ask and the ways in which we organize the information we receive have a profound effect on our subsequent work. At the same time, it is important to not view this process in a strictly linear fashion. Clients’ actions help to form our views of them, and our views of clients help to form the way we interpret their actions. There is a recursive interaction between the two. However, because we have more control over our focus, we can decide to attend to things that will be most constructive and therapeutic. Our conceptual frameworks can highlight the similarities between clients and us and humanize our relationships with them. Our conceptual frameworks can also highlight our dissimilarities, objectify clients, and invite us to treat clients as “other.” Clinical interactions have the potential to invite the enactment of particular life stories for clients. If we use pathologizing categories to understand families, we run the risk of bringing forth pathology. Conversely, if we use categories that highlight clients’ resourcefulness, we increase the chance of bringing forth resourcefulness and possibilities. In short, what we look for shapes what we see, what we see shapes how we act, and how we act shapes what is possible to occur.

EXAMINING THE CONTEXT OF OUR ASSUMPTIONS Our views of clients are embedded in and profoundly shaped by takenfor-granted professional and cultural assumptions about clients, problems, and the process of therapy. For example, treatment traditionally proceeds through a process of conducting an assessment, developing a treatment plan, and implementing a set of interventions based on that

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treatment plan. This process is anchored in a number of assumptions. It begins with an assumption that a client’s condition can be “objectively” studied and identified in order to treat it. This assumption itself is embedded within a broader assumption that “reality” is knowable and its elements can be accurately and reliably discovered and described, and that the observer who is describing it stands outside the observed system. These assumptions are anchored in a set of beliefs about reality that reflect a modernist worldview. Kaethe Weingarten (1998) has concisely summarized the implications of a modernist approach for family therapy: Within family therapy, a modernist approach entails the observation of persons in order to compare their thoughts, feelings, and behaviors against preexisting, normative criteria. The modernist therapist then uses explanations, advice, or planned interventions as a means to bring persons’ responses in line with these criteria. (pp. 3–4)

This process of entering into a family system, observing how it functions, comparing that to our theories of “appropriate” behavior, and then developing a series of interventions to bring about more “appropriate functioning” puts us in a particular relational stance with families. It positions us as outsiders acting on the system. This stance may provoke a response from families who resent the experience of being acted upon. We, in turn, may interpret that response through our lens as “resistance” or “noncompliance” and either pathologize or try to counter that response. (Chapter 3 examines this process in more depth.) Although many experienced therapists have developed a facility for joining with families in order to be incorporated enough into the family system to “move” them, the basic relational stance remains the same. Rather than working more effectively within this positioning, we could instead focus on repositioning ourselves in ways that allow changes to the basic interactional dynamic. As described in the previous chapter, it is helpful for both pragmatic and aesthetic reasons to position ourselves as allies working with families rather than experts acting on them. In my own efforts to develop conceptual models and clinical practices that fit with a relational stance of an appreciative ally, I have been especially drawn to narrative, social constructionist, and postmodernist, and poststructuralist ideas. Much of the material in this book is influenced by these ideas. At the same time, I also draw on ideas that reflect my original grounding in modernist approaches to family therapy (particularly structural, strategic, and Milan-systemic theories). In attempting to draw from both worldviews, I am striving for utility rather than conceptual purity. Even though my

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work is largely anchored in a postmodern or poststructuralist worldview, I want to acknowledge and honor both my own history and much of the field’s history. I am not going to describe these broader epistemological worldviews in great depth in this book.1 I will try to avoid off-putting jargon and yet bring to life the rich possibilities of these ideas through concrete applications. Social constructionist inquiry focuses on the processes by which people come to describe, explain, and account for the world and their positions in it (Gergen, 1985). Social constructionist ideas are embedded in a postmodern worldview in which there are no essential truths and in which the therapist is no longer an expert who knows how families should solve their problems. Rather than developing a series of interventions designed to bring clients in line with normative standards, the therapist is, in the words of Kaethe Weingarten (1998), a “fellow traveler,” listening carefully and participating in conversations that generate many possible ways forward. Anchored in a lateral relationship in which our thinking is made visible to clients, there is an attempt to honor clients’ abilities to develop solutions and move forward in their lives and to draw on their immediate experience as the criterion against which we measure our efforts, rather than normative models. This worldview fits well with a relational stance of an appreciative ally. A social constructionist conception of the self can be helpful in thinking about the effects of our conceptual frameworks on clients. Many individual psychology models assume that what we call the “self” consists of innate personality characteristics that represent the true essence of the person (e.g., Linda is a “borderline”). These models often take an ahistorical, acontextual approach that isolates individuals from their social context. Social constructionist approaches view the self as constructed in social interaction (e.g., we all have multiple possible selves, and Linda would become a very different woman in different cultures and different historical periods). Our ways of understanding ourselves and our relationships to the world develop in the course of our interactions in the world and are profoundly shaped by those interactions. We are continually creating our identities in the moment as we interact with others. This perspective shifts the focus from “who we are” (as an essential preexisting quality) to “how we are” (our ways of being that are continually developing in social interaction). The person one is continually becoming is profoundly shaped by and inseparable from one’s social context. We grow up in a world of conversations, some involving us, some simply about us. These external conversations become internalized and begin to form the stories we tell about ourselves (Tomm, 1992). For example, Linda has heard all her life that she was “a good-for-nothing,

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out-of-control bitch who was going nowhere in her life.” She heard it from her family, from various boyfriends, and from a culture in which outspoken, assertive women often come to be labeled as strident or a “bitch.” Over time, those conversations became internalized and operated as a framework for making sense of her life. The conversations that helpers have with and about clients contribute to the construction of their identities and experiences of self. The Linda who interacted with the second team became a different woman from the Linda who interacted with the first team. In the course of her interactions in each context, Linda and the two teams shaped her respective identities. This process occurs in and is profoundly influenced by the broader sociocultural context of those interactions. The assumption that the self is constructed in social interaction rather than preexisting can be perplexing and challenging. The claims of social constructionism violate fundamental cultural assumptions that permeate much of Western civilization. However, they provide a useful guideline for approaching clients. If we assume that our conversations about and with clients have important effects on how they become in their lives, it behooves us to think carefully about how we organize both our internal conversations about clients and the interpersonal dialogues we have with them. Our conceptual models shape our internal conversations about clients. We can think about these conversations as the stories we develop about clients in the course of interacting with them. The stories that we carry with us organize what we see and shape how we respond in our interactions with clients. It is inevitable that we develop such stories in our interactions with clients, and it is inevitable that those stories have a profound effect on us, on clients, and on our relationship. Knowing this, we can attempt to develop conceptual models (or professional stories about clients, problems, and therapy) that will have the most useful effects. From a social constructionist perspective, our hypotheses or formulations can be seen as stories we are creating in the course of our interactions with families to organize our work. Within this perspective, it is particularly important to think about the effects of the formulations we are developing. The following questions provide criteria for evaluating the effects of our formulations: • What are the effects of our formulations on our view of clients? • What are the effects of our formulations on clients’ views of themselves? • What are the effects of our formulations on our relationships with clients? • To what extent do our formulations invite respect, connection, curiosity, and hope?

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In an attempt to be sensitive to the effects of our formulations on the relationship we develop with clients, this chapter highlights ways of understanding problems that are nonblaming and nonshaming and that pay particular attention to family wisdom, competence, and resourcefulness. The concept of constraints provides one foundation for a different way of conceptualizing families and problems.

EXAMINING CONSTRAINTS TO PREFERRED DIRECTIONS IN LIFE Many of our attempts to understand situations involve a search for causality (e.g., Why did X happen?). Another way of attempting to understand a situation draws on the concept of constraints (e.g., What prevented something other than X from happening?). When applied to problems in life, the concept of constraints shifts the organizing question from What caused the problem? to What constrains an individual or family from living differently? We can identify constraints at a number of levels, including a biological level, an individual level, a family level (which includes family of origin), a social network level (which includes helpers as well as neighbors, friends, and relevant others), and a sociocultural level (the taken-for-granted cultural assumptions and social practices that inform our sense of self and the world around us). At each level, we can examine those factors that constrain people from addressing a problem differently. The following example highlights constraints across multiple levels.

Constraints across Levels Charlie is a hyperactive 7-year-old Irish American boy in foster care who was removed from his home 3 years ago because of neglect. Both biological parents currently have no contact with him. For the past year he has lived with his second foster parents, Maria and Joey, a childless Italian American couple who hope to adopt him. He has been referred for therapy for help with attentional and behavioral difficulties. When he is alone with his foster parents, he does fine. However, at school and when they visit Maria’s large family, Charlie becomes scared and out of control and ends up fighting with other children. His foster parents, who normally are nurturing, firm, and consistent, become tentative with him, alternately pleading and threatening. Charlie has recently disclosed being sexually abused by an older sibling in his previous foster home, which held a total of eight natural and foster children. His disclosure has prompted a crisis for Maria, who was willing to take in any child except one who was sexually abused and who now feels trapped by discovering

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that Charlie was abused after growing so attached to him. She fears that the abuse will scar Charlie for life and yet is in great conflict with the school personnel, whom she views as scapegoating him after they were told by his protective worker, Pam, that he had been sexually abused. Maria senses little support from Pam, whose office is a great distance away, and feels very alone in now dealing with Charlie’s disclosure. If we pose the question of what constrains Charlie from better managing his behavior, we can identify constraints at a number of levels. Charlie does fine in a small, structured setting. However, in larger chaotic situations, he loses focus and becomes fearful, easily distracted, and unmanageable. At a biological level, attentional difficulties may constrain him from more effectively organizing the myriad stimuli impinging on him. Perhaps medication would help bolster his ability to manage chaos. At an individual level, Charlie states that he “can’t trust adults.” This belief, anchored in his traumatic experiences of being neglected by his biological parents and abused in his first foster home, constrains his ability to turn to Maria and Joey for support when he feels overwhelmed. The lack of support and resulting sense of isolation leaves him even more vulnerable to the disorganizing effects of chaos at school and in Maria’s large extended family. In this way, the effects of trauma may further constrain his ability to manage his behavior in less structured settings. At a family level, we can identify a number of interactional constraints that hinder Joey and Maria’s efforts to help Charlie better manage his behavior. When Charlie begins to misbehave in family gatherings, Joey watches while Maria pleads with him. As Joey gets frustrated with the ineffectiveness of Maria’s pleading, he threatens Charlie that they will go home if he doesn’t straighten out. Maria, anxious to avoid a scene, responds with further pleading, which invites further threats from Joey. This interaction undercuts each parent’s efforts and constrains their ability to more effectively parent together. Their parenting is further hampered by Maria’s family’s dismay at Charlie’s behavior. As Maria’s mother becomes more judgmental, Maria becomes more tentative, which invites increased judgment. The cumulative effect of these patterns constrains Joey and Maria from effectively supporting Charlie in managing his behavior. At a social network level, there is a constraining interaction between the protective worker, Pam, and Maria. Maria’s discovery of Charlie’s sexual abuse has left her feeling lied to and unsupported by Pam. She can’t believe Pam doesn’t understand how shocking the disclosure was for her. Pam, in turn, sees Charlie as one of the more functional kids in her caseload and believes Maria is exaggerating her concern about his

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difficulties. The more Maria feels Pam is minimizing her concerns, the more Maria feels compelled to emphasize them; the more Pam feels Maria is maximizing her concerns, the more Pam dismisses those concerns. As this pattern develops a life of its own, it significantly constrains their ability to work together effectively. Finally, at a sociopolitical level, we can identify a number of ways in which gendered beliefs support particular family interactions and constrain alternative possibilities. Maria’s pleading and Joey’s threatening are embedded in cultural ideas about men’s and women’s roles and power in relationships. Consider Joey’s statement, “I hate it when Charlie doesn’t listen to his mother. I can’t just sit by and let him do that to her.” When asked about that statement, he replies, “What kind of man would I be if I just sat back and let her take that?” This response is strongly influenced by broader cultural ideas about how men and fathers “should” be and act. These ideas can be seen as cultural specifications that encourage particular ways of being and discourage others. Often they are unspoken but extremely powerful. They specify normative roles and delegitimize actions that fall outside those specifications (Freedman & Combs, 1996b). In that sense, they constrain alternative courses of action. Another example of the constraining influence of taken-for-granted cultural assumptions is the way in which Maria experiences significantly more judgment than Joey from her family. She says, “Joey doesn’t notice, but when Charlie starts acting out, I can feel their eyes on me. It’s not enough I couldn’t have my own kids, now I can’t even manage this one.” This statement is embedded in strong premises that evaluate Maria’s adequacy as a woman in terms of her ability to conceive children and manage them. These premises, in turn, are embedded in cultural ideas about Maria’s role as a woman and mother. For both Joey and Maria, these broader cultural ideas both shape and constrain their options in responding to Charlie.

Discourse as a Way to Understand Sociocultural Constraints Numerous authors have suggested the usefulness of “discourse” as a way to examine the influence of our broader culture on individuals and families. Discourses shape the underlying worldviews that structure and guide people’s thoughts, feelings, and actions in a given culture. Rachel Hare-Mustin (1994, p. 19) defines discourse as a “system of statements, practices, and institutional structures that share common values.” In this definition, discourse includes a triad of taken-for-granted cultural assumptions (e.g., in Joey and Maria’s situation, the cultural “truths” that “men should protect their women” and “a mother is responsible for

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her child’s actions”), unexamined daily habits (e.g., Joey steps in to discipline Charlie when he talks back to Maria, and Maria apologizes to her mother when Charlie misbehaves), and the economic, political, and cultural institutions that support and are supported by these assumptions and actions (e.g., a gendered division of labor in which men have higher earning power and taking care of children is seen primarily as “women’s work”). Taken-for-granted cultural assumptions shape how Joey and Maria interact when Charlie misbehaves, and their interactions around his misbehavior maintain the prevailing cultural assumptions. The ideas that Joey should protect Maria when Charlie is disrespectful and that Maria should defer to Joey both reflect prevailing gendered relationships and support their continuation. Discourses paint events in a certain light and contain invisible assertions or “presumed truths” (e.g., dandelions are weeds) that seem natural, sit in the background of everyday life, and become difficult to question. They influence attitudes and behavior and shape identity. In our lives, we are subjected to multiple and often conflicting discourses (e.g., “A real woman is devoted to her family” and “A modern woman should be able to handle the demands of career and family”). However, over time, certain discourses become dominant and take up more space in our culture. They both reflect prevailing social and political structures and tend to support them. Discourses are often prescriptive, including specifications or expectations about how people “should” be (e.g., children should grow up and leave home; big boys don’t cry or play with dolls; men should provide for their families; and women know more about child rearing than men). These ideas often become internalized standards against which people compare themselves. In this way, discourses shape our sense of who we are and who we “should” be. Discourses are not good or bad per se, but can have a limiting effect on our sense of options (e.g., Joey and Maria might both prefer it if he sat back and she set limits when Charlie treats her disrespectfully). They can marginalize alternative understandings and courses of action for individuals and families. As people interpret their lives through the lens of dominant discourses, their own knowledge and preferences may be obscured. In this way, discourses shape identity and constrain alternative possibilities.

The Constraint, Not the Person, Is the Problem The family just described illustrates constraints at multiple levels. Based on a theory of constraints, therapy can become a collaborative effort in which a therapist works with a family to help its members identify and address the constraints in their lives. In Charlie’s family, constraints included Charlie’s possible attentional difficulties at a biological level

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(“hyperness,” as his foster parents called it), Charlie’s mistrust and suspiciousness at an individual level, a threatening/pleading interaction between Joey and Maria at a family level, a minimize/maximize interaction between Maria and the protective worker at a social network level, and the influence of gender discourses at a sociocultural level. We can think about each of these constraints as a distinct entity separate from the people involved. This conceptualization opens space to examine the relationship between the family and a particular constraint. At times it is helpful to personify problematic constraints. For example, we could think about hyperness (or mistrust or suspicion) as an entity that has come into Charlie’s life and now wreaks havoc. We can then think about Charlie as being in a relationship with hyperness, rather than being hyper or having an attention deficit disorder. The process of talking with clients about problems in this way is referred to as engaging in “externalizing conversations.” This profound shift in thinking about problems was originally developed by Michael White and David Epston (1990) and has been subsequently elaborated by many others within the narrative therapy community. Externalizing is not simply a therapy technique, but a way of organizing our clinical thinking. It offers a way to think about people as separate from and in a relationship with the problems in their lives. From this perspective, the person is not the problem; the problem or the person’s current relationship with the problem is the problem. This organizes our thinking differently. The goal is to separate people from problems in order to challenge ways of thinking that are blaming and unhelpful, and to open space for people to experience their association with a problem as a modifiable relationship with the possibility of developing a different, preferred relationship with that problem. We can also externalize constraining interactions and beliefs. For example, the threatening/pleading interaction between Joey and Maria can be thought of as a pernicious pattern that gets hold of them and significantly interferes with their joint parenting. Similarly, the beliefs that “men should protect their women” and “mothers are responsible for their children’s actions” can be seen as prevailing ideas in our culture that can get hold of people. We can examine the current relationship these ideas have with Joey and Maria, as well as the relationship Joey and Maria would like to have with these ideas. This way of thinking is radically different from traditional internalizing assumptions that conflate problems with individuals (I am a problem or have a problem) and may be difficult to incorporate. However, it can be extremely useful. The use of externalizing conversations to help clients shift their relationship to constraining problems, interactions, and beliefs is explored in more depth in Chapters 6 and 7.

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The shift to a conceptual model based on constraints, in which individuals are seen as being in a relationship with constraints, has a number of advantages. By shifting our focus from cause to constraints, we orient ourselves to context and expand our unit of analysis. By seeing people as separate from and more than the constraints in their lives, we open space to connect with them as human beings and appreciate their resourcefulness in addressing constraints. Finally, by focusing on a constraint or a person’s relationship with the constraint as the problem, rather than the person as the problem, we can unite with clients against problems and build stronger relationships. This focus invites a stance of solidarity in which our task becomes one of working with clients to identify constraints and then supporting and assisting them in renegotiating their relationship with constraints. This section has focused on constraints across multiple levels. We can also conceptualize constraints in realms of action (interactional patterns) and meaning (beliefs and life stories).

CONSTRAINTS IN A REALM OF ACTION People’s actions are often embedded in interactional patterns that constrain alternate possibilities. One of family therapy’s great contributions to the field of mental health has been the shift from focusing on individuals to focusing on interactions. We can take this shift further and separate the patterns from the people caught in them. An organizing schema that is particularly useful for distinguishing and externalizing interactional patterns was developed by Karl Tomm (1991). Rather than diagnosing individuals, Tomm sought to diagnose what he refers to as pathologizing interactional patterns, or PIPs. This section draws heavily on his organizational system. Over time, the ways in which people interact repeat with some regularity and develop into a pattern. Patterns of interaction have a major influence on individual experience. Some patterns can help us feel competent and connected to others. For example, every time Jane brings home a test with a B, her father compliments her on her effort and she responds by asking for help with the questions she got wrong. His compliments make it easier for her to ask for help, and her requests for help make it easier for him to compliment her. In the interaction, both feel competent, connected, and hopeful about the future. Other patterns can help us feel incompetent and disconnected from others. For example, every time John brings home an A−, his father chastises him for not getting an A. John responds by declaring that school doesn’t mean anything anyway, which confirms for the father that he’s not working

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hard enough. The father’s criticism invites the son’s defensiveness, and the son’s defensiveness invites further criticism. The outcome of the sequence can leave both John and his father feeling incompetent in their respective roles as student and father, disconnected from each other, and distinctly unhopeful about future interactions between them. The effects of patterns depend on the nature of the actions and the meanings attributed to them. In the second example, the effects of the interaction on John would depend on how his father criticized him and what meaning he made of his father’s criticism (e.g., the effects of his father’s criticism would be quite different if John saw it as confirmation that he just wasn’t good enough than if he simply saw his father as an old perfectionist who can’t help himself). Interactional patterns can be seen as a series of mutual invitations in which the actions of one person invite a particular response from the other and that response in turn invites a counter response. In the preceding example, the father’s criticism invites defensiveness on John’s part. John’s defensiveness (“School doesn’t mean anything anyway”) in turn invites further criticism from the father (“See, you’re not taking your studies seriously”), and on and on. Over time, these patterns take on a life of their own and induct participants into them. John and his father each “know” the other’s response before they hear it. As the pattern becomes stronger, it develops into a major organizing component of their relationship and has significant influence on their experience of each other and their relationship. The pattern may be diagrammed as follows:

In examining this pattern, it is important to acknowledge that the participants do not have equal opportunities to contribute to the interaction. Although both the father and son contribute to it, they do not have equal participation and influence in the interaction. Fathers (as a cultural group) have more power and influence than sons (as a cultural group). Preexisting power differences shape participation in interactions and need to be taken into account. As a result, this diagram is organized with the father placed vertically above the son to remind us of the broader cultural power relation.

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The Pattern, Not the Person, Is the Problem Focusing on the pattern, rather than simply the people involved, represents a fundamental shift in perspective. In this shift, we are moving from diagnosing and labeling people to diagnosing and labeling patterns. As we separate the pattern from the family members caught up in it, we can focus on the pattern rather than a person as the problem. From this perspective, the family is in a relationship with the pattern. The pattern influences the family’s life, and the family influences the continued life of the pattern. Although we can view people as caught by a pattern, they are not simply victims of the pattern. The pattern may pull them into itself, but they have opportunities to resist that pull and often have numerous experiences with each other outside the pattern. Our work can focus on eliciting and elaborating those experiences outside the pattern as a foundation for resisting the pull of the pattern.

Some Examples of Constraining Patterns Karl Tomm (1991) and his colleagues have distinguished more than 200 specific PIPs that generate or support common problems. Similar patterns have been described elsewhere (Cade & O’Hanlon, 1993; Madsen, 1992; Watzlawick, Bavelas, & Jackson, 1967; Watzlawick, Weakland, & Fisch, 1974; Zimmerman & Dickerson, 1993).This section describes several patterns to highlight the shift from locating problems in individuals to locating problems in patterns and then examines the usefulness of this schema for addressing patterns. The following are examples of interactional patterns that often constrain the effective management of problems faced by families.

Overresponsible/Underresponsible Jim is a stubborn, independent old Irish immigrant who smokes like a chimney and insists that his chronic lung disease is not a problem. A retired assembly-line worker, he describes himself as a “hardworking guy who just ran out of gas and retired.” Given his family history of early deaths, he sees himself as “more or less living on borrowed time” and accepts his situation fatalistically. He doesn’t let things bother him, and his attitude toward life is visible in the wry smile that accompanies his persistent refrain, “The rain’s gonna fall, nothing to do about it.” His wife, Chris, also a smoker, is very worried about his medical condition. She left her family-of-origin role as a caretaker to become an emergency medical technician and is proud of the fact that “no one has ever died on

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her watch.” After Jim’s forced retirement due to health issues, she took on his medical condition as a project, minimizing her own health concerns. However, the harder she tries to get him to stop smoking, the more he smokes, and the more he smokes, the harder she tries to get him to stop. We could make sense of this situation in a number of ways. Jim could be seen as being “in denial” about his medical condition. Chris could be seen as “codependent,” using her husband’s health crisis to conveniently avoid her own issues. We could also focus on the interactional pattern between them as a constraint to effective management of his medical condition. Jim’s underresponsibility for managing his medical condition invites Chris’s overresponsibility. As she puts it, “I have to nag him about smoking because he won’t take it seriously.” Chris’s overresponsibility for the management of his medical condition invites Jim’s underresponsibility. In Jim’s words, “She worries enough for both of us. Why should I add to that?” Paradoxically, the interactional pattern rigidifies Jim’s stance that his smoking is not a problem and constrains him from better managing his medical condition.

Minimize/Maximize Mary is a 43-year-old white teacher who suffers from progressive kidney disease and deteriorating eyesight due to unmanaged diabetes. She hides her medical problems from her Christian Scientist parents, who she thinks view illness as a weakness of character. She lives with her husband Bruce (45), and their three children. There have been numerous crises in the family over the years, and Mary, in her role as family manager, has had little time to focus on her own medical condition. When she does, she alternates between obsessively worrying about her declining health and berating herself for being in such bad health. Bruce’s concerns about her medical condition are eclipsed only by his fears about her pessimistic attitude, which lead him to continually encourage her to be more optimistic. When Bruce, distraught about her pessimism, tells her she’s got to be more positive, Mary responds, “What’s there to be positive about? The only thing that’s positive is that I’m gonna get sicker, I’m gonna need a kidney transplant, and I may die.” Bruce, as a Pop Warner football coach, tries to tell her that with that attitude, she’ll never win the game, and she responds with, “Oh, you want optimism, how about this? The good news is when I lose my kidneys, I’ll have already lost my eyesight, so I won’t have to watch the gruesome scene.” This of course, confirms Bruce’s belief that she needs an attitude transplant. Bruce’s attempts to help her are experienced by Mary as minimizing her concerns (“It’s not that big a deal, just get a better attitude”), which invites her to respond by maximizing her concerns (“You don’t realize

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how bad it is, let me explain it to you”), which invites more minimizing (“Now, honey, get a grip, you’ll never win the game with a losing attitude”). As the sequence unfolds, both Mary and Bruce feel increasingly misunderstood and compelled to state their cases more strongly. In the process, Mary continually emphasizes how little control she has over her medical condition. The pattern rigidifies her stance that her medical condition is beyond her control and constrains effective management of it. When describing sequences such as this, it’s common to describe the reaction to the “identified patient” first in an attempt to move from focusing on the individual to focusing on the interaction. This is not meant to imply that the pattern starts with minimizing. Such a pattern can also be described as maximize/minimize.

Pursue/Withdraw Susan and Richard are an upper-middle-class white couple who both work and share parenting responsibilities for their two children. Each morning at breakfast, Richard reads the newspaper and Susan tries to talk to him about their plans for the day while also getting the kids ready for school. At night, when work is over and the kids are asleep, Susan wants to talk about their respective days, but Richard wants some downtime after a stressful day at work and would rather watch his favorite sports team on TV. Periodically, Susan complains, “We never talk anymore.” Richard feels backed into a corner and doesn’t know how to respond. He retreats into his newspaper or sports, and Susan, feeling increasingly alone in the relationship, tries various ways to connect with him. The more she pursues him, the more he withdraws, and the more he withdraws, the more she pursues. The pattern organizes the responses of each, and their actions intensify the pattern. Although focusing on the pattern allows us to shift away from locating the problem in individuals, it is also important to take the broader cultural context of the pattern into account and acknowledge the ways in which gender roles and expectations contribute to the construction of this pattern.

Demand Disclosure/Secrecy and Withholding Denise is an African American 12-year-old, brought to therapy by Yolanda, her single-parent, working-poor mother, after Denise was arrested for shoplifting. Yolanda is irate about her daughter’s arrest and the fact that Denise keeps lying to her. Yolanda worries about the prevalence of gang activity and drugs in their inner-city neighborhood and keeps a tight rein on her daughter. Denise is furious that her mother doesn’t trust her more and periodically sneaks out at night to “get some

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space.” She’s spending more and more time locked in the bathroom, the only private room in their apartment, and Yolanda is very worried about what she’s doing in there. However, the more Yolanda demands answers, the more Denise clams up and tells her mother to get out of her face. Denise’s secrecy drives Yolanda crazy and sends her into a flurry of accusations and interrogation. Yolanda’s interrogations reciprocally enrage Denise, who experiences them as confirmation of mistrust and responds by refusing to answer her mother. The shift to a focus on the pattern rather than the individuals holds the potential to depersonalize and deescalate their interactions.

Correction and Control/Protest and Rebellion Bart Jr. is a 12-year-old working-class white boy who has been brought to therapy by his single-parent father, who is fed up with his son’s absolute refusal to respond to limits. Bart Sr. describes himself as “growing up in a rough neighborhood, falling in with the wrong crowd, and doing time in prison as a young man before seeing the light and turning his life around.” He has vowed that his son will not repeat his mistakes and keeps his son on a strict regimen of chores and studying in an attempt to keep him away from bad influences. However, the more chores assigned to Bart Jr., the more he refuses to do them, and the more he refuses to do the chores, the longer the list of demands on him grows.

Addressing Interactional Patterns This shift from assessing people to assessing patterns holds significant advantages. It allows clinicians to make sense of families in ways that objectify patterns rather than individuals. It positions clinicians in a different relationship with families, inviting more compassion and empathy and minimizing judgment and blame. It helps family members to resist self-stigmatization and to join together against the pattern rather than against each other. It also creates space for them to distance themselves from the pattern and develop a new relationship to it. Finally, a focus on patterns implies directions for intervention. In an overly harsh/overly soft sequence in which a father’s harsh discipline invites protectiveness from a mother and her “softness” invites increased “harshness” on his part, the clinician could intervene in a number of ways. From a structural family therapy perspective, the clinician could set up an enactment in which he or she invites the mother or father to shift their responses as the pattern is played out in the session. The therapist could ally with one member and unbalance the couple in an attempt to shift the pattern. From a strategic family therapy perspective, a therapist could prescribe

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and exaggerate the pattern in an attempt to disrupt it. From a solutionfocused perspective, the therapist could inquire about exceptions in which the couple’s stances are less polarized or when one’s response supports the other. And, from a narrative perspective, the therapist could externalize the pattern; examine the effects of the pattern on the husband, wife, their parenting, and their relationship; examine ways in which cultural discourses about gender and parenting coach the father and mother into those patterns; and support them in developing a different pattern of interaction that better fits the type of parenting relationship they would like to have. The therapeutic approach that is chosen will depend on the therapist’s theoretical orientation, but this categorization schema can be useful across orientations. It provides a concise model for assessing patterns that reinforce particular ways of interacting and constrain alternatives. Once these patterns have been clearly described, strategies for addressing them follow fairly easily. In each of these situations, the pattern could have been described in a number of ways. There is significant overlap between these patterns. It’s important to note that these patterns do not represent real, objective facts but, rather, distinctions drawn by the therapist. In this sense, this taxonomy of pathologizing interpersonal patterns is no more real than the traditional taxonomy of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) used to diagnose individuals. Any assessment or formulation consists of distinctions drawn by the worker. The important question becomes how useful are they and what are the consequences of using them? For example, what are the effects of thinking about a family this way? How does it help us to understand its members and guide us in our work with them? What view of them does it give us? What is the impact of that view on our relationship with them? To what extent does this formulation invite respect, connection, curiosity, and hope? A number of patterns are highlighted here to help orient the reader toward possible patterns. However, in distinguishing these patterns, it is important to trace them out with families and draw on their language to label each of the patterns. Otherwise, we run the risk of debating among ourselves the question of which description captures the “real” pattern, and then imposing that description on the family.

CONSTRAINTS IN A REALM OF MEANING We can also distinguish constraints in a realm of meaning. Beliefs shape responses and constrain alternative possibilities. Important constraining beliefs to consider include beliefs about the problem, beliefs about treatment (or what should be done about the problem), and beliefs about

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roles (or who should do what about the problem) (Harkaway & Madsen, 1989; Madsen, 1992). Within these three broad areas, we can identify a number of important questions that elicit family beliefs in each area.

Beliefs about the Problem Relevant questions about family beliefs about the problem include the following: • • • •

Do clients see this as a problem? For whom? In what way? How do clients think this came to be a problem? Do clients believe they have any control over the problem? What special meanings are associated with the problem for clients?

These questions are sequential. The answers to each profoundly affect the framing of subsequent questions. For example, if the “problem” is not defined as a problem, then the question of client influence over the problem is irrelevant.

Do Clients See This as a Problem, for Whom, and in What Way? If clients do not view as a problem what appears to us to be a problem, it makes sense that they may not be invested in addressing that problem. Jim, the smoker with chronic lung disease did not view his smoking as a problem. He did, however, see smoking as a problem for his wife (because she was “still young and healthy”). Jim would be willing to stop so that his wife would get off his back and address her own smoking. Knowing this belief allows us to shift our efforts and engage Jim around quitting to help his wife’s health (which generates more interest for him) rather than to improve his own health.

How Do Clients Think This Came to Be a Problem? The way in which family members view the evolution of a problem profoundly shapes their attempts to manage the problem and their expectations of treatment outcomes. For example, Thomas misbehaves. His mother views his restlessness and behavioral difficulties as signs of an undiagnosed attention deficit disorder and seeks medication for him. A psychiatrist meets with Thomas and his mother, prescribes medication, and later learns that the mother never filled the prescription. He calls their home and finds out that the father, who is adamantly opposed to

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medication, threw out the prescription when the mother brought it home. The father views Thomas as spoiled and believes that Thomas needs limits, not medication. The parents’ differing views of the etiology of Thomas’s behavioral difficulties lead them to different preferred treatment protocols (medication for a biological problem vs. consequences for a behavioral problem). The way in which they manage their different opinions constrains their attempts to parent together. The psychiatrist schedules an appointment with the parents and, taking some time to enter into their respective views of the evolution of this problem, develops a better appreciation for their respective beliefs. Within their logic, he emphasizes the importance of a containing environment to help manage a problem that may have both biological and behavioral aspects, and suggests that medication may help Thomas better respond to limits. The parents develop a mutually acceptable plan for dealing with their son.

Do Clients Believe They Have Any Control over the Problem? Donna was a single-parent of four strapping adolescents who all drank heavily and terrorized the neighborhood. Donna grew up in an alcoholic household and was repeatedly abused by her father until she left home, marrying a man who later began to periodically rape and batter her when he was drunk. When he abandoned the family, she was left to raise the four large adolescent boys, who scared both her and the neighborhood. Attempts to get her to set limits on the boys and hold them accountable for their actions devolved into a minimize/maximize sequence in which the therapist’s plans for consequences were repeatedly met with a litany of the boys’ infractions. When the therapist addressed Donna’s belief that she had no control over her boys and shifted to the effects of her multigenerational story of victimization on her parenting, Donna began to identify times when she didn’t feel completely victimized by her sons’ actions and used that realization as a foundation to begin to demand that they at least treat her with respect in her house. That demand represented an important first step in their development of accountability.

What Special Meanings Are Associated with the Problem for Clients? Often problems carry with them issues of family membership and loyalty, for example, “All the boys in the family have done time in juvenile hall” or “He’s just like Uncle Joe.” The following situation highlights another example of special meanings of problems. Mark was having

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difficulty finishing high school when his father’s sudden death threw the entire family into a panic. Mark became depressed and was hospitalized. At the hospital, he complained of vague hypnagogic hallucinations as he was falling asleep, in which he would have visions of his father, which terrified him.2 He was prescribed an antipsychotic medicine, which he refused to take. His family’s support of this stance precipitated significant conflict between the family and the hospital staff. However, this decision became understandable in the context of a long family history of having conversations with dead relatives and seeking their advice. The boy needed his father’s advice about surviving his death and graduating from high school, and he feared that the medication would take his father away yet again. Within this context, Mark’s resistance to medication became more understandable. When a consultation interview elicited the special meaning associated with Mark’s “visions,” the psychiatrist was able to discuss with Mark and his family ways in which medication might be able to take the edge off his conversations with his father without eliminating the possibility of such conversations, and the family’s resistance to medication eased.

Beliefs about Treatment We can also frame questions about clients’ beliefs about treatment with a focus on two questions in a sequential flow: • Do clients believe something can be done about this problem? • What do clients believe would be the best thing to do about this problem?

Do Clients Believe Something Can Be Done about This Problem? Beliefs about whether “treatment” is effective are exemplified in the following situation. Samuel is a 70-year-old African American man with chronic hypertension. Partway through a physical examination, he turns to the white medical resident and says, “You know, son, I’ve been coming here for 30 years, and each year I get one of you young fellows telling me to take these pills and stop eating salt. Salt ain’t got nothing to do with my tension and these pills ain’t nothing but sugar. I’m old, but I ain’t a dead horse, so when you gonna stop beating your head against me?” When the resident heard this, he realized the futility of prescribing a treatment that the patient did not believe to be useful. The resident inquired about Samuel’s belief that hypertension medication was not useful and learned that he took it only when he got heartburn. The physician continued to ask Samuel what he thought should be done about

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hypertension and learned a wealth of interesting folklore and alternative treatments. Out of a discussion about their respective beliefs, a mutual respect and trust emerged that allowed Samuel to give the medication a chance, even though he was skeptical. Repeated experiences of treatment failures may contribute to a belief that treatment isn’t effective. Understanding such a belief makes a client’s unwillingness to pursue a particular course of action understandable and may suggest different ways of framing suggestions.

What Do Clients Believe Would Be the Best Thing to Do about This Problem? Clients’ explanations of a problem and their views about its etiology profoundly affect their ideas about how the problem should be addressed. As we saw in the example of the mother and father who disagreed over the cause of their son’s misbehavior, different family members may hold divergent beliefs about what should be done about a problem. Conflicts over the “appropriate” treatment may constrain effectiveness and polarize the participants, inadvertently rigidifying each person’s position. Understanding clients’ beliefs about treatment allows us to work within clients’ logic and be more effective.

Beliefs about Roles Finally, we can identify client beliefs about roles, or who should do what to address the problem with a focus on the following questions: • How should family members divvy up roles in addressing the problem? • How should family members and professional helpers divvy up roles in addressing the problem?

How Should Family Members Divvy Up Roles in Addressing the Problem? Thomas’s parents, who disagreed about what should be done about his difficulties (medication or limit setting), also disagreed about their respective roles in addressing this problem. The father thought the mother should provide more discipline, and the mother thought the father should get more involved with his son and fill the prescription. Understanding client beliefs about their roles in managing a problem gives us an appreciation of the internal logic of their actions.

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How Should Family Members and Professional Helpers Divvy Up Roles in Addressing the Problem? Some families may think it is more appropriate to handle a situation themselves than ask a professional, who is an “outsider and doesn’t know our child the way we do.” It is important that professionals not move in too quickly in our attempts to be helpful. We are better positioned when we first obtain an invitation to help before proceeding. However, getting such an invitation need not be a process of sitting around and waiting for it. We can actively work to obtain authorization to help. Chapter 3 outlines concrete, active steps to engage reluctant families. At the other extreme of client beliefs about the role of professionals, some families may feel profoundly disempowered and believe they should place their child’s care in the hands of an expert who will take charge. The mother with four strapping adolescents continually looked for a therapist who would successfully tell her boys to stop being rowdy. At the same time, she didn’t trust that anyone could really help and found herself continually second-guessing every helper involved with her family. In the context of her history, that combination of personal disempowerment and protectiveness for her boys becomes understandable. In medicine, it is considered unethical to prescribe a medication without knowing some basic biological facts and having an awareness of other medications a patient is taking. It is important to have a full understanding of the receiving context into which a medication is introduced, as well as to be aware of its potential interaction with other medications. Likewise, in psychosocial interventions, it is important to fully understand the receiving context and the potential interaction effects between therapist interventions and client meaning systems. Assessing client beliefs about problems, treatment, and roles helps us to do this.

MEANING AND CLIENTS’ LIFE STORIES As we focus on constraints in a realm of meaning, we can also examine the constraining effects of life stories or personal narratives. As highlighted in the Introduction to this book, human beings organize life experiences in the form of stories (Bruner, 1990). There are always multiple stories available to us, and always experiences that fall outside any one story. However, over time particular narratives are drawn upon as an organizing framework and become the dominant story. These dominant stories are double-edged swords. They organize our field of experience, promoting selective attention to particular events and experiences and selective inattention to other events and experiences. Those

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events that fall outside dominant life stories become obscured and phenomenologically nonexistent. Life stories become problematic when they constrain us from attending to experiences that might otherwise be useful to us. We can refer back to Charlie, Maria, and Joey for an example of this process. Maria described growing up as the “lost child who could never quite measure up” in her family. Her two older brothers were encouraged to make something of their lives in the United States by their Italian immigrant father. Her older sister was considered eccentric, and Maria took care of her two younger sisters. Maria grew up in a very traditionally gendered household. Her father worked hard and was seldom home. Her mother worked at home as a housewife and devoted herself to the children. Maria developed a strong internalized voice telling her that “a mother’s life is her children.” This voice received significant support from her family of origin, her ethnic culture, and gendered ideas about women’s roles in families. Maria was the first to marry, and her parents eagerly awaited grandchildren. When she found that she was unable to bear children, after years of unsuccessful attempts, shame kept her from telling her mother for 2 years. When she finally told her mother, the mother wept uncontrollably for 3 days. Maria blamed herself for this effect on her mother, which exacerbated her shame and strengthened her story of “not measuring up.” Charlie entered Maria and Joey’s life as an explosion of joy. However, that joy was shattered when he disclosed sexual abuse in a previous foster home. Once again, Maria felt unable to measure up, shamed, and isolated. As Charlie began “not measuring up” at school and in Maria’s family of origin, she feared he was scarred for life. This story of not measuring up and being a victim to lifelong scarring resonated for her and led to incredible despair for Maria in thinking about Charlie’s plight as well as her own. This story of “I’m alone and I can’t measure up” organized Maria’s experience of herself and of Charlie. It led to great distance from her husband, who worried that she was slipping away from him. Maria’s understanding of her life was filtered through this story. Those events that fit were reinforced. She was acutely aware of her family’s response to Charlie’s misbehavior. She was furious with Pam (the protective worker) for her lack of availability to Charlie and the family, and she was in a pitched battle with the school personnel over their scapegoating of Charlie. However, the events that fell outside the story of “I’m alone and can’t measure up” were rendered almost invisible. Maria was a wonderfully competent parent to Charlie. She was adept at sensing his needs and had a deep connection to him. Her home was the first place he felt secure enough to disclose the abuse. She had two friends who marveled at how she parented Charlie (a fact she minimized until the two

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friends were brought into sessions). And yet, within her life story, there was no way to make sense of these experiences. Much of our work with families can focus on helping them challenge the constraining effects of dominant life stories by inviting them to attend to events that fall outside those stories as a foundation for constructing richer stories within which to interpret their lives. For example, as the therapist elicited Maria’s experiences of competent parenting and her thoughts about those instances, Maria began to reconsider her perception of herself and her life. As her two friends were asked to comment on those instances of competence, the emerging threads of this richer story could be woven together in a more complex pattern. Rather than viewing this process as an attempt to “point out” exceptions to the dominant story, we can think about it as metaphorically shining a bright light on events outside the dominant story and asking clients what they see and how they make sense of those events. The use of questions to help clients reflect on constraining life stories and embed their lives in richer alternative stories is extensively examined in Chapter 7. The phenomenological disappearance of instances of competence in Maria’s dominant life story raises a question of how the story of “I’m alone and can’t measure up” became so strong and so thoroughly edited out experiences of competence that didn’t fit within it. To address this question, we need to return to an examination of the internalization of cultural discourses and consider the ways in which broader cultural narratives constrain the development of alternative stories that might highlight Maria’s competencies and connections.

THE SOCIOCULTURAL CONTEXT OF LIFE STORIES The stories that shape our lives are not simply our own. In many ways, they are received from and embedded in family and cultural stories that shape our sense of self and our relation to the world. Stephen Madigan (1997) quotes feminist author Jill Johnson (1973), who claims, “Identity is what you can say you are, according to what they say you can be” (p. 18). The “they” in this case refers not to particular individuals, but to cultural assumptions and practices passed on through those around us. As described earlier, cultural discourses are internalized by individuals. Weingarten (1998) describes internalized discourses as “the kinds of selfstatements that can be produced by incorporating dominant cultural messages” (p. 9). These self-statements are comparative and evaluative, filled with “shoulds” and “oughts.” We all live with internalized discourses, and they often leave us believing that we, just like Maria, have not measured up to them.

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Maria’s story, that she couldn’t measure up or look to others for assistance, is shaped by cultural shoulds and oughts for women in our culture. Her sense of being defective because of her inability to bear children and then her anticipated adoption of a “broken” child, is embedded in cultural stories that often equate womanhood with motherhood and a family-of-origin story that a “mother’s life is her children.” Women are encouraged in our culture to take care of others and regard their own needs as secondary (Bepko & Krestan, 1990). Within that cultural idea about how women should be, bothering her husband or her friends with her troubles was an unthinkable option for Maria. She couldn’t impose on others and yet was furious at feeling so alone and unsupported. She had no way of making sense of that fury, and it confirmed for her that she didn’t measure up as a good wife or mother. Throughout the stories we hold about ourselves, we find repeated examples of the influence of our broader culture. Gender, race, class, sexual orientation, and culture permeate our everyday life. Problematic interactional patterns and beliefs, as well as constraining life stories, are embedded in cultural specifications or expectations about how we should be that are taken for granted and often unexamined. These cultural specifications often support problems in people’s lives. Putting constraints in a broader cultural context has a number of effects. It alleviates blame and shame, it counters isolation (e.g., “Hey, I’m not the only one struggling with this; maybe it’s not simply about my inadequacies”), it allows the emergence of personal agency to resist constraints, and it counters the invisibility of cultural specifications by naming them. Placing constraints in a cultural context also enriches workers’ understandings of clients’ lives, facilitates deeper connections, and supports more effective work.

RECURSIVENESS OF ACTION AND MEANING This discussion of constraints has separated out realms of action and meaning. However, they are actually complexly interwoven. The way in which we make sense of the world profoundly influences how we interact in it, and our interactions can support or challenge our beliefs. We play out the stories we hold about our lives. In the process, we invite others to participate in the enactment of our life stories. Their participation shapes those stories. The ways in which others respond may confirm or challenge our life stories. At the same time, others’ actions are interpreted within dominant stories and, as a result, actions that fall outside that narrative may go unnoticed. As helpers, we are often invited to participate in the enactment of

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existing family narratives, and the way in which we respond to that invitation can have a profound effect. In fact, we are often simultaneously invited into several possible family narratives, and we can respond by noting the range of possible narratives into which we have been invited and selecting which ones we will respond to and in what ways. Our interactions with clients can inadvertently invite the enactment of constraining and pathologizing life stories. Our interactions with clients can also invite the enactment of liberating and empowering life stories. Those interactions are shaped by the way in which we enter them and reflect a choice on our part. However, our interactions with clients are influenced by our conceptual models and, in many contexts, channeled through the assessment process.

REEXAMINING OUR ASSESSMENTS As highlighted initially, the need to write assessments in most agencies is a taken-for-granted fact of life. At times that requirement becomes simply an administrative demand. In better moments, that requirement is an opportunity to clarify professional thinking and help us reflect on our understanding of a client or members of a family in order to be more helpful to them. As we have seen, assessments are also interventions. It is helpful to reflect on whom the information that is collected is designed to serve. Some information may simply serve the requirement of completing a form, some information may help clinicians reflect on their work, and, it is hoped, some information will help families reflect on their lives. If families have a sense that the information is being gathered simply to meet the needs of professionals, they may feel alienated by the process and less inclined to participate. In order to promote an inclusive process, it is helpful to reflect on the kinds of questions we ask and the effects of those questions on clients. The most frequent misuse of assessments occurs when they become a laundry list of all the things that are wrong with clients. Ironically, the field of mental health has been much better at emphasizing illness than health. We have many more tools for discovering how things went wrong in clients’ lives than for identifying steps to help them move forward in their lives. If assessments are to be effective guidelines for therapy, we need to understand problems in nonblaming and nonshaming ways and promote particular attention to client abilities, skills, and know-how. Traditionally, assessment forms are organized in a close approximation of the following sequence: Problem and Precipitant, History, Current Functioning, Medical Condition, Risk Factors, Mental Status, Formulation, and Diagnosis. We begin with the problem and its pre-

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cipitants. We then go back to examine the history that led up to the problem. After examining current functioning and relevant medical information, we assess risk factors and mental status. Finally, we develop a formulation that leads to and justifies a particular diagnosis. Although this approach has a long history and is encouraged by licensing and reimbursement regulations, there are a number of concerns that can be raised about it. Briefly, the initial focus on the problem, precipitant, and history entrenches us in a problem focus. It promotes selective attention to dysfunction and selective inattention to competence. It organizes us around a search for causality and locates problems primarily in individuals. This framework directs us to think in ways that run counter to the conceptual models proposed here. Developing formulations that justify a diagnosis runs the risk of simplifying and trivializing clients’ lives. Chapter 1 referred to cultural anthropologist Clifford Geertz (1973), who distinguished thick descriptions from thin conclusions. Thin conclusions refer to the quick formulations we reach about clients that encapsulate their lives within our frameworks.3 Describing a woman as a “borderline personality disorder” obscures the richness of her life. A description of her as “wonderfully resourceful” is also a thin conclusion. Thick descriptions refer to richly developed descriptions of people’s lives that incorporate many aspects of their lived experience and are expressed in the context of their own meaning systems. Although we are pushed toward thin conclusions by many forces, our assessments can also be vehicles for thick description. We can develop assessment formats that invite both clinicians and clients to develop rich understandings of families’ lives. The traditional assessment outline is anchored in a medical model. Its continued use is encouraged by licensing and reimbursement regulations that mandate the inclusion of particular sections. Our forms shape the questions we ask clients, and those questions shape the stories clients tell us about their lives. In telling those stories, clients experience themselves, their lives, and their relationships with helpers in particular ways. Assessment questions shape our interactions with clients, our experience of them, and their experience of self in the process. This is not to say we are bound like automatons to forms and that the forms determine our interactions with clients. The forms we use invite us into particular interactions with clients, and we can accept or decline those invitations. For fine examples of engaging in postmodern practice within traditional modernist contexts, I recommend the work of Glen Simblett (1997) or SuEllen Hamkins (2005). However, we can also consciously develop assessment forms that encourage ways of thinking about and interacting with clients that are more congruent with preferred values and principles. The assessment outline presented in the next section organizes our

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understanding of families in ways that support the ideas in this book. It is offered not as the way to conduct assessments, but as one example of various alternatives we could derive.

AN ASSESSMENT OUTLINE The following assessment outline initially grew out of an endeavor to rewrite forms for a community agency that was integrating home-based and clinic-based therapy. The goal of that effort was to promote a collaborative clinical approach while remaining in compliance with licensing and reimbursement regulations. This outline includes refinements influenced by its actual use in a number of different community agencies. It is presented as a generic outline that can be modified for children, adolescents, and adults and in both individual and family therapy. I believe the distinction between individual and family therapy is an unfortunate one. It pushes us to define therapy in terms of who is in the room. If we consider family therapy as a way of thinking about our work rather than a modality of therapy, the distinction between individual therapy and family therapy begins to dissolve. In many ways, “family therapy” is an unfortunate term that runs the risk of arbitrarily limiting the relevant system of conceptualization to simply the family. It is important that we broaden our thinking beyond families to social networks and that we include the sociocultural context of people’s lives in our thinking as well. The following outline has been influenced by the work of Alexander Blount (1987, 1991) and builds on an assessment form he originally developed. The outline of the form is followed by brief explanations of each section. It is also included as an outline in Appendix A.

ONE ASSESSMENT FORMAT Identifying Information • Demographic information Description of the Family • Brief appreciative description of client, family network, and community supports (attach genogram or eco-map) • Living environment and recent changes in household composition • Family hopes and preferred directions in life Presenting Concerns • Presenting concerns in the words of the referral source

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• Client/family response to referral • Client/family members definition of their concerns (in rank order) • Client/family vision of life when concerns are no longer a problem Context of Presenting Concerns • Situations in which problem(s) is most/least likely to occur • Ways in which client and others are affected by problem(s) • Client/family beliefs about the problem(s) • Family interactions around the problem(s) • Cultural supports for the problem(s) Family’s Experience with Helpers • Client’s/family’s current involvement with helpers • Client’s/family’s past experience with helpers • Impact of past experience on view of helpers Relevant History • Multigenerational history organized by theme that captures presenting concern, constraining interactions, beliefs and life stories, and experiences with helpers Medical Information • Status of physical health and relationship to the presenting concerns Mental Status • Effects of presenting concerns on concentration, attention, memory, etc. Risk Factors and Safety Factors • Suicide, violence, sexual abuse, neglect, substance misuse • Personal, familial, and community abilities, skills, and knowledge that protect from risk and promote safety • Individual and family preferences, intentions, and hopes that protect from risk and promote safety Diagnosis • DSM diagnosis if required (may also include client colloquial language) • Ways in which client’s experience is different from standard description of that diagnosis Formulation • Include information that addresses: 1. Client’s/family’s hopes and preferred direction in life 2. Existing supports and constraints at biological, individual, family, network, and sociocultural levels (as appropriate)

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Identifying Information This section contains the relevant demographic information typically used. In discussing demographic information, it is particularly important to locate a family in terms of race, class, culture, and sexual orientation. We often launch into a description of a family in which these elements become important only if individuals represent a nondominant group (e.g., we note when a family is African American but not white, or we note when a family member is gay but not straight). The assumption that families are white and straight unless otherwise specified contributes to the marginalization of nondominant groups. In addition, culture and class are factors that profoundly affect families’ experience, and it is important to contextualize families within these factors.

Description of the Family This section begins with a brief description of the important persons in a client’s life in ways that bring them to life and attempt to convey their humanity. We can move away from sterile descriptions, such as “the identified patient is a 15-year-old girl who presents with oppositional defiant disorder,” to richer descriptions that capture the client’s passions, hobbies, idiosyncrasies, and quirks (e.g., “Lyra is a 15-year-old white working-class girl with flaming red hair, multiple piercings, caustic humor, and a flamboyant disdain for authority figures”). The inclusion of family network and community supports pushes us to think beyond a narrow definition of “family.” Who else might be involved in this client’s life? What neighbors or relevant members of the family’s network would be important to include in our thinking? This expanded unit of conceptualization is based on the concept of the “problem-determined system,” which views the relevant system as all those who are involved with or talking about the problem (Anderson et al., 1986). The description of the living environment (the home and neighborhood) helps us get the flavor of the family’s life space. Do the family members live in a cramped apartment in public housing with leaky windows in the winter? Are they renting the upstairs apartment in a twofamily home, with the landlords living downstairs with a newborn who cries continually? Do they own their own home? Is their living space hazardous with exposed wires, comfortable and filled with photographs and children’s artwork, or a precisely decorated space with white carpets and fine antiques, populated by a couple with a young child? The section on recent changes in the household composition highlights any notable transitions in family life and the family’s social environment. Finally, family hopes and preferred directions in life help us to get to know

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families outside the immediate concerns that bring them to therapy and help us identify goals that we can begin moving toward. (The usefulness of developing a proactive vision to guide clinical work is further examined in Chapter 4.)

Presenting Concerns This section begins with a description of the presenting concerns in the words of the referral source or whoever initiates contact. Beginning in this way highlights that someone is describing the problem in a particular way. It sets the stage to examine how concerns are defined and reminds us that the description we’ve received of the problem is an opinion rather than an objective declaration. Describing the family’s response to the referral helps us to avoid beginning to work on a problem that is not defined as such by the family (see Chapter 3) and leads naturally into the family’s definition of its concerns (which may be to get the referral source off their backs). This sequence aids in developing an agreed-upon focus with the family that will serve as the basis for a therapy contract (explored more in Chapter 4). We can frame presenting concerns as constraints to preferred direction in life, which helps make the assessment process more relevant to client life. The presenting concern is the hanger that holds the rest of the assessment. The more clearly problems can be concretely described, the easier it will be to write the rest of the assessment. Finally, including a description of how life will look different when these concerns are no longer a problem elicits hope, generates motivation, and begins an interventive process.

Context of Presenting Concerns This section includes the situations in which the most pressing problems are more or less likely to occur (e.g., Freddie’s tantrums are more likely to happen when his father is on the road and his mother is home alone and exhausted, and least likely to happen when both parents have more energy and are more available to him). This section gives us information about the interactional context of the problem and opens space for eliciting and building on exceptions. The examination of ways in which the client and others are affected by the problem begins a process of labeling the problem as the problem rather than the person as the problem. It allows us to examine the effects of the problem on individuals and relationships (e.g., the tantrums scare Freddie, who fears losing control; the tantrums get his father angry, and he then distances himself and spends more time at work; the tantrums pull his mother into hopelessness; the tantrums lead to fights between the parents about how to manage

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Freddie). Client/family explanations of the problem elicits family beliefs about the problem and how they shape the family’s experience and handling of the problem (e.g., Freddie has no idea where the tantrums come from, his mother believes he’s cursed, and his father thinks Freddie’s mom is just spoiling him). Describing such beliefs highlights constraints in a realm of meaning. Examining interactions around the problem elicits constraints in a realm of action (e.g., when Freddie’s mother expresses her belief that he is cursed, his father tells her to stop acting so stupid and says he just needs a good “whupping”; the mother defends Freddie; and their actions escalate into an overly harsh/overly protective pattern). The questions about cultural support for the problem encourage us to take a broad view and include constraints at a sociocultural level (e.g., the father’s culturally embedded belief that he should be able to just tell his son to knock it off and to get more respect from his son and wife because he’s working hard to build a life for them).

Family’s Experience with Helpers This is one of the most useful sections of this outline. It seeks a description of clients’ current involvement with helpers along with their previous positive and negative experiences with helpers. It is important to include the impact of these past experiences on the family’s current view of helpers. For example, we might learn that a family members’ previous experience with a helper in which they felt interrogated and judged has led them to believe that you can’t trust helpers but have to go through the motions of talking to them. Alternatively, we might learn that a family had a previous helper who was nice and listened attentively but never offered the suggestions the family members desperately sought, and they have concluded that therapy is supportive but basically a waste of time. This section is helpful because it gives us a preview of difficulties we may fall into with a family (as well as what has been helpful in the past). In this way, we can learn from the efforts of previous helpers and utilize previous successes and difficulties to build a more constructive therapeutic relationship. In this process, it’s important to draw a distinction in our own heads between the “facts” of a situation and a family’s experience of it. Acknowledging a family’s negative experience of a particular situation does not mean agreeing that another helper is “bad.” It simply means accepting the validity of the family’s experience. For families who have had multiple negative experiences with helpers, the process of asking about their previous experiences may help to define this current relationship as different. The simple fact of asking about their experience often opens the possibility of developing a different relationship with them.

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Relevant History After getting this initial information, we can move into relevant history. Traditionally, historical information has followed presenting problem and preceded current functioning and social information. I find it more useful to have a history follow the presenting concern, its context, and the family’s experience with helpers. In this way, the history becomes theme driven rather than an outpouring of every piece of data available about this family. This sequencing helps us to focus our work and avoid unduly long assessments. We can focus our historical investigation on elaborating themes related to the presenting concern, constraining interactions, beliefs and life stories, and the family’s experience with helpers.

Medical Information This section includes information about family members’ physical and mental health and their relationship to the presenting concerns. It also includes a listing of any medications that various family members might be taking.

Mental Status This section is traditionally included in individually focused assessments and is typically required by licensing regulations. Although mental status is often viewed as an individual quality, we can also think about it as an effect of problems and locate it in a social context. Alexander Blount (1987) has reframed mental status as the ways in which a problem impairs the day-to-day functioning of those people affected by it and suggests that we can include all members of a family whose day-to-day functioning has been impaired by a problem (e.g., tantrums affect Freddie’s judgment, his mother’s mood, and his father’s concentration). In this consideration, we can include the usual categories such as appearance and behavior, general orientation, thought content and organization, attention, concentration, memory, intellectual functioning, mood and affect, and judgment and insight.

Risk and Safety Factors Risk factors include issues such as suicide, violence (by or toward others), sexual abuse, physical abuse, neglect, and substance misuse. In our attempts to emphasize family resourcefulness, it is important that we not lose sight of risky situations and ensure that risk factors are always being adequately addressed. However, safety is more than the absence of risk.

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As Andrew Turnell and Steve Edwards (1999, p. 102) have emphasized, “Change and safety in child protection is about the presence of something new, not just the absence of risk.” Risk assessment often becomes too one-sided. Although the assessment of risk is exceedingly important, it does not point to solutions. It highlights what to worry about in a situation, but offers little guidance in rectifying the situation. In an attempt to address this limitation, Turnell and Edwards (1999; Turnell, 2004) have developed an approach to child protection work that assesses both signs of risk and signs of safety.4 They point out that focusing exclusively on risk is like “mapping only the darkest valleys and gloomiest hollows of a particular territory” and emphasize the importance of striking a balance that gathers information about past, existing, and potential safety as well as risk (Turnell & Edwards, 1999, p. 101). Safety factors can include the personal, familial, and community characteristics that promote resilience and protect clients from risk (Walsh, 1996, 2006). Safety factors can also include clients’ intentions and purposes, hopes and dreams, and preferred views of self. People are often at their best when they act in line with their preferred views of self. (Chapter 3 examines a process of engaging reluctant clients by eliciting their preferences, intentions, and hopes.) Focusing on safety as well as risk elicits a balance of information that supports a comprehensive assessment and expands our options for enhancing safety. In fact, although this assessment outline focuses largely on elements that constrain families from living preferred lives, we could equally focus our attention on elements that sustain families in the pursuit of desired lives. Turnell and Edwards (1999) envision signs of risk and safety as a continuum that moves from risk to safety. With this in mind, we can place factors that contribute to each at various points along that continuum.

Diagnosis Most assessment forms in public agencies require a diagnosis from the fourth edition (at the time of this writing) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994). DSM-IV is the major classification system of “mental disorders” used in North America. The question of how to incorporate DSM-IV diagnoses in family assessments is a thorny one. Many family therapists find DSM-IV to be of limited use in understanding families or planning family treatment. Family systems theory and DSM-IV are based on different epistemological paradigms, and Denton (1989, 1990) has raised a number of ethical questions about using DSM-IV in family therapy. Duncan, Miller, and Sparks (2004) review numerous studies that suggest DSM-IV lacks both validity and reliability and is not as

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scientifically sound as its overwhelming dominance in our field might suggest. And numerous authors have also raised serious questions about the negative effects of the use of DSM-IV labels (e.g., Duncan et al., 2004; Gergen, 1990; Tomm, 1990). A thorough consideration of these concerns is beyond the scope of this section, but I briefly review some of them here. It is important to acknowledge that some behaviors are indeed weird, deviant, and distressing and that some people find comfort in a label that can make their experience understandable. Nevertheless, the current system of DSM-IV has significant drawbacks. It locates problems within individuals and obscures the influence of social context. It promotes selective attention to deficits and selective inattention to client competence and knowledge. The labeling process is often stigmatizing and pathologizing. It creates a relationship that can be objectifying and dehumanizing of clients who are subjected to professional classification. Personally, I have not found it useful in the determination of a specific treatment plan. It tends to support thin conclusions rather than thick descriptions. And, most important, it invites us into relationships with clients that may not support the development of a relational stance that we would prefer. Based on concerns such as these, a number of clinicians have refused to use DSM-IV diagnoses. I think this is a courageous stand and one that I support. At the same time, in many settings, the use of DSM diagnoses is an implicit condition of employment. For many clinicians, the decision not to use diagnoses is not a viable option. If we are using a diagnosis, it is important to see it as one of a number of possible stories about a client and to be clear about why and in what manner we are using it. Blount (1991), in his development of a systemic mental health center, has recommended the inclusion of the following category after a diagnosis: “Ways in which the experience of the person(s) diagnosed is different from the standard description of that diagnosis.” I think this is an interesting addition to a diagnosis and encourage others to utilize it. It helps to remind us that people are more than the diagnoses we assign them and pushes us to move from thin conclusion to thick description.

Formulation The formulation we develop about a family can be thought of as a story we have created to organize our thinking in order to be helpful to that family. Our formulation is not “objective truth” but one of a number of possible stories. Our formulations have the potential to become selffulfilling prophecies. Once again, what we notice shapes what we see, what we see shapes how we act, and how we act shapes what is possible to occur. Thus, it is important to consider the consequences of the

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formulations we develop. A useful way to organize formulations is to attempt to address three questions: • Where would the client/family members like to be at the end of our work together? • What supports and constrains them in accomplishing this? • What abilities, skills, and know-how might they draw on or develop to enhance those supports and address those constraints? In addressing these questions, it is important to include information that addresses multiple levels, including biological, individual, family, social network, and sociocultural factors. Chapter 4 examines these three questions in more detail.

SHIFTING OUR ROLE IN THE ASSESSMENT PROCESS This alternative assessment format may encourage the development of different descriptions of clients and families, but it is also important to critically reflect on the process through which we obtain assessment information. The traditional assessment process places therapists and clients in a particular power relationship. In that relationship, client experience is often organized into professional categories. This process runs the risk of obscuring and marginalizing client expertise and knowledge and can have inadvertent disempowering effects on clients. In this relationship, professionals are in a position to “know” and clients in a position to receive that knowledge. Often clients who don’t “appropriately” receive that knowledge are labeled “resistant.” Although the power difference between therapists and clients cannot be erased, there are many ways in which we can make therapeutic interactions more egalitarian. There are several inherent risks when one party assesses another. Clients, as the objects of assessment, may feel objectified and disempowered. The process of assessment may also encourage distance and disconnection in the relationship between the assessor (clinician) and the assessed (client). One way to use the assessment process constructively is for therapists to shift from a role in which they as experts assess clients or families, to a role in which they and the families together draw on their mutual expertise to collaboratively assess the problems that have come into clients’ lives. This shift draws on externalizing assumptions discussed earlier in this chapter. If we think about people as being in a relationship with a problem rather than having or being a problem, we can conceptualize the assessment process as one in which therapists and clients jointly conduct an assessment of externalized problems. In this

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way, the concerns raised about the assessment process can be used to mutual advantage. As therapists and clients jointly become the assessors of problems, they increase the possibility that problems (rather than clients) become objectified and disempowered. An assessment of externalized problems may also encourage a distancing in the relationship between families (the assessors) and problems (the assessed), rather than between clinicians (the assessors) and clients (the assessed). The following outline offers a series of questions that can be asked of families to engage them in this type of assessment process. The particular questions outlined here represent questions therapists might hold in their heads and clearly need to be adapted to the language of any particular client or family. These questions are also included as an outline in Appendix B.

QUESTIONS TO ASSESS EXTERNALIZED PROBLEMS RATHER THAN FAMILIES Description of the Family • Who are the important people in your lives? • Can you tell me about your life together outside the immediate problems that bring you here? • As I get to know you better, what do you think I might particularly appreciate about you? • Where would you like to be headed in your life together? Presenting Concern • What is the referral source’s biggest concern? • What is your reaction to that? • What concerns do you have (in rank order)? • How will your life look different when these concerns are no longer problems? Context of Presenting Concern • In what situations is the problem most/least likely to occur? • What is the effect of the problem on you and your relationships? • How does this problem interfere with your preferred life together? • How do you explain the problem? • How have you attempted to cope with the problem? • What broader cultural support does the problem receive? Family’s Experience with Helpers • What helpers are currently involved with you? • What has been your past experience with helpers (good and bad)? • What impact does that have on your view of helpers? • How might that affect our work together?

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Relevant History • What is the history of the relationship between the problem and you? • When has the problem been stronger/weaker in the history of that relationship? • When have you been stronger/weaker throughout the history of that relationship? • What has supported the problem’s influence on you (family-of-origin level, family–helper level, broader sociocultural level)? • What has supported your influence on the problem (family-of-origin level, family–helper level, broader sociocultural level)? Medical Information and Risk Factors • What effects has the problem had on your physical health? Has it exacerbated existing medical concerns for you or others? • What, if any, interactions has the problem had with suicidal ideation, violence, substance misuse, sexual abuse, or neglect in your lives? Formulation • Where would you like to be headed in your life together? • What constraints stand in the way of your getting there? • What abilities, skills, and wisdom might you draw on to address those constraints? When I have used this framework, I have often begun with a contextualizing introduction that goes something like this: “As you probably know, one of the things I’m required to do is write up an assessment of your situation. However, because this assessment is a story about your lives, I would like to propose that we do it together. What I would like to do is ask you a series of questions to get some information and write down much of what you say so I can make this assessment as close to your words as possible. After we are done here, I will write it up and we can go over it and see what you think. We can see what fits for you, what doesn’t, and what you think we should add. How does that sound to you?” I often give families an outline of the categories and offer some explanation for their inclusion. In my experience, clients have found this a valuable and empowering experience. The framework views people as separate from and more than the difficulties in their lives and begins with a focus on getting to know families outside those difficulties. This helps to engage clients who might initially be suspicious about the process. If, in the course of a discussion of the draft assessment, differences of opinion emerge, these can be discussed and brought into the final

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assessment. In this way, the assessment becomes an acknowledgement of multiple perspectives rather than an imposition of a homogeneous single perspective. This process takes more time, but leads to the creation of assessments that organize and support our work. In this way, paperwork becomes intimately connected to the process of therapy rather something that is done the night before a paperwork audit. The framework laid out here does not include information on mental status or diagnosis. If, as described in the first assessment framework, we think about mental status as including some of the effects of the problem(s) on individuals, that section can be captured in the context of the presenting concern. I do not find diagnoses useful, and in fact, I find them potentially harmful for families for reasons outlined out earlier. My preference would be to not include a diagnosis in an assessment that I would write with families. However, if we are required to include a diagnosis, I recommend a frank discussion with families about that requirement and our thoughts about how to handle it. This process can lead to interesting, though potentially difficult, discussions between clients and therapists that make visible the power dynamics in the relationship in ways that may become uncomfortable. However, these power dynamics exist even when they are implicit. Raising them to an explicit level can be a productive experience for everyone involved.

SUMMARY This chapter has emphasized the ways in which our conceptual models shape our experience of clients, our interactions with them, and their experience of self in the process. A social constructionist approach highlights the ways in which the assessment process constructs rather than discovers realities. With this in mind, we have a particular responsibility for developing conceptual models that promote nonshaming and nonblaming ways of understanding problems and focus particular attention on family abilities, skills, and know-how. Drawing on the concept of constraints, we can examine constraints at a level of action (problematic interactional patterns) and meaning (constraining beliefs and individual, family, and cultural narratives). In this way, we can shift our assessment efforts from assessing families to assessing constraints in their lives. Throughout this process, it is important to keep in mind that the attitude with which we conduct assessments is a powerful intervention (Madsen, 1998). It is important that we conduct assessments in a friendly, positive atmosphere, that we use normal everyday language, that we maintain a hopeful view of clients and families, that we acknowledge their expertise on their lives, and that we attempt to put

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ourselves in their shoes and conduct ourselves in ways in which we would want others to treat us. Finally, it is important to keep in mind the honor and privilege of being allowed to enter people’s lives. It is useful to receive the information shared with us as a gift and to keep in mind that we need to “earn the right” to conduct an assessment. We are not just due this information because of the role we are in. It’s helpful to pose to ourselves the question, How would a complete stranger need to interact with us for us to be willing to share our life story with him or her? The next chapter examines ways to engage clients who may be understandably reluctant to begin that process. NOTES 1. For readers interested in one very accessible discussion of social constructionism, see Burr’s (1995) An Introduction to Social Constructionism. For a simple introduction to poststructuralism as it applies to therapy, I recommend Thomas’s (2002) Poststructuralism and Therapy—What’s It All About? Finally, for a more detailed examination of poststructuralism, I recommend Weedon’s (1987) Feminist Practice and Poststructuralist Theory. 2. Hypnagogic hallucinations can occur in that nebulous area between wakefulness and sleep and are normal phenomena. 3. The endpoint of many traditional assessments is a DSM diagnosis, which is represented on Axis I or II in a numerical fashion (e.g., 313.81 for oppositional defiant disorder or 301.83 for borderline personality disorder). This encapsulation of an individual’s life and experience into a five-digit number may be the ultimate thin conclusion. 4. This section offers just a brief description of their work. For readers interested in learning more about a signs-of-safety approach to protective work, I recommend Turnell and Edwards (1999; Turnell, 2004).

CHAPTER 3

Collaboration Is a Two-Way Street Engaging Reluctant Families

In working with multi-stressed families, we often encounter situations in which families minimize problems or insist that the problem lies with only one particular family member. In both situations, such families may be reluctant to actively engage in family therapy. We also encounter families that seem grateful for our suggestions but somehow never follow through on any of them. Attempts to engage reluctant families are informed by our beliefs about “resistance.”1 This chapter examines various conceptualizations of resistance and explores ways to develop collaborative relationships with reluctant families. As a starting point, consider the following clinical situation. Carolyn is a 35-year-old mother who looks beaten down by life. She’s on medication for depression and anxiety and has difficulty venturing out of her house. She grew up in a white working-class family of heavy drinkers and became impoverished when her husband abandoned her and their four children. Carolyn lives in a subsidized apartment with the children (ages 13, 11, 8, and 2) and her brother, Frank, who is on disability for a back injury. Frank drinks heavily and has physically beaten Carolyn in the past. The family has a long history of involvement with protective services because of neglect concerns. Her daughter, Maura, is a hyperactive 11-year-old with a genital abscess that hasn’t healed over a long period of time. Carolyn emphatically declares that Maura got the wound when she fell on her bed frame, but various helpers are concerned about possible sexual abuse by Frank. Despite the presence of 87

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home health aides to help monitor her progress, Maura’s wound has not healed and medical personnel are concerned about infection. The home health aides complain that the house is filthy and dangerous. The kitchen is infested with cockroaches and the bathtub is black with grime. Medical personnel are frustrated in their attempts to teach the girl daily hygiene skills and furious with Carolyn for her lack of support for their efforts. Maura’s physician, at a prestigious hospital an hour away, has given Carolyn multiple stern lectures on the need to take better care of her children and has strongly recommended that Frank leave the house. The physician, concerned about Carolyn’s apparent unwillingness to help her daughter, demands that Carolyn bring Maura to the hospital twice a week in order to better monitor her progress. Carolyn is furious and disgusted with the medical personnel. She feels demeaned by the way she is treated and makes a point of rubbing dirt on her hands in the parking lot before taking Maura into the hospital for appointments, just to annoy them. The physician makes a referral to family therapy and Carolyn refuses to cooperate. We could make sense of Carolyn’s reluctance to engage in therapy in a number of ways. We could focus on Carolyn, seeing her as “in denial” about her daughter’s condition and resistant to services. We could focus on the medical personnel, viewing them as overzealously imposing their ideas because of their alarm over Maura’s lack of healing and possible sexual abuse issues. We could focus on the interaction between Carolyn and the medical providers, outlining a pattern in which their imposing of ideas invites her resistance to their ideas and her continued resistance invites escalating imposition. Finally, we could focus on the taken-for-granted professional and cultural assumptions about how families and helpers “should” interact and reflect on the degree to which that normative expectation fits with the actual situation between Carolyn and her family’s helpers. Each of these different ways of viewing this situation affects how subsequent interactions will unfold and has distinct consequences for how we understand and evaluate both helpers and families. The next section delineates some of the ways in which resistance has historically been viewed in family therapy.

WHAT DO WE DO ABOUT “RESISTANCE”? Within family therapy, there have been a variety of available formulations of resistance. These formulations can be seen as metaphors that organize our thinking about resistance. The way in which we understand resistance shapes how we respond to it. Clients respond to our responses, and the resulting interaction shapes the unfolding therapeutic

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relationship and the possibilities that can occur within it. Although our understanding of resistance may be a metaphor to guide our thinking, the metaphors we choose have real effects on therapists, clients, and helping relationships. These effects may be positive, negative, or mixed. This section explores some of the available metaphors of resistance in therapy and examines possible effects of each.

We Can Try to Interpret Resistance Sigmund Freud developed the concept of resistance. He found that individuals who approached him for help were at times hesitant to reveal their thoughts and feelings to him, not accepting of his interpretations, and reluctant to explore their relationship to him. Freud believed that despite their desire for help, patients unconsciously employed a host of defensive maneuvers to avoid becoming aware of unresolved intrapsychic conflicts or unacceptable thoughts and impulses (Freud, 1949). The concept of resistance became a cornerstone of psychoanalytic thought. Resistance was seen as residing in the patient’s unconscious and being expressed in the treatment relationship through transference. A major focus of treatment became the analysis of resistance as it manifested itself in the treatment relationship. The analyst, through interpretation, would attempt to “make the patient aware that he [sic] had the resistance, why he had the resistance, and why he had it in that form” (Fenichel, 1954, p. 201). The therapeutic endeavor emphasized interpretations generated by the analyst based on psychoanalytic theory to help patients work through resistance and gain insight into underlying conflicts, thoughts, and impulses. Within this conceptualization, Carolyn’s resistance to therapy might be seen as a defensive avoidance of the anxiety provoked by having to face her daughter’s possible sexual abuse by Frank as well as her own trauma history. This is a reasonable hypothesis and offers one framework for understanding Carolyn’s hesitations about therapy. It holds the potential to invite a degree of compassion for Carolyn because of the difficulty of this situation. At the same time, it is important to hold our hypotheses lightly and remain open to other possible explanations. Maura’s physician saw Carolyn as a fragile, anxiety-ridden woman with primitive defenses. She adamantly believed Carolyn needed to kick Frank out of the house but lacked the emotional resources to do so. We could draw an important distinction here between what Carolyn needs to do and what her physician would like her to do. We don’t yet know whether Maura is at risk from Frank. Although a thorough assessment of her safety is imperative, it is important that we not enter with an assumption of “guilty until proven innocent.” We also don’t know

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whether there are positive effects that Frank’s presence may have on the family and what the family would prefer in this situation. When we place ourselves, as helpers, in a superior position of “knowing” and interpreting that knowledge to clients as we deem appropriate, we run the risk of obscuring client knowledge and depriving ourselves of access to potentially important wisdom. As we organize client experience within professional categories, we are likely to learn more about our categories and less about client experience. This privileging of professional knowledge also has the potential to mystify the politics of therapeutic interactions. Carolyn was distinctly unhappy about the ways in which she was treated by medical personnel and outraged by her experience of being forced into hospitalizing her daughter. Her habit of rubbing dirt on her hands could be viewed as a political protest against perceived abuses of power by helpers in a context in which Carolyn sees few alternative ways to express herself. However, when professional categories become the sole container of truth and professionals are placed in a position to determine what particular behaviors really mean, there is a danger that client experiences of disempowering processes are obscured and mystified in the process. In addition to the negative effects on clients, this unfortunate process deprives us, the professionals, of potentially valuable feedback about the effects of our actions.

We Can Try to Challenge Resistance Resistance is often seen as a universal property of individuals and families. This conceptualization is based on Newton’s third law of motion, “For every action, there is an equal and opposite reaction,” and is often transferred from the physical realm to the realm of human interactions. When applied to individuals and families, it suggests that all individuals and families have a resistance to change in the status quo, and anyone who seeks to bring about change will experience resistance to his or her efforts. Within systems theory, families are viewed as having a tendency toward both change and stability (morphogenesis—changing structure and morphostasis—stable structure; more commonly referred to as homeostasis). Within a homeostatic metaphor, families are viewed as systems that regard change as a threat and respond with attempts to maintain stability. This metaphor dates back to the earliest days of family therapy. Don Jackson (1957), researching family dynamics in the etiology of schizophrenia, observed that changes (even improvements) in the identified patient often led to family destabilization. He concluded that the primary function of symptoms was to maintain the homeostasis of the family.

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This metaphor offered family therapy a way of making sense of the difficulty of change and led to the development of intervention strategies aimed at disrupting homeostasis. Salvador Minuchin and Charles Fishman (1981, pp. 26–27) viewed therapy as a “process of taking a family who are stuck along the developmental spiral and creating a crisis that will push the family in the direction of their own evolution.” From a structural family therapy perspective, this induction of crises is done by challenging family symptoms, family structure, and family beliefs (Minuchin & Fishman, 1981). Within this metaphor, a home-based team might initially see Carolyn’s family in its home to provoke a crisis that will bring the family into a clinic. An intention to disrupt family homeostasis can position clinicians as outsiders acting on families. It can contribute to antagonistic relationships in which clinicians are trying to beat homeostasis and families are trying to maintain it. This setup can be experienced by the family as implying that the family has an investment in maintaining status quo and can be experienced as critical judgment, which provokes a family response that is professionally interpreted as further resistance. As Christian Ransom (1982) points out, what families may be resisting in these situations is not change, but the attitude and approach taken by the therapist. If we begin with an assumption that families are committed to stability, we are most likely to notice their efforts to maintain stability. Conversely, if we begin with an assumption that families are also continually changing, we are more likely to notice openings for change. What we look for shapes what we see and what we see, shapes how we respond and what is possible. Homeostasis has been a useful conceptual tool in the history of family therapy. It provides a clear organizing framework and has led to the development of powerful interventions. However, like all metaphors, it has real effects, both positive and negative. In using a homeostatic metaphor, it could be possible to separate family members from a hypothesized force of homeostasis and ally with them against it. However, homeostasis has traditionally been seen as a property of the family. When we become frustrated in our attempts to help families, locating the difficulty in them can provide us with easy answers (“Oh, there they go being homeostatic again”). Our hypotheses then become statements of certainty rather than questions of curiosity and close down space for the emergence of new ideas. In addition, we run the risk of minimizing our own role and contribution to the family’s reluctance. Though a homeostatic metaphor has been a fundamental concept in family systems theory, it is important to consider both the positive and negative consequences of drawing on this metaphor in our work.

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We Can Try to Outwit Resistance Attempts to outwit resistance are mostly associated with the various strategic schools of family therapy. Michael Nichols (1984) points out that “tactics to outwit resistance are the very essence of strategic therapy; they are both its greatest contribution to the field and the object of its strongest criticism” (p. 466). The strategic schools assume that resistance is central to change efforts and have developed sophisticated strategies to minimize or overcome resistance through such techniques as reframing, prescribing, and restraining. These techniques offer exquisite ways to minimize opposition and negotiate the shoals of relational politics. At the same time, attempts to outwit resistance can position us in a chess match with families in which we seek to meet and counter their moves. We run the risk of focusing on beating the resistance rather than meeting the client. These attempts have been critiqued as “techniquism,” in which we become obsessed with high-tech interventions designed for a quick fix2 (Nichols, 1987). This technological focus can be experienced by families as disingenuous game playing by tricky therapists and provoke a continuation of such games. In attempts to outwit resistance, strategic theory has often drawn on a “function of the symptom” metaphor. Related to homeostasis, this concept views symptoms as serving a protective function for a family. The adoption of this metaphor has been so pervasive in the field of family therapy that it has achieved the status of myth. It is important to remember that it is a concept we invented to support our work with families, and to judge its value by its utility in that work. A functionalist metaphor has been useful in developing a better appreciation of a family’s mix of desire for change and fear of the unknown and has provided a foundation for the development of a number of powerful interventions. In the previous clinical example, one could hypothesize that Maura’s symptoms serve the function of keeping Carolyn focused on Maura and distracting Carolyn from other painful aspects of her own life. This hypothesis may help us appreciate why attempts to help Carolyn better care for her daughter may not progress easily without addressing the function we’re assuming Maura’s difficulties serve. However, a functionalist metaphor is a slippery slope. We can easily slide from thinking about symptoms as serving a protective function to thinking about a family as needing the symptom. In moments of frustration, we can fall into attributions of intent and come to believe that a family may want a symptom in order to avoid change. This subtle blaming of families invites anger, suspicion, and defensiveness on their part, which can then be interpreted as evidence of resistance and make collaboration difficult. In the clinical example, none of the helpers had ever

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discussed his or her idea about the function of the symptom (or the related concept of secondary gain) with Carolyn, and yet that idea was subtly but strongly communicated to Carolyn. Her experience of the negative effects of a functional metaphor is captured in the following quote: “It’s like they have this idea that I want Maura to not get better, like I enjoy taking half a day twice a week to drag all my kids into the city so they can watch me get berated by that doctor because Maura’s not getting better. They have no clue what it’s like living with Maura and trying to contain her.” In examining a functionalist metaphor, it is important that we examine its relational as well as conceptual utility. A functionalist metaphor can also encourage us to locate the problem of resistance in the family, thus minimizing the potential contribution of family–helper interactions as well as broader cultural and economic contexts that affect many families’ lives. In the example previously discussed, a number of workers complained about the filth of Caroline’s house and attempted to deal with the situation by grossing each other out with escalating stories of encounters with cockroaches and lice. One consultant, in hearing these stories, hypothesized that the family was fearful of the outside world and suggested that the dilapidated condition of the house served a protective function to keep unwanted workers out and maintain stability in the family. This formulation highlights the danger of overextending the field’s preoccupation with a functionalist metaphor. It is understandable that workers may be hesitant about going into housing with poor lighting, hazardous conditions, and cockroach or lice infestation, but framing inadequate housing as serving a protective function in the family rather than as an effect of poverty is a dangerous accusation. We risk adding therapeutic insult to economic injury. In the process, we direct attention away from professional judgment and blame as potential contributors to difficulties in the therapeutic relationship and focus attention on the family as the source of those difficulties. We also run the risk of encouraging families to blame themselves for the effects of broader economic conditions.

We Can Try to Understand Resistance Lynn Hoffman (1985) was one of the first to note the shift from a hierarchical relationship with clients to a collaborative one. In the context of addressing resistance, the shift from beating resistance to understanding resistance is exemplified in the conceptual evolution of the Milan

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Associates. They began in a strategic orientation, developing elaborate strategies to outwit family games with a strong focus on moves and counter-moves (Palazzoli, Boscolo, Cecchin, & Prata, 1981). Over time, they shifted from managing resistance to understanding resistance (Cecchin, 1987; Tomm, 1984a, 1984b). The process of “positive connotation” shifted from a strategy to disrupt family stuckness to an attempt to better appreciate the internal logic of a situation. When applied to resistance, the shift raises questions such as, “How do family actions make sense? What is the internal logic of these actions? And what particular dilemmas arise for family members in this situation?” In this shift, a metaphor of understanding resistance invites the therapist into a relationship characterized by curiosity and appreciation. This stance has a profound effect on the developing relationship and is a response to resistance that does not exacerbate resistance. At the same time, it is important to remember that curiosity and appreciation are means to an end rather than simply an end in and of themselves. There are therapists who have formed strong relationships with families that have been interesting and rewarding, but have not led to improvements in their lives. It is important that appreciative understanding contributes to changes in people’s lives. Chapter 5 highlights ways in which inquiry and understanding can become a powerful intervention. Attempts to understand resistance have also sought to examine helpers’ contributions to the development of treatment difficulties. In the process, the relevant unit of analysis for understanding resistance came to include the helping system as well as the family system. Carol Anderson and Susan Stewart (1983) offered a working definition of resistance that included family members, the therapist, and the therapist’s agency or institution. In their definition of resistance, they included all those behaviors in the therapeutic system (family, therapist, and institution) that interacted to prevent the therapeutic system from achieving the family’s goals for therapy. Even though their understanding of resistance was embedded in homeostatic and functionalist metaphors (which were the dominant metaphors at that time), they were among the first to include helpers’ contributions to resistance. Many people have argued for expanding our unit of analysis in attempts to understand resistance, but Evan Imber-Black’s (1988, 1991) work on families and larger systems has given the clearest structure to this expansion. Broadening the unit of analysis offers an understanding of resistance as an interactional process and forces us to consider our helpers’ contributions to difficulties that develop (Harkaway & Madsen, 1989; Madsen, 1992). A framework for understanding resistance is further developed after one final metaphor of handling resistance is explored.

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We Can Try to Dissolve Resistance Steve de Shazer (1988) heralded the “death of resistance.” Acknowledging the cybernetic concept discussed earlier, that families simultaneously maintain stability (morphostasis or homeostasis) and continually change (morphogenesis), he proposed that we focus on supporting and strengthening families in their continual process of change rather than trying to disrupt their attempts to maintain stability. As David Cooperrider (2000) points out, what we attend to grows. If we emphasize continual change, we end up looking for ways in which families are changing and build on that. This leads to an expectation that change is not only possible, but inevitable. De Shazer found the belief in resistance to be problematic because it implied that stagnation was inevitable. De Shazer’s decision to not believe in the idea of resistance was taken even further by Lorraine Wright and Anne Marie Levac (1992), who claimed that noncompliance was not only a conceptual error, but also a biological impossibility. They based their claim on Humberto Maturana’s metatheory of cognition. The details of his theory are quite esoteric but have useful applications for family therapy. One valuable idea is the claim that it is impossible to instruct others. As one person talks to another, the listener takes in that information in ways that are determined by the listener’s individual structure. The speaker cannot control how that information is received. From this perspective, we can influence others but we can’t predetermine how they will be influenced by us. We cannot put particular information into someone, because we can’t control how or in what form that information will be incorporated. For example, when Carolyn’s physician lectures her about the need to kick Frank out of her apartment, she is trying to get Carolyn to do something in particular. But the physician has no control over how Carolyn will process and respond to her instruction. Carolyn may learn a wide variety of things from the physician’s instruction. She may learn that she should kick Frank out. She may learn that the physician doesn’t have a clue about what her life is like. She may learn that the physician is a frustrated professional who hates men (regardless of the physician’s actual feelings about her job or men). Whatever Carolyn learns will be determined by her own history, life experiences, and perceptual structure. The physician cannot control what Carolyn will learn. This is not to suggest that we cannot impart ideas. We just can’t control how they will be received. For example, have you ever had clients, at the end of your work with them, thank you for an idea you don’t remember conveying and in fact would never have intended to convey? Within this metaphor, we cannot put information into clients, but we can invite reflection by creating a context for change and then framing questions,

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ideas, and suggestions in a way that makes it easier for clients to take them in and reorganize around them. We cannot determine how clients will take in our offerings, but we can be sensitive to the receiving context and attempt to frame them in ways that are more likely to open possibilities for change. Concrete examples of this approach are examined shortly. Although a metaphor of dissolving resistance holds significant promise to reorganize our responses to reluctant clients, it too can have potential negative consequences. One consequence is an unfortunate creation of an either/or situation in which families may be seen as either maintaining stability or continually changing, which runs the risk of contributing to a polarization between practitioners informed by this metaphor and those drawing on other metaphors. The idea that resistance is just a unique way of cooperating can also be experienced by therapists who are struggling with families as invalidating. As a student told me, “Boy, for something that’s not real, it has sure done a number on me.” Although the decision to not believe in resistance is a powerful approach for engaging reluctant families, the blanket declaration that there is no such thing as resistance can be as invalidating to therapists as the concept of resistance can be to families. As a foundation for examining our understandings of situations in which families are reluctant to engage in therapy, this section has traced a series of metaphors for handling resistance that in some ways parallels broader developments in the field of family therapy. In my own clinical work, I have been profoundly influenced by each of the metaphors at one time or another. Although I currently prefer to be more influenced by metaphors of understanding or dissolving resistance and less influenced by metaphors of interpreting, challenging, or outwitting resistance, I value the ways in which each metaphor has informed my thinking at various times. From here, let’s consider how a cross-cultural metaphor can inform the process of engaging families.

THERAPY AS A CROSS-CULTURAL NEGOTIATION Each metaphor of resistance just described is embedded in broader cultural ideas that specify “appropriate” relationships between clients and helpers. This section draws on a cross-cultural metaphor to examine resistance in the context of family–helper interactions and the broader cultural context in which those interactions are embedded. As discussed in Chapter 1, each family and helper can be seen as a distinct microculture with its own beliefs and preferred style of interacting. Therapy can be seen as a cross-cultural negotiation in which the two parties

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interact in a mutually influencing relationship. In this interaction, the actions of each party may be more understandable through its own lens. Therapy proceeds better when both micro-cultures (helper and family) are on the same wavelength (i.e., hold similar beliefs about what the problem is, what should be done about it, and who should do what in addressing the problem or are aware and respectful of differences in those beliefs). Therapy can become problematic when therapists and clients hold different beliefs regarding problems, treatment, and roles of the client and therapist and those differences are covert and unacknowledged (Madsen, 1992). As helpers and families attempt to manage unacknowledged differences in beliefs, a variety of interactional patterns may emerge between them. In the situation described at the beginning of this chapter, Carolyn and the health care providers held differing beliefs about the severity and etiology of Maura’s abscess, different ideas about what should be done about it, and different ideas about who should do what and how that should be decided. As each attempted to convince the other of the value of their respective beliefs, an escalating struggle arose. The more the medical personnel tried to get Carolyn to cooperate with their treatment plan, the more she felt insulted by their unwillingness to solicit her ideas and the more she then refused to go along with their plan. As she put it: “You know, they got some interesting ideas, but so do I. Those people don’t seem too interested in any of my ideas, so why should I give them the satisfaction of looking like I’m interested in their ideas?” Her refusal to cooperate could be seen as a protest (albeit ineffective) against their unilateral definition of the relationship. In the course of this interaction, each party’s actions and intents may be misinterpreted through the other’s lens. For example, the medical personnel saw Carolyn as an inadequate mother who minimized her daughter’s medical concerns and was “in denial” about possible sexual abuse by the uncle. Carolyn, on the other hand, saw the medical personnel as “stuffed shirts who just sneer down their noses at me.” These misinterpretations invited attributions of mal-intent (expressed in sentiments such as “Can you imagine a mother who lets her house get that dirty?” and “Those people don’t care about my daughter, they just want to bust my chops”). Within a cross-cultural perspective, the development of collaborative working relationships is a two-way street. Therapists as well as clients can be oppositional. From Carolyn’s perspective, the medical personnel were incredibly resistant to her attempts to get them to change

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their behavior with her. When Carolyn shared some of her ideas about her daughter, she felt as though the medical personnel wouldn’t listen to her. If Carolyn was to meet with a peer supervision group of clients dealing with “resistant helpers,” what do you think she might say to them? How would she describe the medical personnel? What sort of consultation might she get from her colleagues to help her interpret, challenge, outwit, understand, or dissolve her helpers’ “resistance”? Questions such as these highlight who defines resistance. In viewing therapy as a cross-cultural negotiation, it is important to keep in mind that the parties are not in an equal relationship. Clients are generally more vulnerable and, despite attempts to flatten the hierarchy in therapeutic relationships, therapists have distinctly more power. The power discrepancy is particularly salient when clients come from nondominant cultural groups in which the power differences between clients and professionals parallel cultural power differences.

THE BROADER CONTEXT OF FAMILY–HELPER INTERACTIONS The cross-cultural negotiation between clients and therapists is also embedded in a broader social context and reflects the politics of that context. Although increasing attention is being paid to gender and race dynamics in therapeutic interactions, there are also powerful class dynamics that may play out in treatment difficulties, which have received less attention (Kliman & Madsen, 2004). Therapists are individuals but also represent a particular class background, which may or may not fit for individual clinicians. The profession of therapy is embedded in what has been called the professional middle class or professional–managerial class (Ehrenreich, 1989; Ehrenreich & Ehrenreich, 1979). This class includes doctors, lawyers, managers, academics, other professionals, service providers, and others. Many of the families (though not all) who come to be referred to as “difficult to engage” in community agencies are poor or working class. Just as interactions between a male therapist and a female client or a white therapist and an African American client reflect and replicate cross-gender or cross-race interactions, so too interactions between therapists (who are socially defined as professional middle class) and poor or working-class clients can represent a cross-class negotiation. It is important then to look at the effects of historical relationships between these classes as one organizing issue in therapeutic relationships. There is a long history of tension between professionals and poor and working-class people that is often invisible to professionals but painfully apparent to the poor and working classes. The professional–

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managerial class emerged amid the labor unrest of the 1900s and has had a rather inglorious history in regard to workers. As Ehrenreich (1989) puts it: Minds and mills did not have to be hotbeds of working class sedition; they could be run more smoothly by trained, “scientific” managers. Working class families did not have to be perpetual antagonists to capitalist society; they could be “Americanized” by teachers and social workers and eventually seduced by ad men and marketing experts. Almost every profession or would-be profession from sociology to home economics, had something to offer in the great task of “taming” the American working class. (p. 134)

Although the historical tension between the professional middle class and the working class may no longer be as strong as in the past, a common perception remains among many poor and working-class people that middle-class professionals don’t really do anything that justifies their superior pay and status. Within the workplace, interactions between middle-class professionals and working-class people are often managerial. As one informant in Ehrenreich’s study put it, “We’re the ones who do the production. They’re just here to make sure we do it like they want” (Ehrenreich, 1989, p. 138). Outside the workplace, workingclass and poor people are most likely to encounter professionals as teachers, social workers, or physicians. Such relationships are frequently marked by helpful interactions, but the professionals often have the authority and power to make judgments about others, and sometimes that judgment is not experienced as positive. Sennett and Cobb (1972) found that the anger and resentment engendered by this experience were seldom expressed to professionals. In this way, resistance to services can at times be seen as an act of protest against unexamined professional privilege. For example, Carolyn’s view of her helpers as “stuffed shirts sneering down their noses at her” reflects a historical class tension that is rarely communicated directly and when perceived by the medical personnel, may be interpreted as Carolyn’s “bad attitude.” Carolyn’s resistance to the information provided by medical personnel may be her protest against having her life defined by someone else’s criteria. Unfortunately, this cultural protest and desire for self-determination is often interpreted as pathological personal resistance to services. Viewing her actions within a broader context helps to make them more understandable and less personalized. This particular interaction transcends the involved individuals and has a significant historical and cultural context. Understanding this fact is an important first step in developing relationships across class lines.

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In a cross-cultural negotiation, collaboration is a two-way street. Because therapists are in a leadership position in this exchange, they have a greater responsibility for the development of a collaborative relationship. A collaborative relationship begins with us entering into clients’ particular personal cultures rather than simply expecting clients to enter into ours. This ties back to the commitment to work in partnership and fit services to clients. One way to begin this process is to attempt to understand how clients perceive what we see as problems in their lives.

EXAMINING THE STANCE THAT CLIENTS HOLD TOWARD PROBLEMS In a study of the interaction of patient, spouse, and physician beliefs in situations in which patient medical conditions had been chronically mismanaged, I found two common patterns of treatment difficulties (Madsen, 1992). I think an awareness of these patterns can support us in the process of engaging reluctant clients. Often, when people seek or are mandated for help with a particular problem, they hold a conceptual stance about that problem that reflects their relationship with it. There are a number of possible stances that clients may hold toward problems, and their stance significantly affects their ability to deal with problems. Consider the following three examples: Jaime calls up and says, “I’ve been kind of depressed lately, it’s interfering with the life I want to have. Can you help me do something about it?” Roxanna calls for couple therapy saying, “Our relationship is going down the toilet. We’re fighting all the time and it’s escalated to violence. Last night we began throwing things at each other and a window got broken. I’m afraid one of us is going to get hurt and want someone to help us get things back to how things used to be.” Vanessa, who lives with her mother and two teenage daughters, calls for family therapy saying, “Our household has become a living nightmare. My girls are out all night. Nanna and I are spending all our time fighting with them, and then we end up arguing with each other. My older daughter isn’t eating right, and the younger one just got out of the hospital after cutting herself when her boyfriend got her pregnant. This is the last straw and I need some help in straightening them out. Do you think you can help me do that?” Although these three people face problems that differ significantly in their severity, there are similarities in the stance each holds toward

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those problems. At the risk of oversimplifying their lives, we could characterize a common stance they each hold as follows: “This (the presenting concern) is a problem in my life, I have some influence over this problem, and I want to do something about it.” This stance provides a strong foundation from which to address problems. A situation in which clients hold this stance has been described by solution-focused therapists as a “customer relationship” in which a complaint or goal has been jointly identified by clients and therapists, and clients see themselves as part of the solution and are willing to do something about the situation (Berg, 1991, 1994; Berg & Miller, 1992; de Shazer, 1988). This situation is preferred by most helpers and represents a stance we can believe clients should hold about problems. However, clients often hold other stances. The rest of this chapter briefly outlines two stances and then highlights ways to address each in detail.

“This Is Not a Problem” Sometimes people who are referred for help don’t see themselves as having a problem. They may be mandated for treatment or be there under duress. In this situation, they have a very different relationship to the alleged problem and the process of therapy. Consider the following examples: Fred, a bus driver, has been referred by his employee assistance program after verbally abusing a man who didn’t have correct change and then pushing him off the bus. When asked what happened, he replies, “Oh, it’s nothing. We got into an argument because I didn’t let him pull a fast one on me. What’s the big deal?” Roberta has been referred by her protective worker for help in parenting her three young children. She’s had several neglect reports filed on her for leaving them alone while she went to a neighbor’s apartment to get high. When asked her thoughts about the referral, she adamantly responds, “My kids are fine. I don’t have problems with drugs. Why don’t you people leave me alone!” Sammy has been referred for therapy after allegations that he sexually abused his 4-year-old daughter. In the first session, he says, “Hey, this is really getting blown out of proportion. We just cuddle and she enjoys it.” In each of these situations, the referred client could be seen as holding a stance of “This is not a problem” and, as a result, believing there is nothing to be done about it. A no-problem stance evolves in the context of the interaction and often develops when a worker

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persists in trying to define a problem that doesn’t fit for the client. This situation has also been described as a “visitor relationship” in solution-focused terms (Berg, 1991, 1994; Berg & Miller, 1992; de Shazer, 1988). In this situation, helpers and clients build their relationship around different definitions of the problem and vastly different agendas for dealing with it. Interactions can develop that exacerbate the situation and lead to difficulties that constrain effective work. As we try to get clients to see that particular issues are a significant problem, we can inadvertently invite a response that rigidifies a no-problem stance and threatens the therapeutic relationship. Such difficulties are often reflected in situations in which the presenting problem (according to the referral source) is substance abuse, violence, sexual abuse, neglect, or other situations characterized by “denial.” I am putting the word “denial” in quotation marks here because it is one of our takenfor-granted terms that often refers to clients not seeing what we view as the problem. Even though our determination that this is a problem may have a solid basis, it is important pragmatically to own it as our determination.

“This Is a Problem, but I Have No Control over It” Other times, families may seek help with a clear sense of the problem, but not see themselves as having any influence over it. Consider the following examples: Ellen and her four burly teenage boys are referred for therapy by the court after her oldest son threw another boy through a hardware store window. In the first session, Ellen goes through a litany of complaints about each son and concludes with a shrug, “The court told me to come see you. I can’t do anything with them. This is beyond me.” Maria calls a therapist and says, “Would you call my husband? He has a gambling problem and won’t get any help for it. He won’t listen to me and it’s driving me crazy. Maybe if you talked to him.” Harold calls a therapist saying, “My son is a manic–depressive who was just discharged from the hospital. When he’s depressed, he can become suicidal, so we have to keep him at home. And when he’s manic, he becomes uncontrollable and breaks everything in our house. We’ve become very scared of him because he’s mentally ill and has no control over his behavior. I hear you do home-based work—will you come out to meet with him?”

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In each of these examples, the client could be seen as holding a stance of “This is a problem, but I can’t do anything about it.” I am referring to this stance as a no-control stance to highlight the client’s perceived lack of influence on an out-of-control problem. This stance often manifests itself when parents call about out-of-control youths (mental illness, substance abuse, violence, and high-risk situations that include suicide, running away, risky sexual behavior, etc.) or when spouses call about a partner’s substance abuse or other problematic behavior. In these situations, the person seeking help is often focused on trying to help someone else change (despite that person’s lack of interest) instead of focusing on changes that could be made in his or her own life. Such a situation has also been described as a “complainant relationship” in solution-focused terms (Berg, 1991, 1994; Berg & Miller, 1992; de Shazer, 1988). Attempting to help clients in these situations can be frustrating, and a client can often become labeled as an “enabler or codependent.” Helpers can feel as if clients are trying to hand over work that they need to do and respond by attempting to highlight a client’s contribution to the situation or point out the influence that he or she does have in the situation. The interaction that develops is usually frustrating to everyone involved and can rigidify a client’s no-control stance. Both a no-problem and no-control stance can be seen as constraints that hinder clients from more effectively addressing problems. We can shift from seeing the client as the problem to seeing the stance as the problem. As helpers respond to these stances, the interactions that develop can further constrain attempts to address the problems. The next sections examine ways to avoid problematic interactions with clients who initially hold a no-problem or no-control stance and highlight ways to shift our relationship with reluctant clients, engaging them from a relational stance of an appreciative ally.

SUGGESTIONS FOR APPROACHING A NO-PROBLEM STANCE An example of engaging a client with a stance of “This is not a problem” comes from the story of Bob, a 35-year-old white working-class man referred to therapy by his lawyer after his license was suspended for driving under the influence.3 Bob was not sure why he was coming to therapy, but thought he could use some help in learning ways to meet women. Bob was divorced and lived alone. He worked long hours and would typically buy a six-pack each night on the way home, which he drank while watching rented pornographic movies. His ex-wife had custody of their two girls (ages 7 and 5) and was furious with Bob for

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repeatedly missing scheduled visitations and neglecting his daughters when they were in his care. Bob resented the way his ex-wife treated him around these lapses and wished she would stop making a “mountain out of a molehill.” Bob’s therapist, also a man, raised concerns about Bob’s drinking and irresponsibility, which Bob minimized in turn. Near the end of the first session, Bob described an incident in which he left his daughters sleeping in the car while he ran into a liquor store to buy some beer. There he met two buddies, who invited him across the street for a drink. Because they were sleeping, he figured his daughters were safe and ran into the bar for a quick beer. When he emerged 45 minutes later, they were still asleep. Bob thought nothing of it until confronted by his exwife, who had received a call from a girlfriend who saw the sleeping children as she went into the liquor store. His ex-wife went to court and had Bob’s visitations suspended. As the therapist heard this story, he expressed his concern about Bob’s drinking and suggested he attend several Alcoholics Anonymous meetings during the next week. In response, Bob rolled his eyes and said, “You sound like the broad in the alcohol class I went to for court. I thought a guy would understand this stuff.” Annoyed, the therapist confronted Bob’s “denial,” and Bob listened with a disdainful smirk on his face. At the end of the session, Bob left and the therapist wondered whether he’d return. At this point, Bob and his therapist were not well positioned for future work together. They had radically different ideas about the problem, what should be done about it, and who should do what. Bob defined the problem as getting the court off his back and perhaps getting some help in meeting women, whereas his therapist defined the problem as Bob’s substance abuse and irresponsibility with his children. In their interaction, each attempted to get the other to work on their respective ideas of the presenting problem and each became increasingly frustrated with the other’s “noncompliance.” The therapist wondered why Bob was “in denial” about his problems, and Bob wondered why his therapist kept harping on these issues. They did not have a jointly identified goal, and the attempt of each participant to enlist the other’s cooperation inadvertently backfired and rigidified their respective stances. In this situation, there was a strong temptation to confront Bob’s minimization in an effort to help him grasp the seriousness of the problem. However, in doing so, the therapist became ensnared in an overresponsible/underresponsible pattern with Bob. This pattern could be seen as a set of inadvertent reciprocal invitations. Bob’s stance that his drinking was not a problem invited the therapist to confront that stance. The therapist’s confrontation of that stance invited Bob’s disdain-

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ful smirk. And Bob’s smirk invited further confrontation. As this pattern developed, Bob became increasingly annoyed with the therapist and less open to his ideas. In the process, his no-problem stance was further rigidified. Paradoxically, the more the therapist confronted Bob’s “denial,” the more the therapist inadvertently contributed to entrenching it. At the same time, a decision to not confront Bob’s stance would run the risk of avoiding an important conversation and colluding with that stance. This situation creates an interesting dilemma for practitioners. If we confront a no-problem stance, we can fall into a pattern that inadvertently rigidifies it, and if we hold back, we may end up colluding with a problematic stance. One way out of this dilemma would be to engage Bob outside the overresponsible/underresponsible interaction and look for exceptions to a no-problem stance that can serve as a foundation for eliciting responsibility and constructively addressing problems. The rest of this section outlines five steps to accomplish this effort.

First, Do No Harm4 We’ve examined how an overresponsible/underresponsible pattern constrains clients from addressing situations, rigidifies their position that “this is not a problem,” and takes a toll on the therapeutic relationship. An important first step is to anticipate and avoid being caught in such a pattern. The old medical maxim “First, do no harm” could be translated here as “First, add no further constraints.” However, the trap of an overresponsible/underresponsible pattern is easy to fall into. Let’s examine some of the factors that can pull us into this pattern. People who hold a stance of “This is not a problem” are often constrained from acknowledging difficulties by old habits, interactional patterns, and beliefs. They are often well practiced at attributing responsibility to external factors and inviting others to take responsibility and attend to difficulties for them. In response to the therapist’s questions about the time Bob left his children sleeping in the car while he ran into a bar, Bob declared, “Look, it’s no big deal. They were safe and sound. If my wife would put them down for naps when they need them, they wouldn’t sleep so much when I babysit them.” We can find other examples of attributing responsibility to external factors in client statements such as the following: “If I didn’t work so hard for her and the kids, I wouldn’t need to drink to relax.” “If you want the violence to end, tell her to shut up.” “If my wife gave me sex, I wouldn’t have to have affairs.” Statements like these represent personal lapses in relational responsibility and extreme attributions of responsibility to others on the part of the men making them. These statements also occur in a context of cultural ideas and traditions that often encourage men to look to

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women to take primary responsibility for child rearing, encourage men to assume certain rights and entitlements in relationships, and encourage men to attend less to the effects of their actions on others. Recognizing the cultural embeddedness of a habit of not embracing relational responsibility does not justify or excuse it. It does, however, help us appreciate the strength and persistence of that habit. It is tempting to respond to statements of this kind with attempts to give advice or break down “denial.”5 However, doing so runs the risk of perpetuating the problem. Confronting a client’s stance often invites defensiveness, promotes shame, and constrains the consideration of new ideas. Our clients may be better served by our not seeking to challenge denial but successfully inviting clients themselves to challenge those constraints that hinder them from responding to issues differently. This is a subtle, but important shift. The history of past interactions with helpers and other family and community members also has a strong influence on the way in which an overresponsible/underresponsible pattern plays out. In Bob’s situation, it is unlikely that this therapist was the first person to point out to Bob that his drinking and neglect of his children were problems. Bob’s history of previous interactions with significant others around this issue shapes his response to the therapist. Before the therapist opens his mouth, previous interactions prime Bob to anticipate that the therapist will (in Bob’s words) “make a mountain out of a molehill.” Bob enters prepared to defend himself from an anticipated onslaught of accusation, and the therapist can fulfill that expectation or try something else. Our own emotional reactions to such situations often shape our responses. Many situations in which a person holds a no-problem stance (battering, sexual abuse, substance abuse) pull for judgment. We can easily fall into an emotional response that seeks to punish negative or abusive parents in an attempt to protect children. That emotional response can legitimize interacting with clients in quite disrespectful ways in order to get them to act more respectfully. In discussing his work with men who have battered, Alan Jenkins (1996, p. 122) describes a sense of frustration and impatience which can lead him to “ ‘make the man see sense,’ or even ‘knock some sense into him,’ to ‘make him see what it is like,’ to ‘break down his denial,’ or failing that, to write him off as someone who is evil, bad, and uncaring.” He refers to this part of him as an “inner tyrant” that operates from a position of self-righteous superiority. Jenkins is not alone in these feelings. They are common reactions in situations where clients avoid responsibility and are important to acknowledge. At the same time, these reactions may not be the most useful ones in bringing about change. We need to find ways to respectfully invite those who have been abusive or neglectful to challenge such

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ways of being. This respect does not excuse clients of responsibility or minimize the effects of their actions. In fact, it is important that we act in ways that are always respectful both to those who have abused and to those who have been abused. As Jenkins (1996) puts it, “The issue of respect is critical. I am convinced that interventions which are disrespectful to either party inadvertently contribute to the maintenance and even exacerbation of abusive behavior” (p. 119). Thus, it is important that we begin by thinking carefully about how to respond rather than simply react to client behaviors and statements. One way to avoid an overresponsible/underresponsible pattern when engaging clients who present with a stance of “This is not a problem” is to initially avoid giving suggestions or tasks. For example, telling Bob to go to AA or to reconsider how he treats his kids at this point runs several risks. The biggest risk is that he probably won’t do it. Asking him to do something that he most likely will not do undermines therapist credibility, runs the risk of shaming Bob, and undercuts the developing relationship. This is not to suggest that we ignore the issue and collude with an avoidance of important subjects, but rather that we first establish a foundation for addressing those issues more effectively. One way for us as therapists to hold back from giving advice without an authorization is to think of ourselves as responding to continual invitations for overresponsibility and to decide whether we want to accept those invitations (and the resulting consequences) or decline them at this stage.

Connecting with Clients’ Intentions, Hopes, and Preferred View of Self Alan Jenkins (1996) has a wonderful saying: “Respectful therapy involves a process of knocking on doors and waiting to be invited in, rather than breaking them down, barging in, and then expecting to be welcomed with open arms” (p. 122). One way to get invited in is to elicit and connect with client intentions, hopes, and preferred view of self. If we view Bob as simply a “neglectful alcoholic in denial,” it becomes difficult to make a connection to him. However, if we return to the social constructionist idea that identity is shaped in social interaction, we can view our interactions with clients as a project of assisting clients in creating and recreating their identities. We can begin with an assumption that Bob is (or could be) more than the description presented to us initially and then set about trying to prove that assumption to ourselves. At the same time, while inquiring about clients’ intentions, hopes and preferences, it is important not to lose sight of the effects their actions have on others. We need to insure safety and well-being in the immediate present, while simultaneously seeking to expand client willingness, ability, and

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confidence in promoting safety and well-being on an ongoing basis. It is important to focus on both and not give short shrift to either. In this instance, the therapist was assured that the court had limited Bob’s contact with his children and felt some leeway to engage Bob as part of ensuring their continued safety and well-being. Bob did come back for a second session, and the therapist expressed his surprise. THERAPIST: I’m glad to see you. I thought I was a bit hard on you last week and wasn’t sure if I’d see you again or not. What made you decide to come back? BOB: Oh, I don’t know. I made the appointment, so I thought I should keep it. THERAPIST: So, you’re a man of your word, eh? BOB: Well, yeah, I guess I am. If you say you’re going to do something, you gotta do it. At this point, the therapist has several choices in responding. He could point out to Bob the discrepancy between “being a man of his word” and his history of missing visits with his kids, getting in trouble with the law, and persistent substance abuse. He could also ask more questions to learn about what Bob prefers about being a man of his word in order to help him become more of that person. The therapist chose the latter. THERAPIST: So, it’s important to you to stick to your word? BOB: Yeah. THERAPIST: Who else knows that about you? BOB: Well, my boss knows he can count on me to finish the jobs I commit to. He tells me I’m the most reliable employee he’s got. THERAPIST: What do you think your boss appreciates about your reliability? BOB: I don’t know. I never thought about that. THERAPIST: What do you appreciate about this reliability you’re describing? What makes it important to you? BOB: I never really gave that much thought either. (long pause) You know most people don’t see me as reliable. Most people think I’m just a screw-up.

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This statement is an opening to help Bob take more responsibility. It may even be tempting to ask him why most people think he’s a screw-up. It might even be tempting to offer the opinion that indeed he is a screwup. However, a conversation to invite more responsibility will go further on a foundation of what Bob could be rather than what Bob isn’t. The therapist continued to build that foundation. THERAPIST: And which would you prefer, being reliable or being seen as 6 a screw-up? BOB: Being reliable, definitely being reliable. The therapist asked a number of questions about why being reliable was a preference for Bob and how reliability became important in his life. In response, Bob traced out a story of a domineering, critical father with high expectations that Bob could never live up to. Bob hated his father’s criticisms and initially tried to win his father’s approval. Over time, he developed a sense that no matter what he did or how hard he tried, he couldn’t count on his father for appreciation or support. In his own life, Bob wanted to be a person who was reliable and seen as reliable. As Joe Eron and Tom Lund (Eron & Lund, 1996; Lund & Eron, 2005) have highlighted, there is often a gap between people’s preferred view of self and how they are acting. Helping people notice and address that gap begins with appreciating and validating their preferred view of self. As Bob experienced a sense of appreciation from the therapist, he began to talk in a more relaxed and open fashion. He had a sense that this therapist “got” something about him that others hadn’t seen. He experienced this therapist as an appreciative ally, and that became a foundation to bring forward more responsibility.

Examining the Gap between Preferred Intentions and Actual Effects Once we have a deep appreciation for people’s intentions, hopes, and preferred view of self, we can begin to raise questions about the gap between these and the impact of their behavior on others. In this situation, the therapist eventually returned to the incident of Bob leaving his girls in the car while he ran into a bar. THERAPIST: You know, the first time you told me about leaving your daughters in the car while you ran in for a beer with a couple friends, I didn’t know you very well. Now that I have a better sense

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of you, would it be okay to ask you some different questions about that? BOB: Okay. THERAPIST: As I’ve been thinking about it, I don’t think that when you went into the bar you set out to neglect your kids, and I’m wondering what you were hoping for in that? BOB: For sure, I wasn’t doing it to neglect my kids. I’d never set out to neglect them. I’d have to be a real jerk to do something like that. THERAPIST: So, what were you hoping for when you ran in with your friends? BOB: I don’t know. They said let’s go have a beer and I didn’t want to disappoint them. They look up to me and it was sort of like being one of the guys. THERAPIST: And I know that your girls ended up okay. But how much would it have upset you if you found out that your girls woke up in the car all alone and were scared without you there? BOB: Oh, that would be horrible. THERAPIST: Why would that be horrible? BOB: I’m their dad. They’re supposed to be able to count on me. THERAPIST: So, their being able to count on you. That’s really important to you? BOB: Yeah. THERAPIST: And if they woke up in the car with you not there, would that be kind of like not being able to count on you in that moment? BOB: Well, yeah. (looking downcast) Yeah, that would be a problem. That would be a pretty crappy thing to do to them. Bob’s statement falls outside the prevailing stance of “This is not a problem” and provides an opening for further bringing forward responsibility. The therapist continues his questioning with Bob, moving back and forth between Bob’s intentions, hopes, and preferred view of self and the ways in which his behavior in this instance contradicts that. He attempts to strike a balance between inviting Bob to examine this discrepancy without taking him “off the hook” and building enough of a foundation of appreciating Bob’s preferred view of self to help him remain in the conversation. Throughout, the therapist is on the lookout for statements that contradict or are exceptions to a no-problem stance.

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Building on Exceptions to a No-Problem Stance Exceptions to a no-problem stance are often easy to miss. The trick is to listen carefully for them. In this instance, the therapist built on the glimmer of Bob’s concern about leaving his girls alone in the car and asked a number of questions to build on that small exception. Samples of these questions include: “When you say that’d be a pretty crappy thing to do to them, what does it tell you about what’s important to you in being their father?” “Can you think of times when you’ve been a bit more of that kind of father?” “What is important to you about those times? What does it say about your hopes and dreams in being their father?” “As you think about those hopes and dreams, what do they say about what you want to stand for as a father?” “What effect do you think being that father would have on your girls?” “What difference might that make in their lives?” In the context of these questions, Bob talked with regret about how he screwed up his marriage and his desire not to screw up his relationship with his girls. This desire falls further outside a no-problem stance and offers increased momentum for a new direction in life. The therapist asks Bob to project forward into the future and talk about how he would like his daughters to describe their relationship with him, looking back from their 21st birthdays. Bob describes a hypothetical relationship that is quite different from his current one and begins to get a bit teary eyed. The therapist asks Bob if he would like to try to develop the relationship he would prefer to have with his daughters and finds himself moved by Bob’s wordless nodding. At this point, for the first time, Bob and his therapist have a jointly agreed-upon focus for their work together.

Building on a Shared Proactive Focus for Change At this point, Bob and his therapist have the beginning of what solutionfocused therapists call a customer relationship (Berg, 1991, 1994; Berg & Miller, 1992; de Shazer, 1988). They have a jointly identified goal (Bob would like to develop a different relationship with his daughters). The goal represents an agreed-upon proactive focus (something Bob can be moving toward rather than away from). Bob is beginning to see

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himself as part of the solution in this goal (this is a relationship he would like to try to develop). And Bob is willing to do something about the situation (as evidenced by his wordless nodding that moves the therapist). At the same time, this beginning is just an initial start to the real work. It is important to further solidify these initial steps and ask further questions about why this goal would be important to him, whether he believes he can do something about this situation, and how willing he is to commit to this process. Turnell and Edwards (1999) highlight the importance of scaling questions to assess willingness, capacity, and confidence to undertake goals. Examples of these types of questions in this situation might include: “On a scale of 1 to 10, where 10 means you are willing to do anything to build a different relationship with your girls and 1 means you’re not willing to do much at all, where would you place yourself on that scale? What, if anything, would increase your willingness to do something about this situation?” “On a scale of 1 to 10, how would you rate your ability to develop a different relationship with your girls? What aspects of this project would you feel most able to take on? What or who could help you do this?” “On a scale of 1 to 10, how much confidence do you have that you can make these changes we’ve been discussing? What gives you that level of confidence? What would increase your confidence?” These questions both assess willingness, capacity, and confidence and have the potential to simultaneously enhance them. A collaborative partnership is an interactional phenomenon that is jointly developed between clients and helpers. It begins with finding something that clients would be interested in working on and trying to make helping efforts relevant to clients’ lives. Bob’s agreement to work with his therapist on developing a better relationship with his daughters is the beginning of developing therapeutic goals that hold relevance for his life, as opposed to goals that he opposes or goals that he assents to, but has no intention, ability, or conviction to follow through on. However, this is just the beginning. There is much work to be done in learning about the resources Bob brings to the task of developing a different relationship with his daughters. There may be even more work to be done in helping Bob identify and challenge the constraints to developing a different relationship with his daughters (constraints that will probably include drinking and neglect). However, Bob and his therapist now have a foundation from which that work can proceed more effectively. As you read this story, you may find yourself thinking about Bob in

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a new light. You may see him with more empathy and appreciation and view his relationship with his children and ex-wife with more hope. You may also find yourself concerned about the effect of his neglect on those around him and wondering what will happen with his drinking. It is important to hold both responses. Bob has a possibility of beginning to enact a richer story that will have quite different real effects on his children and his ex-wife. He also has a long history of living his life in a way that has taken a significant toll on others. It is important to strike a balance between holding a belief in the possibility of change and continuing to fully assess risk factors and ensure safety and well-being. A proactive focus provides an organizing theme that helps in this process, and Chapter 4 examines the development of proactive therapy goals in detail. The following five guidelines summarize these suggestions for engaging clients who hold a stance of “This is not a problem”: 1. Anticipate and attempt to avoid an overresponsible/underresponsible sequence. 2. Connect with clients’ intentions, hopes, and preferred view of self. 3. Examine the gap between preferred intentions and actual effects. 4. Build on exceptions to a no-problem stance. 5. Build on a shared proactive focus for change.

SUGGESTIONS FOR APPROACHING A NO-CONTROL STANCE At times, clients have a clear and detailed sense of the problem, but see the situation as out of their control and beyond their influence. An example of this no-control stance comes from an affluent Jewish family that was court mandated for family therapy. The family consisted of Arnie, Peg, and their sons Sam (14) and Jake (8). Arnie and Peg were looking for help with their son Sam, who had been arrested for vandalizing his school and would not listen to them at home. The parents showed up with their younger son, Jake, for a noontime appointment, complaining that Sam was home sleeping and would not come. At the first appointment, I went out to meet them, walked them to my office, and began to introduce myself. My introduction was quickly interrupted by Arnie, the father, who launched into the following tirade: ARNIE: We can’t get Sam to do anything. If he doesn’t want to do it, he doesn’t do it. If he doesn’t want to go to school, he doesn’t go to school. If he wants to wreck the house, he wrecks the house. He does what he pleases . . .

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PEG: (jumping in) Sam’s out of control. He needs a lot of structure, and someone has got to do something quick. BILL: That sounds worrisome. Can I ask what you’ve tried at home? PEG: There’s nothing we can do. He won’t respond to anything. ARNIE: He’s headed for jail. He really is. Let me give you an example. I painted his room for him, and you know what my reward was? He vandalized my home office. Can you believe that? The more you do for him, I don’t know. I can’t understand him. BILL: What was your response to what he did to your office? ARNIE: What do you expect me to do? He’s not going to listen. (Starts in again with a litany of complaints until Peg cuts him off.) PEG: Maybe there’s a program or something Sam could go to. Somebody needs to talk to him and figure out what’s going on with him. BILL: Let me ask you about that. What do you think is going on with him? PEG: I have no idea. That’s why we’re coming to you. Would you be able to meet with him? BILL: Well, that’s a possibility. How could we get him here? ARNIE: Maybe you could talk to his probation officer. In this interaction, the parents clearly acknowledge that a problem exists (defining it as Sam), but do not see themselves as having control or influence over that problem. A no-control stance occurs within a historical and cultural context and receives strong support through the medicalization of deviance, in which misbehavior is increasingly seen as a sign of a mental disorder in which something is inherently wrong with the child (e.g., attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, etc.). This formulation subtly conveys a message that if a child has one of these disorders, the parents are helpless to address it. Therapists have an important choice in responding to a nocontrol stance. Confronting the stance risks a nonproductive struggle over whether the parents can influence their son. Holding back from confronting that stance avoids this struggle, but risks colluding with a disempowering stance. Let’s examine these two possibilities and search for a third alternative.

First, Do No Harm In response to the parents’ statements that they can’t do anything about their out-of-control son (a no-control stance), a therapist might inquire

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about their attempted solutions or offer suggestions. These responses may leave them feeling criticized and provoke defensiveness (e.g., Peg’s response, “There’s nothing we can do. He won’t respond to anything” or Arnie’s response, “What do you expect me to do? He’s not going to listen”). The parents’ responses could invite a counter-response from a therapist to get them to see the control they do have over the situation, which inadvertently may provoke more defensiveness. The resulting pattern could be described as a criticize/defend pattern in which the parents’ perception of criticism invites defensiveness and that defensiveness invites a response from the therapist that they further experience as criticism. As that pattern gains strength, it can lead to an escalating struggle over who should do what about this problem. The therapist’s intention is not to criticize the parents, but they may experience the response in that way. In the process, they end up emphasizing how little influence and control they have and the pattern rigidifies a no-control stance that further constrains their efforts to help their son. This situation can also lead to the development of a second interactional pattern. When clinicians quickly move to offering suggestions, parents may experience those suggestions as minimizing the difficulties they’ve described. From the parents’ perspective, the therapist doesn’t “get it,” which compels them to emphasize the gravity of the situation and their inability to address it. Paradoxically, their response may invite a counter-response from the therapist of further encouraging them to do something they’ve already said they cannot do. This resulting pattern could be described as a minimize/maximize pattern, in which the parents feel their difficulties are being minimized and the therapist feels they’re exaggerating the problem. Each action invites the other, and as the pattern takes hold, each position becomes increasingly rigidified. These patterns are often influenced by interactions with previous helpers. Over time, the patterns can take on a life of their own, pulling participants into them. These patterns have negative effects on the parents. Their no-control stance becomes rigidified, and they experience themselves as increasingly incompetent with their son, disconnected from each other, and further away from the parents they want or hope to be. These patterns can also have negative effects on the therapeutic relationship. They can contribute to an adversarial relationship that promotes particular attention to difficulties and invites criticism and judgment rather than understanding and appreciation. This is not a solid foundation for continued work. The decision not to challenge a stance of no-control is also problematic. As the parents come in and complain about their out-ofcontrol son, a therapist could listen supportively without challenging their stance or mobilizing them as parents. Although this approach may provide some comfort to the parents, it doesn’t help them in

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addressing the situation. The goal here is not simply to avoid a problematic interactional pattern, but to actively enter into an alternative interaction that can better address the problems they’re describing. These potential dangers have been highlighted to help us apply the medical maxim “First, do no harm.” In encountering a no-control stance, the first step is to avoid adding further constraints by not becoming ensnared in a problematic interactional pattern with families or falling into passive collusion with a problematic stance. From here let’s examine another alternative.

Searching for Positive Intentions behind Complaints7 A criticize/defend or minimize/maximize pattern between helpers and parents is often supported by the concern helpers develop for children. Helpers can be drawn into an alliance with children in which their concern for them and desire to be helpful make it difficult to listen to long parental harangues that can feel discomforting or even abusive. This is especially true in residential or school settings where helpers have significantly more contact with children than with parents. Those contexts can often pull for a subtle competition over who has the best interests of the child at heart. Although I had never met Sam, I had heard about him from teachers at his high school where he had a reputation as a kid with potential who came from a troubled home. As I listened to his father’s diatribe, I wondered whether I’d be able to enlist his participation and found myself coming to think of him as part of the problem. I was becoming judgmental of him and wondered about referring Sam to a school-based counseling program at the high school where he could be seen individually. Sending kids such as Sam for counseling outside their family can be a useful way to provide support for them that they may not receive at home. However, Sam’s network is the family he lives in and if we return to the assertion in the first chapter that our job is to support, not supplant, the functioning of clients’ natural networks, we can see how it would be important to find a way to get better connected with the father in this family. The trick here is to be able to simultaneously acknowledge judgmental feelings, examine their potential negative effects on clients, and engage clients in a way that opens space for the development of a different relationship. One way to shift one’s relationship to “difficult” clients in a situation like this is to assume positive intentions behind their complaints and elicit them. As a way to highlight this search, let’s return to the clinical situation. I responded to the suggestion that I talk to the probation officer in the following way:

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BILL: Well, I imagine he might have a lot to tell me about Sam. But I got to believe that even if it doesn’t feel like it right now, you guys know Sam better than anyone else. Can we back up a few steps and have you help me to get to know Sam better? What’s he like? ARNIE: (quickly jumping in) Stubborn, self-centered, selfish, destructive. He does what he feels like. Boy, he’s gonna have trouble when he gets out to the working world. BILL: What do you think will happen when he gets out into the world? ARNIE: I think he’s headed for jail. I really do, because you can’t act that way in this society and get anywhere. PEG: (to Arnie, scornfully) You look so happy when you say “jail.” ARNIE: Well, I think if he did go to jail, it might wake him up. BILL: What’s the wake-up call you’d like him to get? ARNIE: He’s got to learn that he can’t keep running around destroying everything, not listening to anybody, doing whatever he pleases. BILL: You want more than that for him. ARNIE: Yes! BILL: What kind of man do you want him to be when he gets out into the world? ARNIE: Well, I want him to be respectful, not like the little snot that he is. You wouldn’t believe his mouth . . . BILL: (quickly moving in to cut off Arnie’s criticisms) You want him to be a respectful man, and what else? ARNIE: I want him to be able to earn things rather than steal them. I want him to appreciate all that we’ve done for him. If he has a girlfriend, I want him to treat her better than he’s treated his mother . . . The question about the wake-up call was an attempt to move toward eliciting a positive intention behind Arnie’s complaints. Arnie’s initial hopes for his son to become a respectful man were liberally mixed with scathing attacks. I resisted the temptation to point out to him that his attacks were not helpful and continued amplifying his hopes and gently redirecting him when he drifted back into attacks. With this help, Arnie gradually shifted from attacks to hopes. As this shift occurred, he softened a bit. I found myself admiring the kind of man Arnie hoped his son would become and beginning to appreciate the glimmer of connection between them. I summarized those hopes, complimented Arnie on his desire to raise a son up to those hopes, and asked Peg if any of her

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husband’s hopes for their son were surprising to her. She initially responded with a scathing critique of his usual harangues about Sam, but with an acknowledgment of that past history and gently persistent questioning about emerging differences here, she commented on Arnie’s wanting their son to treat her with more respect and appreciated his other hopes for Sam. BILL: And, hearing about Arnie’s hopes for Sam behind all that anger, what’s the impact of that on you? PEG: Well, it’s strange. It’s like Arnie cares more for Sam than I thought. BILL: (to Arnie) It sounds like when those hopes get clouded by the kind of stuff he’s been doing, it drives you crazy. ARNIE: Yeah, I just see red and I go crazy. As I began to appreciate what I saw as a positive intention behind Arnie’s complaints about his son, I felt less judgmental toward him. (This took some work on my part.) I was able to draw a distinction between the positive intention behind his tirades (which I could appreciate and respect) and the effect of those tirades on me and presumably on his son. I began to develop more empathy for Arnie in his outbursts by placing them in the context of his disappointment that his son wasn’t living up to those hopes. Arnie experienced my developing appreciation of him in subtle ways and, as he began to feel heard and validated, eased his attacks on Sam. As Arnie considered his hopes for Sam, he experienced his anger and disappointment in a different way. He became a little less reactive and, although continuing to voice his disappointments in his son, did so in a way that was less vehement. My search for positive intentions behind the father’s complaints had a number of beneficial effects on everyone involved. Arnie felt more understood and less criticized and responded with more openness. Peg felt a little bit closer to her husband and viewed him in a slightly different light. I felt more appreciative of the family and was more hopeful that I could engage the parents’ participation. In this process, positive intentions both provide an opening for change and grow as they are noticed.

Developing Hope and Agency After constructing positive intentions behind complaints, we can further shift our relationships with clients by inquiring about what has kept these intentions alive. Clients who present a no-control stance often feel

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victimized by the problem they’re describing, and it can be very useful (and eye-opening) to ask what has sustained them in the face of the problem. The process of asking about what has sustained them opens space for the emergence of hope and agency (the sense that clients can take action to bring about change in their lives). This is a joint process in which we are not simply discovering preexisting characteristics, but developing clients’ capacities, intentions, and purposes in the course of the conversation. Often hope and agency exist only as faint glimmers that are difficult to detect. In many ways, this process could be thought of as emphasizing the little that is present rather than the much that is missing. The goal is to build a foundation that will help those faint glimmers grow and expand. The process begins with our belief that the father’s outrage could also point toward his hope that things could be different for his son. (One could guess that if he didn’t have hope that things could change, he wouldn’t be so upset.) His outrage can also be seen as a commitment to his son. For a man who is so disgusted with his son, it’s admirable that he continues participating in attempts to help him. Commenting on this commitment is a good starting point. However, this comment is not a simple technique of reframing. It is important to really “see” it and believe it. It works better as a deep conviction than as a facile reframing. From that foundation, we can ask questions to amplify hope and inquire about how he has kept hope alive. Here I return to the clinical example. After eliciting the intentions behind Arnie’s complaints, I marveled at his hopes for his son and went on to inquire about how he had managed to hang onto those hopes in the face of all the difficulties in their life together. BILL: You have a clear picture of what you want for your son.8 Has that picture been easy or hard to hang onto when he’s pulling the stunts you’ve described? ARNIE: It’s been a bear. BILL: How have you been able to do that? ARNIE: I have no idea. BILL: Well, would it be okay with you if we slowed down a bit and tried to figure that out? Because I think it’s pretty remarkable that you’ve been able to hang onto hope in the midst of all this, and if we were able to learn how you’ve done that, it might give us ideas about a foundation for helping your son. ARNIE: Okay.

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I then asked a number of questions about how Arnie had not given up on his son even though he had spent the last 2 years “at the end of his rope.” Arnie initially responded with variations of “I had no choice— what did you expect me to do?” However, continued questioning elicited a story of a beleaguered couple who were very committed to a “frustrating son they just couldn’t understand” and who managed to stay together despite the toll this situation had taken on their relationship. As they described how they managed this feat, they began to describe themselves with such words as “loving, stubborn, persistent, and committed.” These were not words that came easily to them but ones that they nonetheless embraced. As they experienced and began to enact a life story that held more hope and agency, there was a noticeable shift in their posture. They became less slumped in their chairs; they moved closer together and began looking at each other with a new level of interest. This experience is a better foundation from which to help them challenge their victimization by the problem they’ve described. That challenge begins with an examination of exceptions to their experience of no control.

Building on Exceptions to a No-Control Stance One pathway to help clients who hold a no-control stance further develop hope and agency lies in their experience of life outside “no control.” Our efforts can focus on amplifying alternatives to a sense of hopelessness and victimization by the problem. I return to Sam’s family to illustrate this. ARNIE: I think he’s lucky to have us as parents. Most parents wouldn’t have put up with all this. BILL: I think he’s lucky to have parents strong enough and committed enough to put up with him. He’s really given you a ride for your money, and yet you’ve managed to hold onto your hopes for him as he becomes a man. Can you think of a time when you’ve been able to see any glimmers of the man you hope he’ll become? ARNIE: That’s hard to say. I can’t think of any. PEG: Remember when he broke his friend’s videogame and saved up to buy him another one? We didn’t have to hound him a bit about that. But, of course, that was with a friend and not with us . . . I asked a series of questions to get a full description of the incident and learned that Sam broke his friend’s toy and told his parents about it.

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They suggested that the friend would appreciate it if he replaced it but said it was up to Sam to decide how important the friendship was to him. They dropped the matter and were surprised when they later heard from the friend that Sam had saved up and bought him a new game. They were particularly impressed that he hadn’t just gone out and stolen one. I asked them about their contribution to this exception. BILL: You know, often parents influence their kids in ways they’d never imagine. What do you think you might have done in this situation to contribute to Sam’s being so responsible? ARNIE: Nothing, though we didn’t jump all over him. The response of “not jumping all over Sam” is actually a fairly significant exception to the parents’ usual interactions with Sam. In this exception, Arnie stepped back and Sam responded differently. As we discussed the ways in which stepping back might affect Sam, the parents began to experience themselves as having some influence in relation to their son. As we examined that influence, the parents shifted from emphasizing their lack of control over Sam to examining the influence they might have. This shift from control to influence is an important one. Although we have a strong cultural ethos that emphasizes being “in control” and the “master of one’s fate,” one could make a convincing case that we never have control over situations. However, we do have influence. This shift from “lack of control” to “emerging influence” provides a stronger foundation from which to work. It establishes a positive, forward momentum that supports the elaboration of hope and agency. It promotes an empowering partnership and keeps our work anchored in what works within the family’s culture rather than inviting the imposition of preferred solutions from professional culture.

Building on a Shared Proactive Focus for Change At this point, my relationship with the parents had begun to change. They were beginning to see themselves as having some influence over the problem and there was a stronger connection in the therapeutic relationship. As they continued to examine instances of their influence, Arnie commented that Sam responded better to encouragement than correction, though with the disclaimer that “he doesn’t give us many opportunities to do that.” Sensing an opening, I responded with the following remarks:

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BILL: It sounds like when you folks get caught by this dance, it’s much easier to fall into correcting him than encouraging him, and every time you correct him he ends up acting out more, which gets you correcting him more and on and on? ARNIE: You got that right. BILL: And it sounds like that’s been a frustrating process for everyone. Like you’d rather be encouraging him to be the man you want him to be than correcting him from being the boy you don’t want him to be and that he’d rather get your encouragement than your criticism. ARNIE: Yes again. BILL: Would you like some help not getting caught by that dance, where he acts out and you criticize and he rebels and you criticize more and on and on, in order to spend your time instead helping him become the man you hope for? ARNIE: Sounds like a plan. BILL: How about we meet again to develop a plan for that? Do you think Sam would be interested in a plan to get you off his back? ARNIE: We can ask him and find out. Whether Sam would come in or not, I was now in a much better situation with his parents. We had a jointly agreed-upon focus to guide our work and, for the first time, were more solidly on the same page. Although Sam did not come in for the next few sessions, I worked with his parents to help them support each other in not getting caught by the pattern they had described and in developing a different way of interacting with their son. After a several meetings, Sam entered the room in the middle of a session, saying he was in the neighborhood and needed bus fare from his parents. He expressed some curiosity about what people had been saying about him and accepted my invitation to stick around and find out. In summary, we can shift from viewing the “reluctant family” as the problem to viewing the stance of “This is a problem, but we have no control over it” as the problem. We can think about a family and helpers as being in a relationship with that stance and that stance as constraining a family from more effectively addressing a problem and exacting a toll on relationships. The series of guidelines that have been outlined can be summarized as follows: 1. Anticipate and attempt to avoid criticize/defend or minimize/ maximize patterns. 2. Connect with clients by searching for a positive intention behind their complaints.

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3. Develop glimmers of hope and agency into a foundation for challenging victimization by the problem. 4. Build on exceptions to a no-control stance. 5. Build on a shared proactive focus for change.

SUMMARY Although the two stances (no-problem and no-control) are quite different, there is significant overlap in the guidelines offered. In examining the common themes, we can extract three that provide useful generic guidelines for engaging all families: 1. Get to know clients outside the influence of the problem. Families are more than the sum of problems that bring them to therapy. Discovering aspects of their experience outside the influence of problems in their lives builds a strong foundation for a therapeutic relationship. It facilitates connection and bypasses the “resistance” that can be provoked when we confuse family identities with the problems in their lives. 2. Honor before helping. It is important not to attempt to help a family without an authorization to do so. One way to obtain such an authorization is to honor those aspects of families that are outside the influence of problems before attempting to help with those aspects of their lives taken up by problems. 3. Keep the problem on the table. Finally, in engaging families, it is important to remember that our engagement is a means to an end, not an end in itself. We have not entered into clients’ lives simply because they are interesting and resourceful people. We are there for a purpose and need to keep that purpose in mind. That purpose also needs to be continually negotiated with the family in order to maintain our authorization to be in their lives. The next chapter outlines a framework to organize our efforts toward that purpose through the development of collaborative therapy contracts. NOTES 1. “Resistance” is put in quotation marks here to highlight that it is our construction rather than a real entity. I do not continue to use quotation marks around the word because it could become tedious, but I encourage you, the reader, to hold the concept in quotes in your head. 2. It is useful not to locate the problem of techniquism simply in individual practitioners. The search for a quick fix may protect us from the pain of family discomfort, but a “fix-it mentality” receives significant support from the organizational and broader contexts in which we work.

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3. This client was seen by a therapist whom I supervised. 4. These ideas for approaching a no-problem stance have been strongly influenced by Alan Jenkins (1990, 1996), whose work with violent and abusive men I find to be humane and effective. These suggestions are offered as a guideline, not as a recipe that should be followed step-by-step in exact order. 5. In fact, this adversarial and confrontational relational stance underlies a number of common treatment modalities with offenders, batterers, and substance abusers. 6. It is important that this question is experienced by the client as a question of genuine interest, rather than a trick question designed to yield a particular response. Connecting to clients’ preferred view of self requires conveying an honest appreciation for their responses. 7. This description of my work with the family highlights work with the father because more work was required to engage his participation. The interview mainly focused on eliciting the father’s participation; thus, the work with the mother receives less attention here. 8. The father’s clear picture emerged in the interview rather than being a preexisting picture that was subsequently discovered. This process of jointly developing richer experiences and stories through questions is further explored in Chapter 5.

CHAPTER 4

Developing a Proactive Vision to Guide Clinical Work Collaborative Therapy Contracts

The focus of therapeutic conversations has a profound effect on the ways in which clients experience themselves and the possibilities available to them. Traditionally, therapy has emphasized problems. As clinicians, we are encouraged by taken-for-granted professional assumptions and the forms that guide our work to inquire about problems and their etiology. There is an understandable focus on what is wrong and what should be done about it. However, beginning with a focus on problems may have the inadvertent effect of amplifying those problems, further entrenching clients in a problematic identity, and constraining them from developing a sense that “things could be different.” Waters and Lawrence (1993) have suggested, “One of the great deficits of most therapy is the lack of a proactive vision of what people need to move toward instead of a sense of what they need to move away from” (p. 9). In an attempt to develop a proactive vision for therapy, solution-focused therapists have shifted from focusing solely on what needs to change to focusing on what that changed state will look like; in other words, focusing on the nonproblematic future (Berg, 1994; Berg & Kelly, 2000; de Shazer, 1985, 1988, 1991; Durrant, 1993). In this process, therapy focuses on where people would like to be headed in their lives and how we can support them in that process. Sometimes, this shift in emphasis can be a bit disconcerting for clients expecting questions about 125

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problems. A focus on possibilities also needs to include an acknowledgment of clients’ complaints and an appreciation of their experience of difficulties. This chapter examines the usefulness of organizing therapeutic efforts around an investigation of possibilities in life and beginning our efforts by helping clients envision preferred directions in life. The first half of the chapter examines the usefulness of a journey metaphor to organize helping efforts, highlights the benefits of a focus on possibilities, and outlines a number of ways to help clients envision desired futures as well as preferred coping in the present. The second half examines the process of translating this proactive vision into therapy goals. It offers an outline for therapy contracts, examines possible pitfalls in developing therapy goals, and focuses on the development of collaborative therapy contracts in a number of difficult contexts.

THERAPY AS A JOURNEY A number of authors have drawn on a journey metaphor to describe therapy (Adams-Westcott & Isenbart, 1995; Durrant, 1993; White & Epston, 1990; White 2004). Within this framework, therapy can be seen as a rite of passage in which clients (with our support) move from constraining identities to preferred ones. As derived from van Gennep (1960) and Turner (1969), a rite of passage metaphor has three phases. The separation phase involves separating from a problematic identity and an old relationship with particular problems. The middle, or “liminal,” phase is often a challenging and disconcerting time in which people move back and forth between an old identity and a developing newer one. During this time, they can feel adrift; disconnected from the old, but not yet in sight of the new. The final reincorporation phase involves the arrival at a preferred identity and a different relationship with particular problems. The middle phase can be disconcerting in its “betwixt and between” feeling and can provoke crises of confidence and despair. This difficult time can be helped with the development of a proactive vision that provides focus and direction. A proactive vision helps to frame the journey as moving toward the new rather than away from the old. At a clinical level, this shift in focus helps clients envision and develop preferred directions in life rather than simply trying to identify and correct problems. This chapter highlights ways in which a journey metaphor can be used organize our work. It initially examines ways to help clients develop a proactive vision to guide therapy and then outlines a process for the development of collaborative therapy goals.

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DEVELOPING A PROACTIVE VISION TO GUIDE THERAPY The development of a proactive vision can be a process of eliciting hopes for the future (e.g., “What kind of person do you hope your daughter will be when she grows up? What makes those qualities or ways of being in the world important to you? How do you need to be in your life to help her become a person like that?”). This process can also focus on the present (e.g., “As your son continues to struggle with impulsivity and recklessness, how would you prefer to respond to him? How would you describe the stance you’d like to maintain in this situation? What could help you stay grounded in that stance regardless of any surprises you might encounter?”). In this way, a proactive vision is not simply a shift from focusing on what isn’t and should be, to focusing on what is and could be, but rather constitutes an acknowledgment of problems in life along with a focus on supporting preferred ways of being in the face of those difficulties. The next section draws on a clinical example to highlight advantages of a future focus, followed by a vignette to examine the development of a vision of preferred coping in distressing times.

Beginning with a Future Focus: Planning Jon’s Graduation Jon was an 8-year-old Jewish boy whose father, David, and stepmother, Ruth, were splitting up for the fourth time. Ruth, tired of David’s drinking, philandering, and general irresponsibility, ordered both David and Jon to leave her house. David subsequently lost his job and, after a brief stint of homelessness, moved back in with Ruth and her two daughters. The family had a long history of involvement with protective services and was referred to a short-term intensive family intervention service because of concerns about David’s neglectful parenting and the tension between Jon and Ruth. Both David and Ruth were skeptical about receiving help because of numerous negative experiences with professionals in the past. The new therapist took time to get to know the family and then, noticing David’s high school ring and remembering from a conversation with the referral source that David had experienced great difficulty finishing high school, engaged him in a discussion about his high school experience. They talked about David’s track team membership and the difficulty of balancing athletics and schoolwork. David described his commitment to finish school no matter what it took, and in that context the therapist asked David about his hopes and wishes for his son’s future. David replied that he wanted his son to finish high school and get a solid trade. The therapist invited David to imagine his son’s high

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school graduation in 10 years and asked a number of questions to concretize a vision of this graduation. As David began to generate a clear image of the future event, the therapist asked what would need to happen to help Jon get to that point. Even though the therapist would be involved with the family for only a short time, he began with a long-term vision and then focused on what could happen in the next 3 months to help make that vision a reality. This is analogous to strategic planning in which a consultant helps an organization develop a long-range plan even though the consultant will not be there throughout that time to help the organization enact the plan.

Advantages of a Proactive Vision The development of a proactive vision to guide our work has a number of important benefits. Conversations about possibilities invite families to step out from under the weight of everyday problems. At the end of the session just described, David remarked on how fast the time went and said this meeting felt different to him. He reflected on his desire to be the kind of father that he had never had and valued the opportunity to think about the father he could be, rather than simply the father he hadn’t been. Although Ruth still held a lot of anger toward David and wanted that to be acknowledged and appreciated, she also saw glimmers of a different life and felt both intrigued and cautious about that possibility. They both left the meeting a bit more relaxed and hopeful. In this way, beginning with a proactive vision generates possibilities and enhances cooperation. The family was much more willing to continue meeting with the therapist to discuss what could happen in the next 3 months to increase the chances of Jon’s graduating from high school. They agreed to work on developing a stable living situation for Jon and clarifying how they would work together to care for him. David wanted to work on becoming a father whom Jon would be proud to have at his imagined graduation, and Ruth wanted to support David’s parenting without taking over every time he struggled. Both parents were less skeptical of therapy and began with enhanced motivation. In a program evaluation form filled out 6 months later, David noted the difference in this approach: “Before, we had always talked about what others thought we were supposed to work on with Jon and how we still hadn’t gotten there yet. Now, for the first time, we have focused on where Jon is going in his life and how we can help him get there. It gives us a new sense of him and more hope for all of us.”

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These two questions—“What are you working on?” and “Where are you headed?”—point to two different directions (Durrant, 1993). Whereas the first question keeps us within the realm of the problem and may constrain recognition of life outside the problem, the second question orients us to life that may not include the problem and opens up expanded possibilities. This focus does not ignore the existence of problems but invites an examination of those problems from a perspective outside their immediacy. The development of a proactive vision can also help clients cope with difficult times in the present. Markus and Nurius (1986) found that when faced with a crisis, individuals with a vision of the future coped much better in the present than those without such a vision. Though the work with Jon, David, and Ruth started on a positive note, it certainly did not roll along smoothly. David’s lapses in responsibility drove Ruth crazy and periodically led to pitched battles between them. However, throughout this time, periodic reminders that they were building a foundation for Jon’s graduation made the situation more tolerable for everyone and allowed them to hang onto a “this too shall pass” attitude. A hopeful vision of the future supports improved current functioning. A vision of oneself in the future provides clues about the path for getting there and acts as an incentive for present and future behavior. In that sense, a future focus is a profound intervention. It implicitly conveys that an alternative future (and present) is possible. The solution-focused miracle question is an example of a future orientation as an intervention (Berg, 1994; de Shazer, 1985). In the miracle question, clients are asked, Suppose one night there is a miracle while you are sleeping and the problem that brought you here is solved. What do you suppose you will notice different the next morning that will tell you that the problem is solved? (Berg, 1994, p. 97)

A focus on the future eases us into times when desired behaviors are already happening and provide a template for further actions that move us closer to preferred futures. Finally, a focus on future possibilities and preferred living in the present provides us, as clinicians, with a way to collaboratively develop with families the direction that organizes our work. It is difficult to not have some normative model of family functioning that is influenced by our own values and from which we implicitly operate. If we begin by developing with family members a vision of the life they would like to have together, their preferences can subsequently guide our efforts to be helpful in their lives. For example, two parents state a preference to support their daughter in making better decisions in her life rather than

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trying to protect her from making mistakes. Their clinician uses that stated preference to guide her efforts to help them stay grounded in a stance of “support rather than protection” when their daughter struggles with the consequences of questionable decisions. In this way, the development of envisioned possibilities enhances collaboration and keeps our work focused and accountable to clients. It sets the stage for periodically reviewing the course of treatment with clients to assess our progress toward the projected end point and adjust if appropriate.

Coping in the Present: Helping Parents Maintain Preferred Stances in Challenging Times Another way to develop a proactive vision is to shift from envisioning desired futures to focusing on “preferred coping in the present.” At times, life in the present can seem so overwhelming, demoralizing, or tragic that questions about possible futures can seem insulting and totally out of touch. In such situations, it can be useful to first validate clients’ experience of the present difficulties, acknowledge that these difficulties may not be solved quickly, and, as a temporary measure, focus on what clients value in how they are responding to the situation. This shifts our efforts from an immediate focus on solving potentially irresolvable problems to eliciting and supporting the existential stance people would like to hold as they confront difficulties. This is essentially posing the question, “In the face of this very difficult situation, who is the person you want to be and what about being that person would be important to you?” The following vignette exemplifies this approach. Toby and Susan consulted me for help in dealing with their son, Max. Max had a long history of unsuccessful hospitalizations and residential programs for depression, suicide attempts, physical altercations with his mother, shoplifting, and vandalism. He had dropped out of school at age 16 and at 18 was living with various friends for several weeks at a time until he wore out his welcome, usually within a month. Max was a bright, caustic kid, with multicolored hair and numerous piercings. At 17, he came out as gay to his parents, a fact they initially had great difficulty accepting. When I first met his parents, Max was supporting himself by dealing drugs and periodic prostitution. Because of a series of unfortunate encounters with the mental health profession, he was unwilling to participate in therapy or even come to one meeting with his parents. (He did agree to one meeting with me individually.) His father, an ex-marine and construction worker, and mother, a homemaker, alternated between their fears for his safety on the street and their fury at the path he had chosen for his life. Devout Catholics, they were flabbergasted by his rejection of Christianity and his utter disdain

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for their faith. Yet, through all this, they continued to maintain that he was their son and that they loved him deeply, despite actions on his part that made that very difficult. In this situation, beginning with a focus on possible futures would not have fit for the couple. Instead, we began with a thorough acknowledgment of the difficulty of the situation and the complexity of their responses. I inquired why it was important to them to hang onto their recognition of their love for him throughout this situation and learned about their deep commitment to their son and their belief that “God would not give us something we could not handle.” They wanted to find a way to stay connected to him and conduct themselves with integrity in their interactions with him. Our work together began with a focus on helping them clarify the stance that they wanted to hold with their son. This occurred during an election season. They were both avid followers of political news, and together we developed a metaphor of “staying on message,” referring to the importance of political campaigns delivering a clear, concise message and not getting knocked off message by daily developments. The message they wanted to clearly convey to their son was, “We love you and accept that you are gay. However, we think you are making some poor decisions in your life. We recognize they are your decisions, but believe they have harmful consequences and we cannot support them.” We examined what made that particular message important to them, anticipated events that could pull them off message (e.g., receiving desperate phone calls in the middle of the night from their son, responding to questions from extended family members, etc.), commiserated when their own emotional reactions to Max and his situation got the better of them, and explored ways in which their faith could sustain them in staying on message. Throughout this process, I continually posed the question, “In 5 years, when you look back at this campaign, what will you be most proud of in how you conducted it?” as a way to organize our conversations about their responses to him. Over the course of periodic meetings across 2 years, they stayed connected to their son, compassionately expressed their own values and stance, set clear limits about the kinds of financial and emotional support they would offer their son, and continued to support each other in responding to situations they never expected to encounter. Over those 2 years, their son continued to offer them multiple opportunities to “stay on message” and came to appreciate their consistency and support. He is currently employed, supporting himself through an unconventional, though legal job, and has a community of friends. This example demonstrates flexibility in developing a proactive vision. Sometimes it is useful to envision nonproblematic futures that

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help lift clients out of the immediacy of problems. Other times, the possibility of a nonproblematic future may be too remote to consider and we can move into a focus on preferred coping in a difficult present.

QUESTIONS TO DEVELOP A PROACTIVE VISION There are a number of ways in which we can help families develop a proactive vision to guide our work with them. Durrant (1993) has suggested the usefulness of organizing residential programs to provide a period of practice in which young people and their families have opportunities to experience themselves as competent and successful. Through this process, they can develop a new view of self that supports the ongoing development of more helpful, acceptable, and successful behaviors. Within this framework, he suggests the continual focus should be on discharge. Rather than organizing the program to change whatever problem led to the placement, he suggests we orient the placement toward envisioning what things will be like when the young person is ready for discharge. Examples of questions that apply that approach more directly to therapy include: “How will we know when to stop meeting like this?” “At the end of our meetings, what will be different in your life that would tell you coming here had been worthwhile?” “What will others notice about you that is different from what’s happening now?” “If we had a videotape of you now and another one at the end of our work together, what differences would we see?” We can also ask people to project forward to some future date and consider hypothesized futures. Examples include: “What hopes do you have for your son on his 21st birthday? What kind of person would you like him to be? [to the son] What of that would you agree with? What will be different in your family at that point?” “How will you know that your son has gotten to the future you’d like for him?” “What will be different when that is happening? How will that make things different for you? What will others notice about you then?” “If we were at the end of our work together, rather than the beginning, and you were looking back and feeling good about what you had accomplished in this time, what would be different in your life?”

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For each of these questions, it is important to take the time to develop a rich, concretized picture of future possibilities that is close to client experience. The strength of this process lies in the breadth and depth of the details that anchor it. These questions are designed to invite clients into an experience of the future, and the impact of the experience depends on the elaboration of that picture.

What If Clients Have Trouble Envisioning Possibilities? Questions about envisioned futures are not always easy to answer. Many times, people’s hopes for the future have been obscured by problems in the present. One of the most common initial answers to the questions eliciting an envisioned future is, “I have no idea what things would look like.” It’s important to realize the degree to which the ability to answer these questions is constrained not only by the immediacy of problems in people’s lives but also by their expectation that they are supposed to talk about problems (that’s why people usually go to therapy). This focus on the future may be quite unsettling. It is helpful to understand the magnitude of this shift and to be gently persistent in the questioning. We can view the response “I don’t know” as the beginning of a conversation rather than its end. In this conversation, the search for answers needs to be a collaborative process. It can be helpful to first anchor clients in an experience from the past or present that stands out as memorable or especially valued for them. In the interview with David, the therapist’s conversation about David’s high school graduation provided a segue into questions about David’s vision of Jon’s graduation and future. If the therapist had directly asked about David’s hopes for Jon’s future, David might have had trouble responding because of the pervasiveness of problems in the present. The questions about David’s graduation invited both David and the therapist out of the “problem-saturated” present and opened space for a consideration of possible futures. A useful set of questions to accomplish this comes from Appreciative Inquiry (Cooperrider, Sorensen, Whitney, & Yaeger, 2000; Hammond, 1996; Hammond & Royal, 2001). Appreciative Inquiry is an innovative approach to organizational development that can be productively applied to clinical work. Appreciative Inquiry draws on the best of “what is” to envision “what might be” and develop “what will be” (Hammond, 1996). When applied to a clinical context, family members can be asked about “better moments” in their life together as a foundation for exploring what allowed the emergence of those moments and what the family members appreciate about how they were in those moments. This information provides a basis for inquiring about the meaning and importance of those moments

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and helping a family to concretize a vision of life filled with such moments. Examples of this inquiry in work with a couple might include: “Can you tell me about a time when you felt good about being in this relationship? What was happening? What were you doing? What was your partner doing?” “What did you particularly value or appreciate about how you were in that moment?” “Why is that important to you?” “Imagine it is a year from now and your relationship is thoroughly grounded in those things you described as being important to you. How would you know it? What would be happening? What would you be doing? What would your partner be doing? How would your experience of this relationship be different?” The envisioned future that comes out of these questions is built on a foundation of better moments in the present. Because the vision is based on actual moments and grounded in real experience and history, it is both meaningful and realistic for families. Cooperrider (2000) suggests that all groups, organizations, communities, and societies have images of themselves and have a natural tendency to evolve toward the most positive images held by their members. In this way, a concrete vision of possibilities for a family can become an irresistible magnet that gives our work positive direction and inspires clients. This focus on possibilities and preferred ways of being is subtle and yet quite profound. The mental health field is steeped in a focus on deficits, and people often come to therapy expecting to be asked about their faults and failings. In addition, many aspects of our culture promote attention to complaints and problems. We all have had years of practice in the art of addressing problems, and we are all affected by the influence of a fix-it mentality. Thus, it should come as no surprise that families may have difficulty stepping away from a litany of complaints. Although my preference is to begin by eliciting a story of preferred directions in life, it’s important to acknowledge that many families have difficulty stepping out of problem-saturated stories. We need to remain flexible in order to avoid what David Nylund and Victor Corsiglia (1994) have referred to as “solution-forced therapy.” I often offer people the option of beginning with a focus on “what is and could be” or on “what isn’t and what they hope would be,” but in both instances strive to stay attuned to emerging threads of competence, connection, and hope. Johnella Bird (2000, 2004) has offered some interesting ideas on eliciting a presumed “presence” in a description of “absence.” For

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example, one member of a couple might say, “I feel misunderstood” and we could respond with some of the following questions: “When did you notice the understanding in this relationship getting lost?” “Do you think there was a shared understanding about this issue in the relationship before that happened?” “How did the two of you develop this understanding in your relationship?” “Has this understanding in your relationship ever been lost in the past and then found again? How did you do that?” “What would tell you that a renewed sense of understanding had been achieved in this relationship? What would have changed?” For those times when a person has difficulty moving away from complaints, Robert Kegan and Lisa Laskow Lahey (2000) have offered some interesting ideas on helping people identify the hopes and commitments behind presenting complaints. They seek to tap the energy behind complaints as a foundation for examining envisioned futures. Again, examples of this approach as applied to couples might include questions such as the following: “Do you ever find yourself grumbling about this relationship? If you were to think of a complaint that is important to you and that doesn’t single out you or your partner as the problem, what might that be? If you were to put that in a format of ‘It really bugs me that ,’ what would you put in there?” “What would you like to see instead?” “If your complaint and your preferred alternative were somehow a message to you about what you really care about, what is important to you, what you really value, what would that message be?” (It can be helpful to put the answer in the frame of “I am committed to the value or importance of in our relationship.”) “If your relationship were grounded in those commitments, concretely how would we know? What would we see happening that is different?” “Would that be important to you and why? How would that change your experience of being in this relationship?” In this way, we can complement an Appreciative Inquiry focus on eliciting the “best of what is” to envision “what might be” with a focus on eliciting the “worst of what is” to envision “what might be.” This

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combination affords us flexibility in finding multiple pathways to the shared end of envisioned possibilities. At other times when clients are having great difficulty responding to questions about the future, it may be helpful to shift into a discussion of the immediate problem and its effects on their hopes for a future. For example, I recently observed the top of a young man’s head while he avoided eye contact and stared at his shoelaces. As I asked him about his hopes for the future, he responded with vague mumblings that were variations on the theme of “I don’t know, leave me alone.” I asked him when his future had been stolen away from him. He gave me a puzzled look, and I went on to explain that I figured he probably didn’t just give away his hopes for the future and so they must have been stolen away from him. He shrugged, and I continued, “Do you know other kids in your school whose hopes and dreams for their lives have also been stolen away?” His response was an imperceptible nod, and I asked, “Does it seem fair to you that young people’s hopes and lives are being taken away from them?” That aroused some interest, and he began to talk about how it wasn’t fair. His anger and sense of injustice was mobilizing, and we slowly moved into what his hopes might look like if he were to get them back. We talked about what he would like his current life (rather than his future) to look like, and he began interacting with more energy. We moved into a discussion of what he wanted for his life and how our meetings might help him develop that. The process elicited motivation that could be harnessed for our work together.

USING A PROACTIVE VISION AS A FOUNDATION FOR MOVING FORWARD IN THERAPY After clients have developed a vision of preferred directions in life, we can begin to elicit abilities, skills, and know-how they can draw on to make that vision a reality, as well as the challenges they face in “living into” those possibilities. In the clinical example of David and Jon discussed previously, the therapist invited David to examine some of the likely potholes on the road to Jon’s anticipated graduation. David identified his inconsistent presence with Jon as a possible one. When asked what got in the way of his being more present for Jon, David acknowledged that his “drinking and running around” might be a problem. After some exploration about the effects of David’s drinking and running around on Jon and their relationship, David decided to significantly cut back on his drinking and spend more time at home with Jon and less time out running around. If the therapist had begun by raising the issue of David’s drinking and running around as a problem, David most likely

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would have been reluctant to embrace those issues as a treatment goal. Their work together could easily have proceeded down a quite different path, with David acquiring a label designating him as “resistant” and “in denial.” Framing immediate problems in the context of constraints to preferred directions in life increases the probability that addressing the problem will be relevant to the client. The process allows us to join with clients against constraints rather than fall into an adversarial role in which we’re attempting to get them to address problems that may not feel relevant for them. With this general approach in mind, we now shift to an examination of goals and goal setting.

DEVELOPING COLLABORATIVE THERAPY CONTRACTS Many approaches to therapy consider goals important. This view has become even more intensified in an era of managed care when continued funding for treatment is evaluated against the attainment of concrete, measurable goals. In this context, treatment goals can be seen as a necessary evil that have to be completed to obtain continued payment. However, one of the most common reasons that therapists feel stuck is related to unclear goals. Therapy goals provide a focus and an organizational framework for therapy. They can be used to both increase client motivation and ensure that our work is accountable to clients. We can think about goal setting in therapy in many different ways. How we understand the function and process of goal setting has a significant effect on how therapy subsequently unfolds. Every action we take with clients is a potential intervention. The kinds of goals we develop with clients and the process through which we develop them invite the enactment of particular client life stories. These stories may have generative and empowering effects and carry clients forward in their lives. These stories may have constraining and disempowering effects and limit client perception of available options. With this in mind, it is important to be aware of possible negative effects in how we develop goals with clients. The next two examples highlight some of the inadvertent negative effects that can arise in the process of goal setting. Consider a protective services worker who develops a plan for an “underfunctioning, neglectful mother,” which includes a vast array of services for each of her children as well as parenting education and participation in an assertive training group for the mother. The worker goes to the mother’s home with the service plan and reviews it with her. As the mother looks at the multitude of services being “offered” to her, she wonders how she’ll ever find time for all of them and becomes overwhelmed and depressed. The worker senses that this mother will have

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trouble following through and wonders about her ability to parent. Over time, the worker increasingly steps in to do more, and the mother experiences herself as increasingly incompetent and hopeless. The worker is concerned about the mother’s “underfunctioning” and wonders whether she needs more services, but doesn’t recognize how much the existing service plan highlights only deficits and how the process of its development has been profoundly disempowering for the mother. In this instance, both the content of the service plan and the way in which it has been developed have inadvertently undermined its best intention. Or consider a defiant adolescent who is suspended from school and referred to a local mental health center after being found intoxicated in the school bathroom. At a case formulation meeting, the treatment team recommends weekly therapy and regular attendance at an AA meeting for teens to help this young man address his substance abuse problem. The therapist is not sure she can get the young man to go along with these recommendations, but is shocked at the vehemence of his “resistance.” The therapist describes to a colleague how she hates working with oppositional teenagers but doesn’t grasp the degree to which the process of a treatment team developing treatment goals and then trying to mandate client cooperation places the client in a reactive position and invites potential resistance. She also doesn’t realize that the boy is an atheist, for whom the idea of a higher power is anathema and for whom the recommendation of participation in AA is another example of how some adults “just don’t get it.” In this situation, the process of developing treatment goals constrains the development of a collaborative partnership that is sensitive to the unique culture of this particular client. In both of these examples, the process of goal setting is grounded in a medical model in which “experts” diagnose problems and prescribe treatment, and clients receive and cooperate with those recommendations. Although this operational structure may work in some settings, it has the potential for difficulties when differences of opinion arise. We risk interacting with clients in ways that constrain rather than support effective work. This difficulty has been exacerbated over the years as services become more bureaucratized, with increased emphasis on units of service and burgeoning cookie-cutter treatment protocols. One solution to this problem might be to avoid setting goals and let the process of therapy unfold naturally. Unfortunately, this is not an option in many contexts. First, public agencies operate under unavoidable constraints imposed by funding sources and managed care organizations, and that reality needs to be accommodated. Second, goals that are collaboratively developed provide an organizing focus for therapy that can increase its effectiveness and offer an accountability structure through which clients and therapists can mutually define and evaluate the direction of work together. The process of developing goals that

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reflect clients’ agendas leads to more effective therapy outcomes. Consistent research shows that clients are much more likely to pursue goals that they have developed. Berg and Miller (1992) cite studies in the field of alcohol treatment that demonstrate that compliance with therapy increases dramatically when clients set and work toward goals they’ve developed (Hester & Miller, 1989; Miller, 1985). When goals are important to them, clients are more likely to be invested in achieving them. Their investment forms a stronger basis for a cooperative working relationship and enhances therapeutic efficacy. It is important to think of a therapy contract as a work in progress rather than as a finished product. The contract is a guideline that organizes the work that clients and therapists do together. The contract sets out a general direction for the work, but we need to retain sufficient flexibility to make our work responsive to client needs. Goal setting needs to be a collaborative process. The way in which we write therapy contracts and the process through which we develop them profoundly influence how we make sense of clients and how our relationships with them develop. The therapy contract outline that follows, which grew out of the same endeavor to rewrite forms as the assessment outline in Chapter 2, represents an attempt to ground the goal-setting process in the commitments outlined in Chapter 1 (striving for cultural curiosity and honoring family expertise, believing in the possibility of change and building on family and community resourcefulness, working in partnership and fitting services to families, and engaging in empowering processes and making our work more accountable to clients). The therapy contract outlined below and in Appendix C has five components: 1. 2. 3. 4. 5.

Agreed-upon focus of therapy (Long-term goals). Short-term goals. Plan for therapy. Ways that improvement might first be noticed. Indications that goals have been achieved.

Agreed-Upon Focus of Therapy (Long-Term Goals) If we think about therapy as a journey toward new possibilities in life, the agreed-upon focus of therapy can be thought of as a brief, anticipatory summary of that journey. In the situation with Jon, David, and Ruth, the focus of treatment was summarized as follows: David and Ruth want to work together to build a foundation that will help Jon become a responsible young man who is able to complete high school, support himself, and get along with others. David, as the primary parent,

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Traditionally, licensing agencies require that treatment plans contain long-term goals, short-term goals, plan, and outcome measures. The agreed-upon focus of therapy contains long-term goals, though they are framed as something to move toward rather than something from which to move away. The long-term focus provides direction for the immediate work together and a context for subsequent short-term goals. It helps to make our work relevant to clients and organizes therapy in a way that becomes focused on current and future possibilities rather than simply focused on problems. Beginning with a focus on life beyond problems helps to loosen the hold of those problems.

Short-Term Goals Short-term goals refer to the immediate issues to be addressed in therapy that provide a foundation for the pursuit of preferred directions in family life. Short-term goals need to fit in the context of the agreed-upon focus of therapy and be developed collaboratively between therapist and client. We can distinguish between the content of goals and the process of developing goals. In the spirit of self-determination, it is important that clients have a leadership role in the development of the content of short-term goals. The journey that we are supporting them on is their journey, and we need to ensure that our efforts do not inadvertently move from supporting them to supplanting them. In addition, when clients define the goals, they are more likely to pursue them. Therapy begins with increased motivation, and we are more likely to reach goals that have been set when those goals are immediately relevant to clients’ lives. At the same time, therapists play a leadership role in organizing the process of goal development. The process of developing goals is a profound intervention. Clients may set the direction they wish to pursue, but we as therapists bring particular skills to ensuring that their journey is constructive and empowering. The language in which we help clients to frame goals is very important. Goals need to strike a balance between capturing clients’ imaginations and remaining concrete, specific, and achievable. An example of this is one of the treatment goals developed with David: David will draw on his love for and commitment to Jon to move from a Miami Vice lifestyle to a Mr. Mom lifestyle (i.e., find stable employment

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and housing, spend more time at home with Jon instead of out drinking and running around, and provide more consistent parenting to Jon in the form of clear expectations, guidelines, and consequences, as well as special times for fun).

The language for this goal grew out of David’s acknowledgment that his drinking and running around could be a roadblock to being more present for Jon. As the therapist sought to understand what David liked about his drinking and running around days, David spoke admiringly about Sonny Crockett, the Don Johnson character from the old television show Miami Vice who drove flashy cars, was surrounded by beautiful women, and moved in chic and trendy circles. David and his therapist developed a contrast between a Miami Vice lifestyle and a Mr. Mom lifestyle (from a movie David liked in which Michael Keaton portrays a father staying at home and raising kids) and examined the pros and cons of each life. Although a Miami Vice lifestyle strongly appealed to David, he thought that it was ultimately unfair to his son and wanted to move into a Mr. Mom lifestyle for his son’s welfare. In the conversation, David also began to appreciate the joy he found in just hanging out with his son. The simple phrase “moving from a Miami Vice lifestyle to a Mr. Mom lifestyle” captured a whole range of experiences for David and provided a succinct way of talking about those experiences. The language of the goal in parentheses (find stable employment and housing, etc.) was developed at the therapist’s urging to concretize that shift (as well as ensure that the therapy would be reimbursed). The goal, phrased in this way, captured David’s playful, lyrical style while retaining measurable elements. We need to help clients develop goals that both touch them in powerful ways and can be framed concretely. It is also important to help clients develop goals that are achievable. Our overall focus on the future invites hope and a sense of movement. Goals that are too large or difficult to achieve can quickly sabotage that movement. We can help families develop achievable goals by encouraging them to focus on small steps and by breaking down large or vague goals into quantifiable entities through scaling questions (Berg, 1994; Berg & Miller, 1992). An example of scaling questions is, “On a scale of 1 to 10, how much self-control would you like your son to have? How much would you say he has now? What would tell us that he had gone up one step?” Scaling questions help us to keep the focus on the direction of movement even when the degree of movement is small. It is useful to help clients define goals that represent the beginning of new behaviors rather than the end of undesirable behaviors (Berg, 1994; Berg & Miller, 1992). Positive, proactive goals that reflect the presence rather than absence of something continue the momentum to a

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nonproblematic future and lead to more efficient therapy. It is difficult to not do something. In the process, we end up thinking about the activity we are trying to avoid. For example, a treatment goal of “I will not drink” keeps an image of alcohol squarely in front of us. It conjures up the forbidden alcohol, which we then attempt to ignore, making avoidance of it even more difficult. A treatment goal of ending an undesirable behavior keeps us embedded in the problem. A treatment goal of beginning a new behavior invites us outside the realm of the problem and opens up significantly more new possibilities. Asking a client what he or she might be doing instead of drinking leads us into a definition of a positive, proactive goal. For example, such a goal might be “I will exercise every night when I come home from work.” Numerous solution-focused therapists have highlighted the importance of language in inquiring about nonproblematic futures (Berg, 1994; Durrant, 1993; O’Hanlon, 2003; O’Hanlon & Beadle, 1994; O’Hanlon & Weiner-Davis, 1989). If we begin with an assumption that goals will be reached, we increase the possibility of goal attainment. An example of such language is “What will you be doing when this is no longer a problem?” versus “What would you be doing if this were no longer a problem?” Presupposing goal achievement can help orient clients to an expectation of change. It is also important to emphasize client agency and action in these questions (e.g., “What will you be doing when this is no longer a problem?” vs. “What will be happening to you when this is no longer a problem?”). Emphasizing client agency and action embeds the notion that clients can do something different, that they are the ones who need to do it, and that doing it is what will make the difference. Although the language is important, the true power of this phrasing relies on our faith and conviction that people can and will have better lives. At the same time, it is useful to frame goals as involving lots of hard work. Berg and Miller (1992) emphasize that this realism protects client dignity and allows graceful acknowledgment of past failures if clients are unable to reach a goal. This creates a win-win situation in which failure to reach goals can be seen as due to the difficulty of the endeavor (creating a stronger base from which to try again) and in which success validates clients for their hard work. It also can help to avoid a minimize/ maximize sequence in which clients emphasize the ways in which goals can’t be achieved and therapists end up urging them to try harder. Each of these suggestions for our leadership in the process of goal setting (helping clients develop goals that capture their imagination and also remain concrete, specific, and achievable; helping clients to define positive, proactive goals; using language that orients clients to an expectation of change; and validating the hard work that goes into addressing the issues in their lives) helps to enhance the potential of goal setting to be an important intervention.

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Plan for Therapy Goals have two components: what you are aiming for and what you are going to do to achieve it. The plan for therapy section of a contract highlights the latter by spelling out in concrete detail who will do what, with whom, for how long, in order to accomplish the agreed-upon goals. The plan gives us a template against which to evaluate our work with clients. It allows us to review periodically what we’ve agreed to do and examine the degree to which the actual work fits with stated intentions. In situations in which there is a discrepancy, a written plan allows us to evaluate together our reactions to that discrepancy. Although therapy goals often specify actions to be undertaken by family members, it is important to include the efforts of various helpers as well. In the example of David, Ruth, and Jon, the plan for therapy included a number of specific things the therapist would do to help David in job hunting. When, after several weeks, the therapist hadn’t completed those activities, David was in a position to draw his attention to it and inquire why he hadn’t done anything yet. The plan for therapy should hold helpers as well as family members accountable for the actions each agrees to take.

Ways That Improvement Might First Be Noticed This section of a therapy contract orients therapists and clients to change. By inviting reflection on how changes might first appear, it promotes attention to the direction of change rather than the magnitude of change and reinforces a positive focus and sense of movement. The examination of ways that improvement might first be noticed increases the probably of noticing forward momentum. Framing it as ways that improvement might first be noticed alleviates discouragement that could arise in the event that changes are not noticed and opens up space for an investigation of other ways in which improvement might first be noticed. This section also helps to break goal attainment into concrete, measurable steps. For example, David’s goal of moving from a Miami Vice lifestyle to a Mr. Mom lifestyle included some of the following ways that improvement might be first noticed: • • • •

David would put together a resume. David would buy the Sunday paper and read the want ads. David would call two friends about potential living situations. David would notice what he particularly appreciates about the times he’s home with Jon playing quietly. • David would take a deep breath before responding to Jon next time he misbehaves.

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These first indications helped David to stay on track toward the goals he had defined for himself and reassured him that changes were indeed happening even though they were beginning first steps. Focusing on the direction of change rather than the magnitude of change helped David to stay hopeful, positive, and forward thinking.

Indications That Goals Have Been Achieved This section helps to clarify a stopping point and make therapy more accountable to both clients and funders. It institutionalizes the question raised previously, “What needs to happen for us to stop meeting like this?” It is particularly useful for clients who have had chronic involvements with multiple providers. Often, services go on and on with no end in sight. A clearly demarcated stopping point gives structure to the work and provides clear distinguishing features against which to determine the necessity for continuing services. It also helps to make services more accountable to clients. We can measure events in clients’ lives against the material in this section and use that comparison to make ongoing evaluations about whether to continue or end services. It is important in this process that these indications be mutually defined and mutually evaluated. The indications that David’s goal of moving from a Miami Vice lifestyle to a Mr. Mom lifestyle had been achieved included such things as the following: • David and Jon will have a stable living situation. • David will have stable employment, be home more often, and provide more consistent parenting. • Jon will respond to David’s limits and be spending more time hanging out with David rather than fighting with him. • Jon will be asking to spend more time with his dad. The indicators for this goal were jointly developed with David and had interesting effects on him. David later commented that the process of thinking about indicators helped make the shift to a Mr. Mom lifestyle more concrete. It invited him to step into the experience of an envisioned future. The next sections examine the process of developing therapy goals in different challenging situations.

DEVELOPING GOALS WITH MANDATED CLIENTS Attempts to develop goals with mandated clients who have been required or “strongly urged” to pursue help can be a frustrating

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endeavor for everyone involved. Mandated clients often do not define themselves as needing “help” and may have strong reactions to being mandated to receive it. Sometimes these reactions are immediately apparent. For example, a single father who is called to a school meeting because of concerns about possible abuse of his child greets the school personnel with the statement, “I can’t believe I have to take off work to meet with a bunch of people who can’t get a real job and spend all their time sticking their noses into other people’s business.” Such statements can provoke strong reactions on our part. It is easy for us to get caught in a struggle with mandated clients over whether they really need to be in therapy or not. We can be captured by our own indignation that they refuse to see the need for or value of our services and can become ensnared in an escalating struggle over whether or not they need help that inadvertently adds further constraints. Other times, clients may conceal their resentment of mandated services and present with a pseudo-compliant stance in which they hope that if they pretend to go along with us, we’ll eventually take the hint and let them alone. Their real feelings may remain concealed because they feel they can’t risk sharing them with us. In these situations, therapy can take on an investigatory air in which we try to find out “what’s really going on” and clients try to figure out what we are “really up to.” This atmosphere takes a significant toll on the developing relationship. It is important to begin therapeutic relationships with mandated clients in a way that acknowledges their humanity. This is important for both ethical and pragmatic considerations. All clients deserve respect, and respect serves as a foundation for efficient and cost-effective work. One way to accomplish this is to recognize that mandated clients who attend an initial meeting could have decided to not meet with us. There is something that they want in meeting with us, even if it is to avoid the consequences of not meeting. The decision to meet is a proactive step that constitutes an opening for engagement. An adolescent comes to counseling so that his parents will let him back on the Internet. A husband meets with a substance abuse counselor so that his wife will let him back in the house again. The aforementioned father who argued with school personnel comes because he doesn’t want to lose his children. In each of these examples, there is something positive that clients seek and that we can use as an opening to make ourselves relevant. The suggestions in Chapter 3 for engaging clients who present with a stance of “This is not a problem” constitute a foundation from which to begin goal negotiation with mandated clients. In addition, we can pose the following questions to ourselves to help us develop a constructive relational stance with mandated clients:

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• What questions can I ask that will help me feel connected to this person? • What questions can I ask that will help this person present himor herself in a rehumanized manner? • What questions can I ask that will help both this person and me to be open to the possibility that we could constructively work together? • What do I need to do to make sure I am not avoiding the issue that has led to us meeting? It is crucial that goal negotiation with mandated clients be done in a collaborative fashion. Mandated clients, especially those involved with protective services, often receive “help” in an antagonistic context. Mandated clients often expect clinicians to react to them in judgmental ways and may very well engage in ways that protect themselves from that anticipated onslaught. Engaging with respect and connection can catch mandated clients off guard and open up space for the development of a different relationship. It is important to remember that a sympathetic stance does not mean condoning behavior, just that you are willing to hear the client’s side of the story. Within this context, it becomes important to strike a balance between developing treatment goals as an ally rather than an adversary and engaging clients in a way that does not lead to a coalition against other providers. The process of negotiating treatment goals with a mandated client is highlighted in the following clinical example.

Cheryl’s Strong Will Cheryl was an African American single mother with two preschool children who were placed in a foster home in the custody of protective services after a charge of neglect was filed by a neighbor. Cheryl was referred for therapy because of concerns about her level of substance use, her neglect of her children, and her tendency to fly off the handle when frustrated with her children. She came to the first session with a hard glare on her face. After spending 15 minutes getting to know her, her white male therapist moved into the following dialogue: THERAPIST: So, whose idea was it that you come here? CHERYL: It sure wasn’t my idea. This is not my idea of a fun time. My protective worker told me I gotta come here or they were going to take away my kids. She’s always nosing about in my business. She ought to get a life of her own. (Goes on for a while venting about her worker.)

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THERAPIST: Well, given that you don’t like people in your business, I appreciate your willingness to come here and talk with me. How did you decide to come anyway, rather than blow it off? CHERYL: I blow it off, I lose my kids. Seems pretty simple to me. I ain’t gonna lose my kids. No way! THERAPIST: So, they’re pretty important to you. CHERYL: Yeah, they’re all I’ve got. THERAPIST: So they’re real important to you. What do you think your protective worker would say you need to do differently to get her out of your face? CHERYL: I got no idea what she wants from me. THERAPIST: Sometimes it’s tough figuring out all the ideas that helpers have for you. What’s your guess? What do you think it would take for protective services to close your case and get out of your life? Cheryl took a while, struggling to find an answer to this question. Despite her outrage at having protective services in her life, she had trouble imagining them ever leaving. Finally she came up with an answer. CHERYL: They want me to dump my boyfriend, be a miss prissy, and quit partying. THERAPIST: So, if you did all that, they wouldn’t be bothering you? CHERYL: I don’t know, maybe. They’re so suspicious, they’d probably never be satisfied. THERAPIST: That would be a lot to give up. CHERYL: Damn straight. THERAPIST: But your kids are important to you. CHERYL: Yeah. THERAPIST: Important enough to get protective services out of your life and get your kids back? CHERYL: What are you up to? THERAPIST: I’ll tell you what I’m up to. It seems like protective services said you need to be in counseling because they’re concerned about the kind of care your kids are getting. That’s what they do. It’s their job to be suspicious. Now, I don’t know you, and so I’m in no position to say anything about what kind of parent you are. You strike me as someone who is very committed to her kids, otherwise you wouldn’t be here. So, what I’m up to is trying to see if there’s a way that I can help you get your kids back. Would that interest you?

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CHERYL: Yeah, but how do I know I can trust you? THERAPIST: You don’t. I’d encourage you to not trust me unless it feels right to you. CHERYL: (Stares quietly at the therapist and then softly answers.) Yeah, I don’t know about trusting white folks, but you seem okay. THERAPIST: Thank you. So tell me, why are your kids so important to you? Cheryl went on to talk about what made each of her children special to her. The conversation invited Cheryl into an experience of connection with her children and competence as a mother that provided a stronger foundation for a subsequent conversation about what she would need to do to get her children back. The therapist sidestepped the invitation to tell her that partying was how she lost her kids in the first place. He focused on a future of reunification and searched for positive intentions that might organize Cheryl’s parenting. THERAPIST: Can I ask you something? It’s real clear you weren’t too excited about this meeting and you could easily have blown it off. And yet you came because, as you say, your kids are your life. What does it tell you about yourself that you’d be willing to jump through all these hoops to hang onto them? CHERYL: What kind of stupid question is that? THERAPIST: It is kind of weird isn’t it, but what do you think? CHERYL: It tells me that no matter what, I’m going to get them back. If I have to walk across fire, I’ll do what it takes to get them back. THERAPIST: Do your kids know about this commitment you have to do whatever it takes for them? CHERYL: Yeah, they’re the same way. THERAPIST: So, that’s something you’ve passed onto them. Is that a commitment you’re proud of? CHERYL: Yes, I do what I need to do. That’s how I get by. THERAPIST: So, you’re someone who is really committed to her kids and someone who wants to put that commitment into action. How committed are you to getting them back? Like on a scale from 1 to 10? CHERYL: I don’t know. Eight or nine, I’m real committed to getting them back.

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THERAPIST: Eight or nine? That’s a lot of commitment. What do you think you need to do to get your kids back? CHERYL: I gotta stop partying. THERAPIST: That’s a lot to ask, but it seems like you’ve got the commitment to do that. So, do you want help in getting them back? CHERYL: You gonna help me with that? THERAPIST: I’ll give it a try if you want. But let me ask you something. Do you just want them back or do you want them back to stay? You know, like do you want to do it in a way that makes sure protective services won’t be in your face anymore? ’Cause that’s a bit harder. CHERYL: Hey, if I’m gonna do this crap, I want to do it once and for all. THERAPIST: All right, so let’s start with putting together a picture of what life would look like with your kids back home to stay. Cheryl began developing a picture of life with her kids back at home and protective services out of her life. She and her therapist agreed to continue meeting, with a focus on helping Cheryl make the changes in her life necessary to get her children back and keep them back. They agreed to work on Cheryl’s becoming a more consistent presence in their lives by staying at home 6 nights a week, by ensuring that her children had a babysitter the one night a week that she went out, and by developing alternative ways of responding to the inevitable frustration provoked by little children. They also agreed to continue to discuss her alcohol use, jointly evaluating the degree to which her drinking might constitute use or misuse.1

DEVELOPING CONTRACTS AMID CONTINUAL CRISES The challenges confronting multi-stressed families are often unremitting, and the process of developing treatment goals can at times feel like cleaning a house in a hurricane. Each meeting brings new crises and treatment goals seem to shift daily. In response, it is important to strike a balance between flexibility and focus. We need the flexibility to respond to family needs, coupled with an overarching focus to give the work direction. If we are simply responding to ever-changing family needs, we miss the opportunity to help family members shift out of a pattern of reacting to ongoing crises. However, the imminent crises in families’ lives easily pull us into a fix-it mentality in which we feel compelled to immediately react. Even if we are able to resist the pull of immediate daily concerns, it can be difficult

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to effectively invite families to step back from the immediacy of crises. The process of developing a proactive vision in the middle of a crisis can often seem like an unaffordable luxury. A common response from families is, “I just need to get through this crisis and maybe then I can think about other things.” However, this crisis often flows insidiously into the next one, and families become caught in a pounding surf of unrelenting crises in which they are continually knocked off balance every time they attempt to get their footing. It is at these times that a proactive vision is crucial in maintaining a focus amid crises. For example, Luiz and Sylvia were a middle-class Chilean couple whose son, Rico (16), had recently been discharged from a psychiatric hospital. He had struggled with multiple serious problems that caused a significant rift between his parents and exacted a terrible toll on their once close relationship. The first three meetings between the family and therapist were each hijacked by a different serious and demanding crisis that required a flurry of follow-up phone calls. The fourth meeting was preceded by a phone call from the mother just before the session, announcing that Rico had overdosed on a cocktail of various drugs at a party the night before and had spent the evening in the emergency room having his stomach pumped. As they entered the session, the therapist began by acknowledging the severity of the most recent crisis and telling the parents that she believed they had many crucial things to talk about regarding that situation. She then compassionately commented on how each meeting so far had been taken over by one crisis or another. Both parents nodded, exhausted, and Rico stared glumly at his shoelaces. All family members seemed more dispirited than alarmed at that point. The therapist asked the parents whether they would prefer to move right into talking about the latest crisis or if it would be okay to take just 10 minutes and talk a little about what a life not continually hijacked by crises might look like. The parents, in their exhaustion, seem relieved at the prospect of a brief respite from dealing with yet another crisis and agreed. The therapist asked them to imagine what their life together could look like if they weren’t caught in these persistent crises. Sylvia commented that they would hold Rico accountable for his actions, he would communicate more with them and earn their trust, she would feel less exhausted and stressed out, and she and Luiz would feel more connected to each other. Luiz imagined that Rico would finish high school and develop more direction in his life, and that he would have more confidence in his son’s ability to manage things and not rush in to fix things so quickly. Rico, however, thought the whole conversation was stupid, was tired of their nagging, and wanted to talk about moving in with his cousin so his parents would leave him alone.

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This momentary stepping back from the immediacy of addressing the crisis helped the parents reflect on how they would prefer to respond to Rico at this developmental point in his life. They began to develop a stance that could organize their responses to Rico and, through the therapist’s questions, generated a metaphor of Rico stepping up and they themselves stepping back. With that metaphor as an organizing theme to guide their interactions with him, the therapist engaged the parents in a conversation about their response to the idea of Rico’s moving in with his cousin for a week to give everyone a break and a chance to recuperate. They thought this idea had merit. The cousin was an older guy who had been more like an uncle to Rico for years, and they thought a short break might be good for everyone involved, given Rico’s annoyance and their own exhaustion. They talked about what it would take for them to be assured of Rico’s safety and generated a number of thoughtful ideas. The parents and Rico arrived at a plan for the next week, and the parents spent time clarifying their bottom line and how they wanted to communicate that to Rico. That conversation gave them a stronger foundation from which to respond to their son, and they developed a plan with Rico that was based on their stepping back and his stepping up. In this way, envisioning their preferred responses to their son proved useful in helping them more constructively respond to him. Although there continued to be numerous crises for some time, the organizing theme of Rico stepping up and his parents stepping back helped the parents to hold a consistent stance through those crises. The therapist worked with them to examine what supported them in staying grounded in that stance, and anticipated elements and forces that could pull them away from that stance. There is an apparent paradox here. If families don’t respond to immediate crises, there may be no future; and if they don’t take time to step out of crisis, they may not escape the tyranny of perpetual crises. Although it is vitally important to respond to immediate danger and safety concerns, taking the time to help families momentarily step outside the immediacy of crises helps them better respond to those crises. However, it requires a leap of faith to see that inviting a family to step outside a crisis to reflect, rather than simply reacting, will be beneficial in the long run.

NEGOTIATING THERAPY CONTRACTS WITH FUNDING SOURCES The funding sources for treatment (managed care companies as well as departments of mental health, social services, public health, etc.) are often hidden but influential partners in the development of therapy

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contracts. The framework for organizing therapy contracts outlined in this chapter can be quite incongruous with prevailing ideas that emphasize problem-focused goals with concrete, measurable outcomes. For example, how many managed care companies do you know that would embrace “moving from a Miami Vice lifestyle to a Mr. Mom lifestyle” as an acceptable goal? This section examines some of the dilemmas in negotiating such therapy contracts with funding sources that emphasize medically oriented, behavioral treatment plans. There is a strong push these days for behaviorally specific goals that can be quantified (e.g., client will increase school attendance by 50% within 30 days). There are three dangers in this push for behaviorally specific goals. First, we can become fixated on the content of goals or the outcome of the work and lose sight of the process of the work. Although specific goals can provide a concrete vision toward which to move, it is important that we not mistake the indicators of enacting a new future for the future itself. Returning to the example of David, Jon, and Ruth, David’s shift from a Miami Vice lifestyle to a Mr. Mom lifestyle may show itself through stable employment and housing, increased sobriety, and consistent parenting, but it is David’s different experience of both himself and his interactions with others that will anchor him in living a different life. The work here is not focused simply on David’s getting a job but primarily on the way in which he experiences himself (and is experienced by others) as he goes about the process of getting a job. The work with David will not be successful if he simply gets a job but still organizes his life within an old story that no longer works for him. The specificity of goals is a means to an end, not an end in itself. We can use behaviorally specific goals as a tool to help clients envision and enact preferred futures, not simply to measure the development of new behaviors. Second, therapy goals can do more than provide measurable outcomes. They have the potential to inspire. David’s commitment to therapy was not captured by a desire to show a 50% increase in job-hunting behaviors, but rather by the appreciation he developed for his commitment to Jon and his willingness to make sacrifices for him in the shift from a Miami Vice lifestyle to a Mr. Mom lifestyle. When we simply collapse goals into entities that can be measured, we lose the artistry, poetry, and magic of therapy—factors that make it a profound and moving enterprise. Finally, as we become caught up in the outcome of the work, we can lose sight of its ownership. In the push to show results to those who reimburse us, we can be influenced by fears such as “What happens if my client increases school attendance by only 40% instead of 50%?” or “What if it takes longer than the 30 days we originally projected?” We

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can then become unduly responsible for the accomplishment of the particular goal. We move out of working with clients and into acting on clients. Handing the development of therapy goals over to “number crunchers” runs the risk of turning us into technicians who become interchangeable parts on an assembly line of therapy. It also runs the risk of colluding with forces that may not be in clients’ best interests. So, how do we develop therapy contracts that inspire clients and keep us rooted in collaborative relationships while acknowledging the realities of how funding shapes the delivery of services? We need to interact with those who reimburse us in the same way we’ve discussed in engaging reluctant clients. We need to build relationships with them, preferably outside the context of struggles around fiscal or ideological differences. We need to think about how to make our efforts relevant to their interests. Fortunately, a future focus, emphasis on resources, and collaborative partnerships are all extremely costeffective. We need to search for funders’ intentions, hopes, and preferred views of self by beginning with an assumption that they want the best for clients. And we need to look for openings in their dominant stories about reimbursement that provide a basis for building on exceptions. In the example with David, Jon, and Ruth, the therapist had an ongoing relationship with the protective worker whose department funded the service through an agency contract. The therapist worked hard to maintain this relationship. The protective worker viewed the therapist as a little odd but very competent. She was amused by the therapy contracts he developed with clients, and he was willing to go over them with her to explain their logic. He framed his efforts with families as attempts to enlist family participation in creating safer environments for children and continually emphasized the degree to which he was attempting to responsibly help families get off the roster of her caseload in ways that ensured they would stay off. She also knew that he could be a fierce advocate for clients when needed. There are times that our accountability to clients may conflict with our responsiveness to funders, and we need to be clear about our priorities.

SUMMARY These first four chapters lay the foundation for our work with multistressed families. Together, they have highlighted the importance of the relational stance we take with clients and examined conceptual frameworks that support that stance in the processes of engagement, assessment, and contracting. Chapter 3 examined some of the ways we can be pulled away from an allied stance in the process of engaging reluctant

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families and offered ideas about how to maintain that stance and work effectively with clients who initially present with a stance of “This is not a problem” or “This is a problem, but I have no control over it.” Chapter 2 examined a conceptual model based on constraints in which clients can be viewed as separate from and more than the constraints in their lives. Particular importance was attached to the way in which we approach the assessment process. Finally, Chapter 4 has highlighted the usefulness of developing a proactive vision to guide therapeutic efforts and examined ways to collaboratively develop therapy contracts with families. The next five chapters examine clinical practices that help to hold workers in a relational stance of an appreciative ally, direct therapeutic efforts toward preferred directions in life, encourage a separation of problems from people, and offer ways to jointly examine clients’ current and preferred relationships with problems in order to envision and develop desired lives. The discussion begins with an examination of collaborative inquiry and offers an organizational framework to guide our work with clients. NOTE 1. The therapist believed that Cheryl’s drinking constituted heavy social drinking, and although he would prefer that she might drink less, he was not concerned about her seriously misusing substances. He felt that when she was not responding defensively to the way in which others expressed their concerns about her drinking, she was able to think about and manage her alcohol use thoughtfully.

CHAPTER 5

Collaborative Inquiry An Anthropological Approach to “Intervening” with Families

The first four chapters examined conceptual models or ways of thinking about families that position helpers as appreciative allies in the process of engagement, assessment, and contracting. These next five chapters examine clinical practices or ways of interacting with families that invite respect, connection, curiosity, and hope. This chapter begins with a brief reconsideration of the process of “intervening” and then offers an organizational framework for collaborative inquiry that positions therapists as co-researchers who are working with families rather than acting on them. An extended clinical consultation illustrates this framework. Subsequent chapters take up different elements of this framework in more detail.

WHAT DOES IT MEAN TO “INTERVENE”? Family therapy has historically had a strong emphasis on intervention. Within the mental health field, family therapy represented not only a different way of thinking about clients and problems but also a significant shift in ways of interacting with clients. It began as a radical move away from the orthodoxy of psychoanalysis and contained a shift from understanding problems as the goal of treatment to doing something about problems in a short time (Ravella, 1994). In this way, family therapy 155

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became quite interventionist. Cecchin, Lane, and Ray (1994) have described an interventionist model as one in which a “therapist organizes an action, suggestion or prescription for the purpose of having a predictable result” (p. 13). Many techniques in the mental health field are grounded in an assumption that we can have predictable results and get clients to see or do things in particular ways at particular times. For example, we offer an insight that we hope will have particular effects, we teach skills that we hope clients will use in particular ways, we set up enactments to achieve a particular outcome, we reframe behavior to promote a particular perspective. In each of these situations, we enter with a predictable result in mind. Often, that hoped for result is informed by an implicit model of how families should function (e.g., what constitutes “appropriate” generational boundaries, or “differentiated” functioning, or “healthy” negotiation of life cycle transitions), and our efforts attempt to bring family functioning in line with normative standards. Unfortunately, our focus on rectifying family dysfunction can pull us into an instrumental orientation in which we engage with certainty and a sense of mission. When we begin specifying how things should be in clients’ lives, we risk losing sight of client preferences. We can get out ahead of clients and end up blocking their view of desired futures. When clients lose sight of their preferred directions in life, they may submit to professional preferences and end up following someone else’s agenda, which doesn’t support long-lasting change. Alternatively, they may actively resist our efforts or become pseudo-compliant, pretending to comply and hoping we’ll go away. Hence, our attempts to achieve a predictable result without explicitly negotiating it with a family may end up making our work harder. The belief that we can get a family to see something in a particular way or bring about a particular outcome has been referred to as a belief in “instructive interaction.” A number of writers have suggested that instructive interaction is impossible and that we cannot get a family to respond to interventions in a predetermined fashion. Although we enter interactions with particular hopes and intentions, we cannot determine the specific effects of our actions on others. Our interventions may trigger responses, but they do not determine them. We cannot get clients to do or see things that we want when we want. The idea that instructive interaction is impossible may or may not be “true.” However, it can be a very useful idea in helping us step back from nonproductive struggles with clients and opening possibilities for alternative interactions. At the same time, it is impossible to avoid influencing others. As Cecchin et al. (1994) state:

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When people interact, they inevitably influence each other, but not always with predictable results. Intervention, when thought about in this way, is unavoidable, because to interact means to intervene in the private space of the other. No matter how much we try, influence is unavoidable. . . . Although it seems true that we do, in fact, influence one another, we cannot predict the outcomes of our efforts. (p. 15)

If we acknowledge that interventions do not have predictable results, then every interaction with clients is an intervention. Everything we say and do has an effect on clients. It is impossible to be noninterventionist. The issue is not whether we are interventionist or noninterventionist, but what stance we hold as we intervene. Harlene Anderson and Harry Goolishian (1988, 1992) have coined the phrase “not-knowing” to suggest a particular stance in collaborative conversations. A not-knowing stance refers to an attitude and belief that a “therapist does not have access to privileged information, can never fully understand another person, always needs to be in a state of being informed by the other, and always needs to learn more about what has been said or may not have been said” (Anderson, 1997, p. 134). As Anderson (1995, pp. 34–36) emphasizes: A not-knowing position does not mean the therapist does not know anything or that the therapist throws away or does not use what she or he already knows. It does not mean the therapist just sits back and does nothing or cannot offer an opinion. It does mean, however, that the therapist’s contributions, whether they are questions, opinions, speculations, or suggestions, are presented in a manner that conveys a tentative posture and portrays respect for and openness to the other and to newness.

Despite Anderson’s (1995, 1997, 2005) repeated attempts to clarify a not-knowing stance, it has often been misinterpreted as dismissing professional knowledge (perhaps an ironic example of the myth of instructive interaction). Another framing of this juxtaposition of knowing and not-knowing that may trigger fewer misperceptions would be a juxtaposition of certainty and curiosity (Amundson, Stewart, & Valentine, 1993). For this discussion, I draw on the phrase “cultural curiosity,” as introduced in Chapter 1, to refer to a continuing attempt to actively elicit a client’s particular meaning rather than assume we already know it or that it is the same as ours. A striving for cultural curiosity begins with a conviction that clients are the experts on their experience and an attempt to fully enter into and honor that experience. It includes a willingness to question what we think we know and a commitment to continually learn more about what

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clients have to say about their experience. This attitude is reflected in a Robert Louis Stevenson quote, “To travel hopefully is a better thing than to arrive.” Although we cannot arrive at a complete grasp of another culture, we can always travel hopefully toward a better understanding. Kaethe Weingarten (1995, 1997, 1998) has discussed a similar process that she refers to as “radical listening.” She characterizes radical listening as the “shifting of my attention from what I think about what my clients are telling me to trying to understand what my clients think about what they are telling me” (Weingarten, 1998, p. 5). This shift could also be summarized as a movement from assigning our meaning to clients’ actions to eliciting their meaning. In this regard, I have often referred to it as listening on client turf rather than on professional turf. Each of these phrases (“not-knowing,” “cultural curiosity,” “radical listening,” “listening on client turf”) captures a shared position from which to engage clients. This position does not disavow therapist knowledge or influence, but draws on it in a different way. In this position, there is an acknowledgement that it is impossible to impose meaning or get people to do or see particular things at particular times, along with a commitment to engaging clients in ways that enable them to generate alternative meanings through invitational interaction.

MOVING TOWARD INVITATIONAL INTERACTION The following story sets a context for discussing the power of invitational interaction. A number of years ago I conducted a study on the interaction of beliefs held by patients, spouses, and physicians in situations of chronic medical noncompliance (Madsen, 1992). One of the couples I interviewed consisted of Pat, a 40-year-old white woman whose hypertension escalated out of control when she drank, and Jack, her 35-year-old white boyfriend with a long history of alcohol misuse. I met with them in their home. About 5 minutes into the interview, Jack excused himself and went into the kitchen. He returned with two cans of beer, offered one to me, and when I declined, shrugged, drained the first, and started on the second. I had a number of reactions. I was shocked and angry that he was drinking. I worried that it would “bias” the results of the interview and wondered whether I would be able to use this interview in my study. At the same time, I didn’t feel comfortable asking Jack not to drink during the interview. This was the couple’s home, and they had graciously let me into it. They were not being paid for the study, and I did not have a relationship with them in which I had an authorization to instruct them on what I might consider “proper etiquette.” I sat there in my discomfort, unsure of what to say. I decided to

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say nothing and continued the interview. Jack drank throughout the interview, polishing off a six-pack by the time we finished. In the interview, we focused on (among other things) the potential consequences of various decisions they might make about alcohol use (e.g., If Pat kept drinking and Jack stopped what would happen to her health and their relationship? If Jack kept drinking and Pat stopped, what would happen to her health and their relationship? What would happen if they both kept drinking? What would happen if they both stopped drinking?). In the course of the interview, the following story emerged. Pat’s original husband had abandoned the family (for which she blamed herself), and she was committed to establishing a two-parent family for her daughter. She believed that if she kept drinking, hypertension would end her life and her daughter would lose a mother. She also believed that if she quit drinking, it would end her relationship with Jack (whose previous marriage had ended when his wife quit drinking) and her daughter would lose a father. Pat felt caught between two pulls. If she didn’t stop drinking, her daughter would lose a mother, and if she did stop drinking, her daughter would lose a father. As I asked about the effects of this dilemma on Pat, she disclosed that it made her feel like a bad mother and left her terribly depressed. She felt that she was caught in a bind that she couldn’t escape and would subsequently become hopeless and end up drinking to numb the pain. As we talked about the effects of this dilemma on their relationship and their future together, the couple became reflective and slightly sad. I left the interview feeling appreciative of the power of this dilemma and its effects on Pat and Jack. Interestingly, in a 6-month follow-up with their physician, I found out that the couple had quit drinking the day after the interview and had maintained sobriety since. In fact, seven of the nine patients interviewed in the study were now managing their chronic medical conditions for the first time in 2 years. A number of patients and physicians attributed that change to the development of different perspectives that came out of the interview process. One informant from the study put it this way: “I’m thinking about the difficulty I’ve had managing my medical condition in a whole different way. It makes sense to me now that I’ve had difficulty managing it and I’m not blaming myself for it. This shift has given me some room to go about dealing with my medical condition in a completely different way.” Although the changes in Pat’s and Jack’s lives were dramatic, I had not been attempting to disrupt their drinking or to get Pat to better manage her hypertension. The interview with Pat and Jack occurred in the context of a research study rather than a clinical intervention, and yet it

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had had a profound impact on the couple. Although my intention had been to gather information for a research study, I had assumed that the process of gathering that information might open new possibilities for Pat and Jack. My experience in this study was very much in line with the efforts of Lorraine Wright (1990), who developed a research intervention for families in which traditional family therapy had proved unsuccessful. In this approach, the therapist would explain that she had no further ideas for how to be helpful to the family and then offer the family an opportunity to participate in a research project that focused on helping professionals learn how families coped with chronic illnesses. Wright found that this shift was not simply an attempt to redefine family therapy, but rather one that changed the context of her clinical work from therapy to research. She explained that this shift in context had a profound effect on therapists. It reduced their usual therapeutic impulse to inform, instruct, direct, or advise family members and contributed to the development of an investment in learning from the family rather than changing the family. Families responded positively, and Wright (1990) concluded, “We facilitate the greatest change in our clinical work when we focus on learning from our clients rather than believing that they are learning from us” (p. 484).

THERAPY AS CULTURAL ANTHROPOLOGY The shift in emphasis described by Wright (1990) fits with an anthropological metaphor for the process of interacting with clients and families. In this metaphor, we can think of clients and their families as foreign cultures. We can think of ourselves as cultural anthropologists or ethnographic researchers who have been given the opportunity to enter into the life space of clients and learn all that we can about the particularities of their culture. An example of this metaphor in action comes from the work of Marilyn O’Neill and Gaye Stockell (1991). They worked in an Australian day treatment center in which eight male consumers were dissatisfied with the system and expressed that dissatisfaction through a variety of destructive behaviors that included abusive language, property destruction, ongoing substance abuse, and a disregard for others at the center. These behaviors had managed to alienate many of the staff, who saw excluding the men from the center as the only viable course of action. O’Neill and Stockell proposed instead to run a group for the men. They decided to view the men as experts in dealing with chronic mental illness and invited them to a group that explored the men’s expertise in managing mental illness. Drawing on an anthropological stance, they elicited the men’s experience of mental illness, the effects it had on their lives, and the ways in which they coped with it. As they

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listened to the men’s experiences of the disempowering effects of mental illness, they resisted the temptation to give advice, offer ideas, or make judgments about their situations. The aim of the group consisted of eliciting and documenting the expertise the men had in managing chronic mental illness. The therapists’ roles consisted of asking questions to guide the process. When asked to provide a name for the group, the men initially decided to call it “The Losers’ Group.” However, halfway through the group, as the participants’ expertise in managing mental illness became more solidified, the men petitioned to change the group’s name to “The Worthy of Discussion Group.” By the end of the group, the men viewed themselves differently and had made significant improvements in their lives (including improvements in daily living skills that were never directly addressed in the group). O’Neill and Stockell (1991) summarized their learning: We observed that changes were occurring for the men. We were also aware that these changes were not due to any teachings about problems and solutions but from the discovery that their special knowledge, skills, and qualities had enabled them to choose a preferred outcome for themselves. The men became responsible for choosing the directions that their lives should take. Our role in these groups was described succinctly by one of the participants: “You [therapists] have been asking us instead of telling us.” (p. 205)

This example characterizes a directional shift in information flow. Information is not coming from the therapist to the client. Instead, it is being jointly developed in the space between client and therapist though a questioning process. This shift could be described as a collaborative coresearch project. David Epston (1999) is perhaps the person most widely associated with the term “co-research.” He initially developed co-research as an approach to situations in which children and adolescents with lifethreatening chronic illnesses were not responding to more conventional treatments. Epston became convinced that clients held alternative bodies of knowledge (consisting of abilities, skills, and wisdom) that could be profoundly useful if tapped. These varieties of knowledge were often obscured, and David engaged families in a co-research project to resurrect them and make them more available for client use. This was not a process of going out and discovering preexisting knowledge, but rather a process of eliciting, elaborating, and bearing witness to abilities, skills, and types of knowledge that are jointly developed in the context of the interview. For example, in the Worthy of Discussion groups run by O’Neill and Stockell (1991), the wisdom offered by the men in the group was wisdom that was developed in the context of the group interviews. This idea of jointly developing shared knowledge rather

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than discovering preexisting knowledge is at the heart of collaborative inquiry. Epston began eliciting and elaborating client knowledge in interviews and subsequently developed written collections or archives of that knowledge that could be made available to other clients. One example of this is his efforts to develop anti-anorexia archives that contain client wisdom about the ways in which anorexia as a problem has affected clients and their families along with accounts of how clients and families have coped with and resisted the effects of anorexia (Maisel, Epston, & Borden, 2004). The process of making this knowledge available to others is both a gift to others and a profoundly empowering repositioning of clients from being objects on the receiving end of services to consultants who have something to offer others. The purpose of generating knowledge in co-research is different from the usual purpose of generating research-based knowledge. Co-research makes no claim to be an objective or neutral process. It has the explicit purpose of supporting clients in reflecting on their current relationship with a problem and, if that relationship does not fit with client preferences, inciting and sustaining resistance to the problem. This is activist knowledge with the explicit purpose of helping people change their lives. The different stories highlighted here illustrate the power and possibilities of invitational interaction and co-research. The next section examines in more detail the process of what I’ve come to call “collaborative inquiry.”

ENGAGING IN COLLABORATIVE INQUIRY Collaborative inquiry can be a co-research project in which therapists engage clients in a joint exploration of preferred directions in life, with an attempt to identify elements that constrain and/or sustain their pursuit of desired lives and an examination of ways in which clients address constraining elements and draw on sustaining ones. In this process, we can view professional expertise as the ability to ask questions that elicit, elaborate, and acknowledge family abilities, skills, and know-how that have been previously obscured. I refer to this as collaborative inquiry to suggest a partnership in which we tap the resourcefulness of both clients and clinicians. The process is not a simple conveyance of professional expertise to clients, nor a simple eliciting of client ideas. Rather, it acknowledges the shared knowledge that can be developed in the context of therapeutic relationships. The purpose of collaborative inquiry is to make space for the emergence of alternative stories that will support people in moving forward in their lives and facilitate their accessing important abilities, skills, and knowledge. Clients are offered an opportunity to reflect on the

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dominant stories that have organized their lives, the degree to which those stories fit or do not fit for them. If the stories do not fit, collaborative inquiry provides opportunities for people to develop and enact richer stories that open possibilities and have the potential to carry them forward in their lives. This is not a process of substituting “old, bad” stories for “new, improved” ones, but rather expanding from sparse stories that are often constraining and pathologizing to broader, richer stories that acknowledge difficulties and also open new possibilities. In the process of collaborative inquiry, our questions become vitally important. Although questions are often used to gather information for our benefit as clinicians, they can also be designed for the benefit of clients. As clients contemplate the questions we ask and undertake a mental search in responding to them, they have particular experiences of self. When such experience is different and powerful, this process can have transformative effects. Although I view this as a collaborative process, I am not suggesting that it is an egalitarian partnership. Clients are in a much more vulnerable position in this relationship, and it is important to acknowledge and be mindful of the power differential that exists. In this process, clinicians have a particular expertise in inquiry and take on a leadership role in the organization of questions, but remain accountable to clients for both the direction of the inquiry and the effects of the questioning process on clients. There are a number of benefits to framing our work as a collaborative co-research project. The process holds the potential to engage clients as active agents in their lives rather than as passive objects of our efforts. This engagement has empowering effects on clients by amplifying their influence and participation in the process. And collaborative inquiry enhances therapeutic relationships. Ryan and Carr (2001) summarize a variety of family therapy process research studies suggesting that when clients perceive therapists to be collaborating and empathizing with them in addressing the difficulties in their lives, they feel a stronger therapeutic alliance, cooperate more, and engage in less “resistance.”

THE PLACE OF PROFESSIONAL VALUES AND KNOWLEDGE IN COLLABORATIVE INQUIRY Engaging in the process of collaborative inquiry does not mean that we, as therapists, abdicate our own values or knowledge. I am not advocating a kind of moral relativism in which we enter into family cultures uncritically and simply accept all aspects of how they operate. It is important to critically examine both our own and our clients’ beliefs, practices, and values as well as the effects they have. In this process,

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there is a focus on the particular real effects of actions on others and on fostering accountability for those effects. For example, we can shift from thinking about substance use as something that is universally evil or bad to examining the real effects of the use of particular substances at a particular time in a particular situation. It would be important to examine the effects of substance use on the person, important others, and the relationships between them. Although I might not tell a mother who is using substances that she should just stop, I would engage her in a discussion about her hopes for herself and her children and how she prefers to be as a person and a mother. I would then explore with her how substance use supports or constrains those hopes and preferred ways of being. I would also engage her in an extended discussion of the effects of substance use on her children, with an effort to elicit her thoughts before offering my own. A preference for an invitational approach is a pragmatic as well as aesthetic decision. Simply telling people to do something often does not work, and as we’ve seen in several examples in this chapter, inviting people to reflect on the consequences of their actions can yield powerful results. At the same time, it is important to keep concerns about the abuse and neglect of children at the center of our practice at all times. If, in this instance, I had a concern that a mother’s substance use put her children at risk, I would not hesitate to raise that concern with her and to notify protective services. In this response, I am aware that I may not be able to “get her to see” that this is a problem (despite my hopes). I think of my job here as not necessarily getting her to see that her actions are problematic, but as taking responsibility for my response to her actions. If I hear about a child who is at risk, I have a legal obligation and ethical responsibility to respond in ways that seek to ensure the child’s safety. This is where I do adhere to a normative standard. The values we hold profoundly influence the ways in which we interact with families, and it is important that we openly and respectfully acknowledge this with them. Rather than pretend that we come to our work value free, we can identify our values and be open about them. Values and the way in which they inform our actions can be an important topic of discussion in our work with families. Within a crosscultural metaphor, it is important to recognize and honor the assumptions that we bring from our own cultures into the negotiation. There are particular values that I hold strongly (e.g., anti-violence, pro-respect) that I communicate to families. However, it is important for me to acknowledge these as my values. They may or may not fit for particular families. If I try to force a fit, my attempts usually backfire. If I offer particular ideas or values as a piece of my culture that clients might find

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helpful, they are more likely to consider such ideas than if I try to “convert” them. At the same time, I strive to consistently act in accordance with my values. For example, in a heterosexual couple in which a man is speaking abusively toward a woman, I would raise my concerns that this way of speaking could feel abusive and demeaning and ask each about their experience of it. I would attempt to focus on the way of speaking rather than the speaker as a possible problem and inquire about effects of that way of speaking on the woman, on the man, and on their relationship. I might examine how those effects fit with the kind of relationship they would prefer to have. In asking them questions, I’d want to keep in mind the power dynamics in the room (e.g., I’d want to be mindful of the gender politics in the room and be sensitive not to put the woman in an overly vulnerable position nor speak on her behalf in a way that she might experience as patronizing; I’d also want to be aware of my own power position in the interaction and raise these concerns as questions rather than declarations, and try to do so in a way that the man experiences them as connected rather than judgmental). I might also ask them about their reactions to my questions and concerns. As a bottom line, I might ask the man to not speak that way while in my office, but would own that as my desire and need (e.g., “I find it too distressing and distracting when you speak to her in those ways and I’d like to ask you to refrain so that I can be more helpful to the two of you”). However, it is important to acknowledge that this response comes from my values and may or may not fit with their values. The practice of transparency (described in the first chapter), through which we make visible the values, thoughts, and assumptions that organize our work, helps to build relationships in which we can discuss and negotiate different perspectives in ways that do not impose our values on families and yet does not ignore them either. Chapter 1 offered a set of guidelines that can be useful in organizing difficult conversations across value differences (Roth, 1999, 2006a). Collaborative inquiry also does not entail an abandonment of professional knowledge. Our professional experiences have exposed us to multiple ways in which other families have coped with particular problems, and there may be some valuable wisdom in those experiences. For example, the distinction between intent and effect, demonstrating that our actions may have negative effects even though our intentions are positive, is one that many couples have found helpful. The distinction between “parenting to protect” and “parenting to prepare” is another useful idea (Parry & Doan, 1994). In parenting to protect, a parent’s job is to protect a child from bad things happening to him or her, whereas in parenting to prepare, a parent’s job is to prepare a child for living in a

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difficult world. Often (though not always), there is a developmental point at which parenting to prepare may be a more useful model for parenting. I have found this distinction very useful and have offered it to parents at times. However, my intention in sharing either of these distinctions with clients is to offer them ideas that might be useful rather than attempt to get clients to embrace the ideas. In a sense, I’m offering a piece of my professional cultural knowledge and heritage that might enrich their lives. I want to emphasize that I am not suggesting we avoid offering useful thoughts to families. The timing of when we offer ideas to families is crucial. My preference is to first elicit client knowledge and bring forth ideas that are jointly developed in the session. Following that, I might offer additional supplemental knowledge that comes from my own professional or personal experiences if it seems appropriate and useful. However, it is crucial that we have an invitation for such an offering and that our ideas are conveyed in ways that acknowledge the family’s idiosyncratic assumptions and values. Families can experience the offering of our knowledge as supporting and enriching their wisdom or as invalidating and supplanting it. It is important to offer our ideas in ways that clients experience as empowering rather than inadvertently disempowering. One way to do this is to make sure that the process by which we offer our knowledge is accountable to clients for its effects on them. We can consistently and repeatedly check with clients about how the process of therapy is going for them and adjust our efforts accordingly.

DEVELOPING A CONTAINING ENVIRONMENT FOR COLLABORATIVE INQUIRY Collaborative inquiry requires an interpersonal atmosphere contained enough to successfully invite clients into a reflective stance (i.e., being willing and able to consider questions and respond to them thoughtfully and honestly). For many clinicians working with difficult families, such containment may seem more often the exception than the rule.1 Family members can present as out of control, continually interrupting each other, and extremely reactive to each other. It can be useful for clinicians to observe the ways in which family members interact as a way to gain valuable information, but it is notably less helpful for family members to repeatedly experience themselves as out of control. The process of collaborative inquiry both requires and contributes to a safe, contained environment. James and Melissa Elliot Griffith (1992, 1994) have distinguished emotional postures of tranquility and mobilization and examined the

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ways in which each opens or closes possibilities for therapeutic dialogue. Postures of tranquility include states of listening, wondering, reflecting, affirming, understanding, and trusting. In emotional postures of tranquility, attention is focused inward, vigilance to threat is low, and there is openness to new information. Emotional postures of mobilization, however, involve the physiological “fight or flight” response and include states of guardedness, hyperarousal, shaming, blaming, attacking, defending, justifying, controlling, distancing, and ignoring. Vigilance is high and attention is focused outward in an effort to predict and control others’ behavior. When people are primed to fight or flee, they are not well positioned to take in information or engage in creative problem solving. Inviting multi-stressed families into an emotional posture of tranquility may strike many clinicians as a kind of oxymoron. These families are often seen as crisis prone, and their suspiciousness and reactivity are viewed as a family characteristic rather than an interactional process between families and helpers. Many families who have had multiple pathologizing encounters with helpers are justifiably vigilant as they interact with therapists. A clinician’s role in collaborative inquiry requires active leadership. This is not a process of just listening to people’s stories. It requires an active presence, setting a tone of respectful curiosity and providing a leadership role in how the conversation unfolds. The process of continually pulling for threads of competence, connection, and hope requires focus and agility. If our job is to open space for people to have a different experience, then our work must begin with a belief that families can have different conversations. There are a number of distinct ways in which we can structure therapeutic meetings that contribute to a containing environment. I have often conceptualized our role as “conversational architects,” in which we collaborate with families to design conversational structures that will hold a different conversation and yield a preferred experience of self and others. I want to highlight three particular ways in which we can develop conversational structures that support collaborative inquiry. These include efforts to help clients become more deliberate in their responses, the use of communication agreements, and the development of conversational structures.2 I discuss work with a couple to highlight each of these. Tom and Beth were a working-class Jewish couple with a long history of screaming matches in which they would talk past each other, cut each other off, and continually go off on attacking tangents. These fights traumatized their 11-year-old son, who increasingly refused to come out of his room at home. Their first two therapy meetings were characterized by the same interactions, and I found myself feeling dizzy, frus-

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trated, and lost. Before the third session, I held individual meetings with each member of the couple to gather information that would help me design and propose a structure to hold a different type of conversation. In the individual meetings, I made a point of building a connection with each member, examined the toll the fights had taken on their relationship, and elicited their hopes for a better relationship. I proposed a context shift in our work together, suggesting several sessions in which they would each agree to momentarily step away from attempts to win the argument in order to preserve their relationship from the costs of waging those arguments. In this shift, there is a movement from a “resolution conversation” aimed at solving the arguments or fixing the problem, to a “learning conversation” aimed at developing a better understanding of the other’s experience of the fights, with the objective of preserving their relationship and building a foundation for subsequent resolution conversations. In many ways, this is similar to the context shift previously discussed in Wright’s (1990) research intervention. Each member of the couple agreed to several meetings for this purpose and agreed to the structures and processes that were developed in collaboration with them, as described in the following paragraphs.

Moving to Planful Responsiveness In the individual meetings, I asked both Tom and Beth to think about what they hoped to accomplish in learning more about the other’s perspective and why that would be important to each of them. At the beginning of the joint meeting, I reminded them of that request and asked them each to pause for a minute and silently think about the purpose that brought them to this meeting. I then asked each to imagine that they were now at the end of the meeting and that purpose had been fully realized. I posed some questions for silent reflection to ground them in that experience and then asked each of them to think about how they wanted to relate to the other in this meeting (e.g., “What tendencies, ways of relating, or ways of being would you each like to bring forward and hold back in order to support the purpose that brings you here?”). They thought about this for a bit and then were asked to say a word or phrase that would capture how they each wanted to be in the meeting. Tom replied, “Standing in her shoes,” and Beth responded, “Open and curious.” I asked each of them why these ways of being would be important to them and what would help them to keep to such ways of relating in the meeting. This invitation to focus on how they each wanted to be in the meeting, rather than how they wanted the other to be in the meeting, helped them move from reactivity and attempts to change the other to reflection and

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planned responsiveness. Asking them to pause and reflect for a full minute before responding to my questions also slowed the pace of the meeting and encouraged a more reflective space.

Communication Agreements Communication agreements, in which participants develop a set of ground rules, agreements, expectations, or shared promises to guide their speaking and listening in a session, can be extremely useful (Chasin, Roth, & Bograd, 1989; Roth & Chasin, 1994). In my individual conversations with Tom and Beth, I asked a number of questions to learn how the upcoming meeting might go well or poorly for them. We discussed a number of possible communication agreements that could support a more constructive conversation, and I proposed a number of communication agreements that could help them have a constructive “learning conversation.” These were framed as agreements or shared promises that the couple were making to each other to support the kind of conversation they wanted to have and promote the kind of relationship they wanted to develop. I proposed several agreements, and we then together worked out a final list. The agreements, framed as shared promises in the service of their relationship, included: “We promise to share speaking time and respond to any time limits set.” “We promise to suspend efforts to persuade in order to seek mutual understanding.” “We promise to speak from our own experience and not attribute intentions or motives to the other.” “We promise to listen carefully when what is said is hard to hear and hang in and not interrupt the other.” “We respect each other’s right to pass in response to any questions asked.” “We authorize Bill to help hold us to these agreements.” This last agreement is an important one. It is important that a therapist have clients’ authorization to help hold them to communication agreements. Having the agreements in place ahead of time and an authorization to help people hold to them allows the creation of a structure that will contain the meeting, rather than relying solely on a therapist’s facilitation skills to contain the meeting. Having that authorization allows the clinician to remind people of the promises they’ve made in support of their purpose rather than trying to impose the clinician’s rules and get them to comply in a heated moment.

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Conversational Structures The final element needed for developing a containing environment for a learning conversation is the use of conversational structures that separate out and clearly demarcate time and space for speaking and listening. The purpose of these structures is to support a learning conversation that will serve the purposes that bring each member to the meeting. This is not an attempt to provide a normative model of functioning for their lives, but to offer them a structure that will support the kind of learning conversation they’ve said they would like to have. This kind of structure often involves having one member speak while another listens. It is important to put clearly defined time parameters on this structure (e.g., “Tom, I’d like to ask you to speak about your concerns about X for 2 minutes while Beth listens. I’m going to hold you to 2 minutes and ask Beth to simply listen, then we’ll shift and I’ll ask Beth to speak about X for 2 minutes and ask you to listen”). Short time frames make it easier to listen (e.g., most people can listen to just about anything if it is only for 2 minutes). The time limits often feel strained and unnatural, but the point is to build a structure that will contribute to a different conversation in that particular meeting. If clients find the structure useful, we can engage them in reflection on what they find useful and whether and how they would like to bring that more into their daily life. One conversational structure involves giving each member set times to speak, and alternating speaking and listening. In another structure, one member is interviewed; the others observe and are subsequently interviewed about their reflections. As we interview one individual, it is important to pay close attention to the others’ reactions during that interview, anticipating their responses and engaging them before they become reactive. We can also repeatedly compliment other family members for continuing to listen in the face of what may be provocative statements. When people are assured of shared speaking time, it allows them to more fully listen and reflect rather than simply prepare their rebuttals. Similarly it can be useful to actively interview a listener about his or her experience in order to highlight particular aspects of that experience. This is a brief explanation of some of the ways in which we can actively contribute to the development of a containing environment. Again, I want to emphasize that collaborative inquiry is an active process that consists of collaboratively structuring a constructive conversation rather than just passively listening to a family’s story. In the next section, I highlight an organizational framework that can ground collaborative inquiry in the four conceptual developments that form the foundation of this book.

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SUSAN DISABLES THE BAD-PARENT BUTTON: AN ORGANIZATIONAL FRAMEWORK FOR COLLABORATIVE INQUIRY We can productively organize our efforts to help clients and families around the following five broad steps: 1. Getting to know clients outside the problem’s influence. 2. Helping clients envision preferred directions in life. 3. Helping clients identify elements that may constrain and/or sustain their development of preferred directions in life. 4. Helping clients address constraining elements and/or enhance sustaining elements. 5. Helping clients develop communities to support the enactment of preferred lives. This section draws on an extended clinical consultation to illustrate this organizational framework. Although the example is a one-time consultation, this framework also can serve as a map for our overall work with families and is applicable across many contexts. After a description of the family, I highlight each step in some detail with reference to the consultation interview.

Description of the Family Susan was a poor, white, working, single mother with two children, Carol (7) and Frankie (5). Her family was referred to a home-based team to help Carol, who struggled with repeated explosive temper outbursts. These explosions had taken a significant toll on both Carol and Susan as well as on their relationship. The family was involved with protective services because of repeated physical fights between Carol and Susan. They had a long history of unsuccessful encounters with numerous helpers. However, over the past 5 months of working with a home-based family therapist and a new after-school program, things had begun to change. Carol was more able to control the temper outbursts and Susan was more confident as a parent. However, the family therapist was concerned that these changes rested on a shaky foundation. Susan had an extensive history of abuse herself and little community to support her. The family therapist requested a consultation to help solidify changes in the family and support Susan in becoming a more effective parent. The consultation interview included Susan, her home-based family therapist, a clinician from the after-school program, and me as the consultant. The consultation was scheduled to include Susan’s daughter, but

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she had been sick earlier in the week and Susan decided it was more important that she attend school than yet another therapy meeting. In the spirit of collaborative inquiry, this consultation was framed for Susan as a consultation we were seeking from her, rather than an intervention we were providing for her. We wanted to elicit, elaborate, and acknowledge her wisdom accrued from coping with a difficult situation. We thought that we as helpers could learn a lot from the consultation and also hoped that the questions in the consultation would have beneficial effects on Susan and her family. Susan felt touched and validated by this request and was very interested in participating. The initial consultation included an interview with Susan and her helpers in one room with a number of team members in another room observing behind a one-way mirror (with Susan’s consent). At some point, three members of the team came into our room and offered reflections that acknowledged the ways in which they had been moved by Susan’s story. Susan and the helpers sat off to the side listening and then Susan had an opportunity to respond to the reflections. The consultation was videotaped, and Susan later viewed the videotape with her therapist to further reflect on it. In addition, I sent her a follow-up letter that documented her abilities, skills, and wisdom that emerged in the meeting and posed additional questions to invite further reflection on her part. Therapeutic letters can be a powerful adjunct to clinical meetings and will be examined in more detail shortly and again in Chapter 9. Finally, the videotape of the consultation was shown to other witnessing groups (again with Susan’s permission) and their reflections were captured and shared with Susan and her therapist.

Getting to Know Clients Outside the Problem’s Influence If we view people as being in a relationship with a problem (rather than having or being a problem), we can begin our work by getting to know clients outside the problem’s influence. Getting to know people as threedimensional human beings with multiple aspects of experience that we can respect and appreciate builds a strong foundation for a therapeutic relationship. Marcia Sheinberg (1992) points out the usefulness of eliciting stories of pride before stories of shame. Inquiry into what clients appreciate and value about their lives facilitates engagement and makes it easier to subsequently examine difficulties. The process of getting to know clients outside the problem’s influence was previously examined in Chapter 3. In this clinical example, Susan arrived late for the consultation and entered angry, exasperated, and embarrassed. I asked about her morning and heard a wrenching story of Susan getting her daughter on the school bus and then noticing some forgotten homework. Susan drove to her

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daughter’s school to deliver the homework, and her daughter greeted Susan with outrage for embarrassing her rather than gratitude for the extra effort. Susan then drove to the consultation in heavy traffic, knowing she was going to be late, anticipating criticism and judgment, and both preparing her defense and preemptively castigating herself. As she told this story, I marveled that she would put all this extra, unrewarded effort into helping her daughter out. Susan replied, “That’s what motherhood is all about. You don’t always get the recognition you deserve.” That reflection provided an important opening, and we moved into a conversation about her commitment to her daughter and how parenting for her was, in her words, “not just a job, but a calling.” The transition from a not uncommon story of parental frustration to an examination of Susan’s commitment to “Parenting as a Calling” carried her out of the harried pace of being late for a meeting and into a more reflective space that provided a stronger foundation for moving forward.

Helping Clients Envision Preferred Directions in Life The process of getting to know clients outside the problem’s influence and eliciting stories of pride as a foundation for subsequent inquiry often leads naturally into the second step of developing a vision of future possibilities or preferred ways of being in the present that can serve as an agreed-upon focus for helping efforts. Chapter 4 examined the usefulness of a proactive focus and offered a number of questions for jointly developing collaborative goals. As clients begin to concretize preferred directions in life, we can help them build a foundation of motivation, resourcefulness, and community that will more solidly anchor this vision. We can ask family members why the direction they’re describing is important to them (enhancing motivation), inquire about when they see threads of it emerging and steps they are taking to live into that vision (elaborating resourcefulness), and seek to learn about who in their lives might appreciate and stand behind their efforts to develop that life (developing a community). In this clinical example, Susan found our initial conversation about Parenting as a Calling to be useful, and I asked a series of questions to take the idea further. I asked what that phrase meant for her and how her parenting was different when she experienced it as a calling rather than a job. The questions tapped into her pride and passion about her parenting. She described moments of a loving, thoughtful, and connected relationship with her daughter, and I asked a number of questions to concretize that description. In an effort to build a more solid foundation for Parenting as a Calling, I asked Susan a series of questions about why this was important to her, how it was currently showing up in her life, and who in her life might appreciate it. The

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phrase “Parenting as a Calling” became an organizing focus for the consultation and allowed us to move into jointly learning more about her efforts to more consistently ground her parenting in that commitment.

Identifying Constraining and Sustaining Elements Once we have helped clients envision preferred directions in life and learned a bit about why those directions are important to them, we can work with clients to identify elements, factors, or forces that might constrain or sustain the development of desired lives. Chapter 2 outlined a number of examples of constraints at different levels (biological, individual, familial, social network, and sociocultural) and in different realms (action and meaning). We can also identify elements, factors, or forces in life that sustain, support, or enhance the pursuit of preferred lives. These may include sustaining beliefs, actions, and interactions at various levels, as well as the intentions and purposes, values and beliefs, hopes and dreams, and commitments people bring to their lives. We can think about people as being in a relationship with constraining and sustaining elements, as shown in the figure below.

In considering this figure, we can think about the relationship between a person and constraining and/or sustaining elements as both ongoing and modifiable. Constraining and sustaining elements can be seen as having significant influence in the life of the person and the person can be seen as having significant influence in the life of those elements. The process of addressing the relationship between people and constraining and sustaining elements is examined in significant detail in Chapters 6 and 7. Although there has typically been more focus on problems and constraining elements, we can also focus our efforts on helping people draw on and enhance their relationship with sustaining

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elements. For example, Susan’s commitment to Parenting as a Calling is sustained by her hopes for her daughter’s future. As she holds a picture of her daughter as a newborn and remembers the hopes with which she brought Carol into the world, her commitment to Parenting as a Calling becomes more tangible and real to her. In this way, helping clients enhance their relationships with sustaining elements in their lives can support their preferred direction in life. With a map of constraining and sustaining elements in mind, we can ask clients whether they would prefer to begin by focusing on things that support their efforts to build desired lives or by focusing on the obstacles on the road to preferred futures. If clients are primarily interested in sustaining elements, we can build on emerging possibilities to develop richer life stories and may not need to directly attend to the problems that initially brought them to therapy. At other times, it may be important to more directly address problems or constraining elements. If so, we can work with people to anticipate potholes on the road to preferred living and help them draw on abilities, skills, and knowledge to address the potholes they experience in their lives. (Conceptual maps for this process are discussed in depth in Chapter 7.) The option of focusing on constraining or sustaining elements offers the flexibility to fit our efforts to client preferences along with our own judgment about directions that might prove most fruitful. The clinical consultation with Susan focused on supporting her commitment to Parenting as a Calling. When offered a choice of focusing on what sustained that commitment or what pulled her away from Parenting as a Calling, she chose the latter and began talking about the many ways in which her daughter would “push her buttons.” She described her parenting at those times as “going right down the toilet.” I asked Susan if it would be okay if we shifted our focus from Carol’s pushing of buttons to the buttons that got pushed and how Susan would rather respond to “pushed buttons.” She agreed, and we talked about pushed buttons as an externalized problem, then moved into a discussion about what Susan called the “bad-parent button.” We explored the influence of the Bad-Parent Button on Susan’s parenting, her sense of self, and her relationship with her daughter. The following dialogue highlights some of the effects of the Bad-Parent Button on Susan’s interactions with her daughter, Carol. BILL: So, this idea that it was your fault that Carol was struggling with her temper, what effect did that idea have on you? SUSAN: It actually made me a whole lot less patient with her ’cause I’m trying to make her perfect because that means I’m perfect if she’s perfect. It just changed my whole attitude with her.

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BILL: So, when her not being perfect becomes a comment on you, would that then steal away any patience you have for her? SUSAN: Yeah. BILL: So, it’s not just her that you’re concerned about, but her and also what it says about you? SUSAN: Yeah. BILL: It’s really unfortunate, I think, the ways in which moms get blamed in that way. SUSAN: I’d have to agree. In examining the effects of the Bad-Parent Button, it’s important to note that this button does not stand alone in isolation. Susan is among many mothers who have been pulled into blaming themselves for their children’s misfortunes. The Bad-Parent Button in Susan’s case (and in the case of many mothers) is embedded in a broader cultural context and receives significant support from the prevalence of mother-blame in our culture. In examining the effects of particular problems on people, it is useful to place those effects in the context of broader taken-for-granted cultural assumptions and practices that contribute to those effects. Exposing and critically examining cultural assumptions and practices that support a problem helps to undermine the influence of that problem and minimize self-blame. The goal here is not to replace one set of prescriptions of how to be in life with another, but rather to make visible the taken-for-granted assumptions that organize our lives so that clients can examine those assumptions and decide how they actually fit for their lives. The rest of the consultation focused on the Bad-Parent Button as a constraint to Parenting as a Calling and helped Susan to shift her relationship to that constraint. As a result, the rest of this section focuses on constraining rather than sustaining elements. We return to and examine the usefulness of building on sustaining elements in more depth in the next chapter.

Helping Clients Address Constraints Once clients have identified particular constraints, we can help them reflect on their current relationship with these constraints as well as the relationship they would prefer to have. Then we can draw on our expertise in inquiry to pose questions that elicit client knowledge, abilities, and skills that can help them shift their current relationship to constraints and more deliberately develop the kinds of lives they would prefer. Again, the focus here is on eliciting client abilities, skills, and knowledge, rather than conveying professionally derived strategies for preferred living.

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As the clinical consultation with Susan continued, she mentioned that there were times when she was able to disable the Bad-Parent Button. I asked a number of questions about how she did that and whether she preferred times when the Bad-Parent Button got pushed or times when she was able to disable that button. The following dialogue highlights her response. BILL: So, I’m sort of sitting here thinking about these times you’ve described where on the one hand (right), the Bad-Parent Button gets pushed and you’re at the end of your rope and feeling like “I just don’t want her in my life,” and on the other hand (left), you’re able to disable that button and remember that “she’s the most important thing in my life.” Does that capture the difference for you? SUSAN: Yes. BILL: This may seem like an odd question, but I want to make sure I’m clear about it. Which do you prefer? SUSAN: Times when I disable the button and remember that she’s the most important thing in my life. BILL: Why is that? It’s clear to me that this is really important to you. Why is that important to you? SUSAN: Because she has been through so much already. I just, I don’t know, it’s . . . she’s been my world since day one and will never stop being my world, no matter how angry she makes me, how frustrated, how sad, how happy, no matter what. She is my world. BILL: So, no matter what buttons get pushed, she will still be your world? SUSAN: Yeah, the fact that she is my world is why she is still with me. I have fought for my daughter from day one, very literally. Although questions about people’s preferences may seem like rather obvious questions, they are actually very important. Questions about people’s preferences provide an occasion for them to make their values and intentions known. To voice a preference out loud is to commit oneself to a direction in life. Preference questions create a context to make such commitments. These questions invite people to clarify and elaborate their values. In this way, preference questions are helpful in mobilizing and aligning a person’s emotional responses behind his or her preferred direction in life (Tomm, 1989). As Susan talked about her daughter’s importance to her, she was stepping into a commitment to disabling buttons. The process enhanced motivation. It also provided a

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basis for further inquiry into Susan’s intentions, values, hopes, and commitments and made the process more meaningful and personally salient. As Susan continued speaking about her commitment to disabling the Bad-Parent Button, her physical demeanor in the meeting shifted. She sat up and became more of a presence in the room. I asked her about the steps she took to disable buttons, and she had little to say initially. This is not unusual. When asking about events that fall outside the dominant stories in people’s lives, it is entirely expectable that those events don’t come to mind immediately. Collaborative inquiry involves a joint search for events that fall outside the dominant story. After several forays into the search for exceptions, the following conversation ensued. BILL: How did you start to disable that button? What were some of the first steps you took to disable it? SUSAN: The biggest step was to stop letting everybody else rule the way I parent my child. A lot of the times the way I reacted to Carol had nothing to do with Carol and it had nothing to do with me. It had to do with everybody else. The fears of how I was going to look to everybody else if she didn’t behave. BILL: So, back to that thing about mothers and fear and judgment? SUSAN: Yes! I was petrified of protective services, which played a big part in how I handled her. My fear would take over and then the anger would take over as well. BILL: From what you’ve been saying, it sounds as though what would happen with your parenting was that there were lots of voices in your head, saying do this, do that. Would that describe it? SUSAN: Absolutely! I had to stop and think of what every single person in my life was going to say if I didn’t do this, this, this, and this. And, I had to stop that. It didn’t matter what everybody else thought, it mattered what I think and my child thinks, and the rest of the world can just disappear. From this exchange, we expanded the frame to examine steps that Susan took away from Pushed Buttons and Parenting out of Fear and Judgment and toward Disabled Buttons and Parenting out of Love and Commitment. Alternating between questions to develop this richer story and questions to solidify its meaning, I sought to elaborate this developing story of Susan’s parenting and invite her reflection on her emerging identity within it. Susan continued speaking more confidently, and we

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moved into an examination of future possibilities that might emerge from these developments. BILL: So, this change in your parenting, who else should get caught up on these changes? Who would be important to have learn about these changes? SUSAN: I don’t know. The one who sees it is the only one that matters to me anyway, and that’s my daughter. BILL: And what has she seen? SUSAN: Mommy’s a whole lot more fun. Mommy’s not saying, “Carol, you’re wrong. Carol, go to your room.” Mommy’s not crying for hours on end because Mommy doesn’t know what to do. Mommy’s able to just sit down and read a book with Carol. Just in the past week alone, I’ve actually found enjoyment in doing homework with Carol, which is a miracle. BILL: So, she sees this different story about your parenting. What effect do you think it has on her? SUSAN: I think it has an awesome effect on her. BILL: And as you continue to keep these buttons disabled, as you continue to have your parenting anchored in your love and commitment for her, how do you think it will affect her life? SUSAN: She’ll continue to grow, she’ll continue to see the right way to handle things, and, hopefully, eventually she will continue to see different ways to handle her anger. Finally, in an attempt to further ground Susan in this developing story of Disabled Buttons and Parenting out of Love and Commitment, I asked Susan what thoughts she would have for other parents looking to disable Bad-Parent Buttons. She outlined three pieces of wisdom: • Be open to what your children have to teach you. • Let your children know they matter and are important. • Don’t let others rule your parenting and don’t parent out of fear. We talked about how she had arrived at these realizations and how she managed to hang onto them in difficult times. Finally, by way of concluding the consultation, I asked her what ideas she would have for professionals trying to help parents disable Bad-Parent Buttons. Her suggestions for helpers were simple:

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“Don’t sit in judgment. When helpers don’t sit in judgment, the defensiveness goes away. Clients don’t feel the need to sit there and defend every little thing they just said or did. When I talk to these guys [the two helpers in the interview], I can say anything and not think, ‘Oh my God, I can’t believe I just said this to them. What’s gonna happen now? What are they gonna think or do?’ When I’m not caught up by that, I can be more open and they can be more helpful. That’s my only suggestion, but it’s a big one.” Although the solicitation of her wisdom for helpers fit the frame of the consultation (to help the helpers), it was also done with the intention of repositioning Susan from being the object of professional efforts to being a more active agent in her own life.

Building a Community to Support Preferred Living Susan was moved by this consultation and seemed to be in a different place at its end. At the same time, the interview itself was quite ephemeral in the grand scheme of her life. To slightly alter an old African phrase, it takes a village to raise a new story. It is important to help people develop communities of support that will stand with them as an appreciative audience for the enactment of new lives. Problems exist within networks of support (e.g., the Bad-Parent Button receives significant support in our culture through mother-blame). Helping clients shift their relationships to problems is significantly enhanced through the development of a community that can support them in that process. We all live out the stories of our lives in our interactions with others, and those interactions solidify our narratives and further shape our lives. As we begin to enact a richer story, the community that witnesses that enactment takes on great significance. The development of a community to witness and support the performance of emerging stories can be a crucial piece of our work. There are a number of ways to support clients in further elaborating and solidifying new lives. This consultation highlights several that are further examined in subsequent chapters. Immediately following the interview, the three members of the witnessing team came in and shared their reflections while Susan and the two helpers observed. Following guidelines for outsider witness groups developed by Michael White (1995, 2000), their reflections were primarily organized by three questions: • What did you hear in this conversation that captured your attention? • How does that connect to events in your own life or work?

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• How have you been moved by hearing this conversation, and what from this conversation do you want to carry back into your own life or work? The purpose of the reflections was to acknowledge the ripple effects of hearing Susan’s story rather than to offer advice or suggestions for Susan’s benefit. Reflecting practices and the use of witnessing teams are further examined in Chapter 8. Following their comments, Susan and the two helpers were asked about their responses to the team’s comments. Susan was visibly affected by the witnessing team and offered the following response: “It’s amazing. I’m not alone. Someone sees the life that everyone keeps telling me I’m making up. They get it and see me as having made some progress and having something to offer others. I’m glad that what I’ve been through is useful to others. I will carry these voices around with me for some time, and my hope is they can continue to grow and crowd out all those critical voices in my head.” The next week, in a continued effort to help Susan keep alive this alternative story, her family therapist met with her to watch the videotape of the consultation and elicit her reflections on watching it a week later. In addition, I sent a therapeutic letter to Susan with my reflections on the session. Therapeutic letters are powerful devices for sustaining emerging alternative stories and are further examined in Chapter 9. Although the experience of a particular meeting can fade with time, therapeutic letters help to keep that experience alive and concrete. The letter below alternates between documenting what Susan said in the meeting and raising questions to continue an internal conversation and invite further reflection on developments from the meeting. Dear Susan, I appreciated the opportunity to meet with you this week and learn about your commitment to “Parenting as a Calling.” In the spirit of supporting that commitment, I wanted to share back with you some of the many things that I found moving and offer some reflections. I appreciated your obvious concern for your daughter, Carol. Her explosions sound as though they have taken quite a toll on her, on you, and on your relationship. At the same time, I was profoundly struck by your commitment to maintain your connection to her despite those explosions.

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You described some remarkable changes in Carol over the last 5 months. When I inquired about how these changes had occurred, you shared the credit among many sources and also included yourself. As you said, “A child learns what the child lives.” I was moved to hear you claim some credit for the changes in Carol’s life. It seems so often the case that mothers receive way too much blame and far too little credit. As you continue to give yourself the credit you are due, what other changes do you think will occur? You talked about the ways in which the Bad-Parent Button could get pushed for you and how you have worked to disable that button and increasingly ground your parenting in love for and commitment to your daughter. You provided a very moving account of some of the steps you took to disable that button, which included: • Taking ownership of your parenting and realizing that you are the primary caretaker and need to go with your gut rather than be preoccupied about others’ criticism. • Focusing on your daughter’s importance to you and remembering your hopes for a different life for her. • Taking time out and stepping out of interactions with Carol to ensure that your parenting stays anchored in the love you have for her rather than reacting to particular situations. I would imagine these steps took a lot of hard work. I asked you how Carol might describe your parenting now, and you thought she’d say, “Mommy is more fun and not crying now.” You described that change as an awesome one. As your parenting is increasingly anchored in these important steps, how do you think your relationship with your children will continue to unfold? I also asked you what of your hard-won wisdom might be useful for other parents who get pushed by the Bad-Parent Button. You mentioned three things: • Being open to what your children have to teach you. • Letting your children know they matter and are important. • Working to not parent out of fear. This wisdom rings true for me, both as a father and as a helper, and I appreciate your permission to share those thoughts with other parents who I think will benefit from them. As you read these ideas, how do you think they might be useful for you? After the three team members spoke at the end of our meeting, you said you wanted to hold their voices in your head as you continue to parent your children. I hope that appreciative voices come to crowd

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out the critical voices and that your parenting is increasingly grounded in the wisdom you’ve described. Who else might appreciate your efforts to disable the Bad-Parent Button? What do you think your efforts would tell them about you? Again, I appreciated meeting with you and wanted to thank you for the wisdom you shared. In appreciation of all that you have to offer, Bill Madsen This letter had a profound effect on Susan. She read it over with her family therapist and they discussed it in great detail, further solidifying her emerging story in the process. In an attempt to continue to keep the appreciative voices alive and assist them in crowding out critical ones, I began to use the videotape of this consultation in various training and consultation groups (with Susan’s permission). I would show participants the tape, and then have them offer reflections following the same three questions that guided the original witnessing team immediately after the consultation. As participants spoke, I took notes and then included them in several follow-up letters to Susan. Here is a composite letter that contains some of the many things people said: Dear Susan, As you know, I have been using the videotape of our meeting to help mental health and social service workers draw on your wisdom in their efforts to become more helpful to other parents attempting to disable “Bad-Parent Buttons.” I recently showed the videotape of our meeting to a group of professionals and then asked for their reflections, which I want to share with you. They were asked three questions: What stood out for you? Why is that important to you? What do you want to take away from this? Here are some of the things they said: “I was really touched by Susan’s ability to find and hang onto her own voice. It is hard to step away from others’ voices when you’re dependent on professionals, when your life hangs in the balance. We get so organized by what you should and shouldn’t do, and I really appreciated her strength and resolve to listen to her own voice. It solidifies for me the importance of going with my own inner voice. Recently I made a decision, and fear gets me to not trust my decision. I can lose sight of who I am and what I know and end up running to others and bouncing off them. Watching this interview helps me get back to my commitment to trusting myself.”

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“It’s hard to hear your own voice, especially when the system is not kind to the fact that people sometimes fall down. For me, the challenge is to look past the sheet of paper that is supposed to tell us about clients and to move beyond our fixed ideas about where we think people should be in their lives or what they should be doing, to where they actually are in their lives. It made me more conscious of how many people are moving through their lives chained down by fear. I think fear shuts people down, and watching this interview gives me ideas about how to be more understanding about that.” “I was moved by Susan’s determination to not repeat abandonment. I have a connection with that. As a man who grew up without a father and is now a father, I really connect with her determination to be a different parent with her children. My fathering is sometimes criticized, and it was very helpful to watch Susan’s determination to hold onto her own voice. I was very moved by that. It confirms for me that it is entirely possible for human beings to turn things around and not be subject to fate or what is written on their assessment sheets. As I watched this, I became more convinced that parents have answers and abilities that we as professionals often miss. Watching this confirms that I need to look for and believe in the inner strength that parents have.” Those are their responses. I’d be interested in whatever thoughts and reflections you might have, and I appreciate your willingness to help others learn from your experience and wisdom. As you think about the effects you are having on an ever-widening circle of helpers, what is that like for you? With continued appreciation, Bill Madsen Susan was very moved by this series of letters. She often carried them with her and would make a point of rereading them when she anticipated difficult situations. As she put it, “These letters keep my head filled with the voices I want in it.” Susan felt wonderful in reading these letters. But this process is not simply about helping people feel good, it is about helping them build better lives.

Comments on This Consultation Susan moved out of state and I no longer have contact with her. At the last report, she and her daughter were both doing better in their lives, though still encountering a number of everyday challenges. Susan had practically no community at the time of this consultation, and the letters

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reflected an attempt to help her develop and hold onto a virtual community. If I had the opportunity to continue working with Susan, I imagine we would focus on helping her develop an actual community of support. Concrete ways to accomplish this are further examined in Chapter 9. At this point, I would like to tie the consultation interview back to the four conceptual developments that form the foundation of this book. Throughout this interview, I was aware of my relational stance with Susan and sought to stay positioned as an appreciative ally in her life. She had a long history of professionals whom she experienced as extremely judgmental. If I became another critical voice in her life, my weight would inadvertently be thrown behind the Bad-Parent Button and Parenting out of Fear and Judgment, which is not where I would want to stand. My attempts to join as an ally working with her rather than an expert acting on her were reflected in my language throughout this consultation. My embracing of externalizing assumptions and viewing Susan as someone who got caught by Fear and Judgment, which undercut her parenting, positioned me differently than viewing her as an inadequate parent. Our efforts to develop a proactive vision of “Parenting as a Calling” allowed her to move more easily into an examination of what pulled her away from that way of being. And finally, framing the consultation as a joint learning project had powerful effects on both her willingness to participate and her developing sense of self. In this process of collaborative inquiry, there was a focus on eliciting, elaborating, and acknowledging her abilities, skills, and know-how, as well as attention to the ways in which the consultation invited the enactment of particular stories. As Susan moved from experiencing herself as an underfunctioning parent to a parent whose buttons get pushed, to a parent who is both affected by and disabling pushed buttons, she was enacting a different story of identity. In this way, the extended consultation could be seen as a shared identity development project. Together, we were constructing a new experience of her identity and opening new possibilities for her life.

SUMMARY This chapter initially focused on the process of “intervention,” highlighting the ways in which all interactions with clients have interventive potential and drawing a distinction between instructive interaction (in which we attempt to get someone to see something or bring about a particular outcome) and invitational interaction (in which we acknowledge that we can’t predict the outcomes of our efforts and seek to interact in ways that invite reflection, expand possibilities, and open space for the consideration of alternative ways of viewing and responding to

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situations). On the basis of this distinction, the chapter examined ways to reorganize therapeutic efforts as an anthropological co-research effort that I described as collaborative inquiry. I examined the role of professional values and knowledge in collaborative inquiry and outlined a fivestep organizational framework to guide clinical work: 1. Getting to know clients outside of the problem’s influence. 2. Helping clients envision preferred directions in life. 3. Helping clients identify elements that may constrain and/or sustain their development of preferred directions in life. 4. Helping clients address constraining elements and/or enhance sustaining elements. 5. Helping clients develop communities to support the enactment of preferred lives. Different aspects of this outline are examined in detail in various chapters. Chapter 3 examined the process of successfully engaging clients. Chapter 4 examined ways to help clients develop a proactive vision to guide helping efforts by eliciting their hopes for the future or preferred ways of coping in the present. The third and fourth steps of identifying constraining and sustaining elements and helping clients address or draw on them are examined in Chapters 6 and 7. And the final step of helping clients develop communities of support is examined in Chapters 8 and 9. NOTES 1. If such containment does seem more the exception than the rule in your work, it might be interesting to examine what is different in those exceptions. What are you doing differently? What is the family doing differently? From a bird’s-eye perspective, what is different about the context? Do you like it better when those exceptions seem to be happening? Based on the differences you’ve noticed, how might you be able to extend those exceptions into more of your work? The same questioning process that we use with families can also be helpful in reflecting on our work. 2. These ideas have been strongly influenced by my involvement with the Public Conversations Project (www.publicconversations.org), an organization committed to supporting constructive conversations across challenging differences (Chasin et al., 1996; Herzig, 2001; Herzig & Chasin, 2006). The Public Conversations Project originally sought to bring ideas and practices from family therapy to work with broader communities. Subsequently, a number of us have brought ideas from this dialogical work back into our work with couples and families. The ideas here have been strongly influenced by my colleagues Corky Becker (2005) and Sallyann Roth (2006b).

CHAPTER 6

Examining the Relationship between Clients and the Problems in Their Lives

The last chapter highlighted a framework for collaborative clinical practice that organizes much of this book. The next few chapters examine aspects of that framework in depth. This chapter focuses on helping clients externalize problems that stand between them and preferred directions in life. Externalizing conversations were originally developed by Michael White and David Epston (1990) and subsequently elaborated by many others (Freedman & Combs, 1996a; Freeman, Epston, & Lobovitz, 1997; Monk, Winslade, Crocket, & Epston, 1997; Madsen, 1999b; Morgan, 2000; Payne, 2000; Roth & Epston, 1996; Tomm, 1989; Russell & Carey, 2004; Winslade & Monk, 1999; Zimmerman & Dickerson, 1996). This chapter provides an overview of externalizing conversations and shows how they can be used to help clients experience the difficulties in their lives in a powerfully different fashion. Externalizing conversations attempt to separate problems from people in order for clients to experience an identity outside the influence of those problems. At its core, externalizing is a way of thinking about and approaching problems. For example, rather than thinking about a woman as being anxious or having anxiety (which internalizes the problem and can lead to viewing the person and the problem as one and the same), a conceptualization based on externalizing assumptions would think about this woman as being in a relationship with Anxiety.1 In this conceptualization, the woman and Anxiety are viewed as distinct 187

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entities in an ongoing, mutually influencing, and changeable relationship. Graphically, this relationship could be portrayed as follows:

In this relationship, we can examine the influence of the problem on the life of the person and/or family as well as the influence of the person and/or family on the life of the problem. When people experience themselves as being in a relationship with a problem rather than having or being a problem, they often experience a sense of relief and an increased ability to do something about the problem. Externalizing creates a space between people and problems that enables people to draw on previously obscured abilities, skills, and know-how to revise their relationships with the problems. In the course of revising this relationship, it is important to note that problems do not exist in isolation. They are embedded in a network of support that includes taken-for-granted cultural assumptions and practices (a classic example of this is the way in which Anorexia as a problem is embedded in and supported by broader cultural values for thinness, perfection, and control). Thus, in order for clients to successfully shift their relationship with a problem that has a network of cultural support, it is helpful if they can also draw on a community of support. (A young woman attempting to resist the effects of Anorexia with its cultural support is better positioned to do this when she can connect with others who acknowledge and support her efforts.) Externalizing conversations usually pay particular attention to the broader cultural assumptions and practices that support the existence of problems. When

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a person’s relationship with a problem is placed within a historical and cultural context, it becomes more possible to explore how gender, race, class, sexual orientation, culture, and other relations of power have influenced the development of the problem and its current relationship with the person or family. Such an understanding helps both clients and clinicians better appreciate the breadth and depth of a problem’s influence and what is required to address it. This appreciation can be profoundly helpful in minimizing self-blame and highlighting the importance of building a community of support. Externalizing assumptions represent a very different way of thinking about the difficulties in people’s lives, and although they can be hard to fully embrace, they hold many advantages for both clients and clinicians. The process of locating problems in individuals runs the risk of entrenching problematic identities as people’s sense of self becomes conflated with the problems in their lives. When problems are seen as an integral part of a person’s character or personality, they become more difficult to address because they are deeply embedded in the person’s being. Locating a problem within an individual may invite shame, blame, and defensiveness that further constrain attempts to address the problem. The process of externalizing creates a space between people and problems that alleviates the immobilizing effects of shame and blame and reduces defensiveness. As clients perceive themselves in a relationship with a problem (rather than as being a problem or having a problem), they often experience more freedom and ability to address the problem. In addition, externalizing can help us as clinicians to develop a more compassionate and connected view of clients who engage in offputting behaviors. For example, when we think of a particular client as being captured by emotions such as rage or hurt or frustration, rather than as being rageful or histrionic or frustrating, we may have a more empathic response to that person. We can become annoyed with the emotional response rather than being annoyed with the client. From there, we can look for exceptions or times when a client has been able to avoid being captured by that emotion or has been able to respond differently despite the emotion’s presence. When we are in a position of supporting clients in building a life in the face of negative effects of problems, those problems are less likely to disrupt our relationship with them. Finally, externalizing assumptions may offer a way to transcend an unfortunate dichotomy that has arisen between being problem-focused or being solution-focused. One oft-heard critique of strength-based approaches is the claim that they romanticize families and minimize any discussion of real problems that families face. Helpers can fall into

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polarized camps that emphasize either problems or solutions and complain about the perceived excesses of the other camp. The process of externalizing provides us with a way of thinking that both acknowledges problems (while viewing clients as distinct from them) and focuses our attention on client resourcefulness that can help people develop a different relationship with problems. It is important to acknowledge clients’ and helpers’ experience of problems when they loom large. Externalizing provides a way of doing this without inadvertently contributing to clients’ feeling defined as problematic, disordered, or deficient and responding with a sense of incompetence and powerlessness that further constrains their attempts to deal with problems.

Beginning an Externalizing Conversation The process of externalizing begins with how we listen to clients. As we ask clients about their experience, we can listen with an “externalizing ear” that translates their descriptions into externalized entities (Freeman et al., 1997). One way to begin this process is to transform adjectives into nouns. For example, in response to a man who says, “I’m afraid,” we can inquire about how Fear first showed up in his life, what toll Fear has taken on his life, what his relationship with Fear is like, when Fear seems stronger and when he feels stronger in that relationship, and so on. The process begins with our thinking about these “characteristics” as external entities rather than as internal qualities. We can also move into externalizing conversations by asking questions such as, “How would you describe the problem that brought you here?” or “If we were to give this problem a name, what might we call it?” Often, questions arise about what problem to externalize. As a number of authors have emphasized, the naming of a particular externalized problem is less important than the process of talking about problems in an externalizing fashion (Freeman et al., 1997; Monk et al., 1997; Winslade & Monk, 1999; Zimmerman & Dickerson, 1996). The problem that is discussed in externalizing conversations often changes over the course of an interview. It can be helpful to not externalize the first problem, belief, experience, or pattern that emerges but to first develop a rich appreciation of the person or family’s experience and to think in an externalizing fashion. Monk et al. (1997) suggest the usefulness of using the word “it” or “this problem” before assigning a specific label in the early part of an interview. The choice of what to externalize often depends on how the problem is discussed by the family, what effects the problem has on the family, and whether other institutionalized ways of thinking about the problem have influenced clients’ thinking (Zimmerman & Dickerson, 1996). I prefer to externalize those

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things that stand between people and the lives they would prefer to lead. In that regard, we can externalize problems, feelings, interactions, beliefs, lifestyles, life stories, dilemmas, and situations. When a family is united around a concrete definition of a problem (e.g., Depression, ADHD [Attention-Deficit/Hyperactivity Disorder], Tantrums), it can be useful to begin by externalizing that problem. In this process, it is important to use language that fits with client experience. We can do this by involving clients in developing a name to be used for the problem and in using that name tentatively and making sure the name fits for clients. At the same time, because we are attempting to create some space between the person and the problem, we need to take care that our language invites distance rather than closeness between a person and a problem. For example, consider the different effects in talking to the parents of a boy struggling with Temper Tantrums between the questions “What toll have the Tantrums taken on your relationship?” and “What toll have his Tantrums taken on your relationship?” That latter question, which reinternalizes Tantrums, runs the risk of being heard as blaming the boy for the deterioration of his parents’ relationship. Possessive pronouns tend to internalize and run counter to a process of externalizing. It is also important to develop externalizations that fit with clients’ colloquial language rather than professional descriptions. For example, Matt and his mother came to therapy after a school counselor had diagnosed him with ADHD. We began talking about the effects of ADHD on Matt and his family. Matt’s description of his experience included the sentence, “I feel itchy all over and can’t sit still. It’s like I’ve got the itchies.” When asked if “the Itchies” was a better name for the problem, both Matt and his mother enthusiastically agreed. Whereas ADHD was a foreign term that held little meaning for Matt’s family and implied a disease that was overwhelming, the Itchies, however, felt more familiar and manageable. As Matt’s mother put it: “When I heard the diagnosis ADHD, it scared me to death. I had no clue how to begin dealing with it, and I feared I was going to have to turn my son over to the professionals. That felt horrible. When we talked about the Itchies, it was such a relief. I know the Itchies. I can deal with the Itchies.” That term better captured their experience with the problem and made subsequent discussions more relevant and meaningful to them. At other times, families may be divided in their definition of a problem, which can lead to blaming and polarized escalations (e.g., “You’re the problem.” “No, you’re the problem.”) In such situations, it can be

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useful to begin by externalizing an interactional pattern or relationship variable. For example, Fred is furious that his son Ray is having difficulty getting a job, whereas Ray insists there would be no problem if his father just got off his back. As we trace out a pattern in which Fred’s “nagging” gets Ray to “blow him off” and Ray’s “ignoring of his father” gets Fred even more “up in his face,” I ask them each whether they like this dance. They come together in their mutual dislike for the dance (though they still blame each other for its existence). In response to a request for a good name for this dance, Fred replies, “The slower he goes, the faster I have talk.” His son immediately chimes in, “You mean, the faster you talk, the slower I go.” We come to call the dance “that Fast/Slow–Slow/Fast Thing,” shorten it to the “Fast/Slow Thing,” and begin examining its effects on each of them and on their relationship. We could also have come up with “tension” as an effect of the pattern as something to be externalized. Often clients hold particular beliefs that severely constrain their options in life. We can externalize these beliefs and move from viewing them as beliefs held by clients to viewing them as beliefs that come to hold clients. An example of a belief that can be externalized comes from the life of an African American single mother who believed, “When you get right down to it, I am basically good for nothing and don’t deserve much in this world.” Rather than thinking about this woman as suffering from low self-esteem or holding negative cognitions, we could think about her as being in a relationship with an externalized belief that speaks to her with considerable authority in its claims about her life. That belief may receive significant cultural support from her experience of how poor women of color are often treated in this culture. We could carefully elicit her experience of this belief, the way in which the belief speaks to her, and how it has become so powerful in her life. From there, we could inquire about the ways in which the claims made by that belief fit or don’t fit with her preferences for her life and move into helping her shift her relationship to that belief and the role it plays in her life. When families are confronted by multiple problems, it may be useful to work toward an externalization of a metaphorical phrase that captures the lifestyle they are living. Previous examples of this are the contrast between a Miami Vice lifestyle and a Mr. Mom lifestyle, in Chapter 4, and the contrast between Pushed Buttons and Parenting out of Fear and Judgment, and Disabled Buttons and Parenting out of Love and Commitment in Chapter 5. Another example comes from a family with a teenage girl, Lyra, who struggled with Impulsivity and a host of accompanying problems that included sexual promiscuity, extensive substance use, shoplifting, and running away. In a conversation with members of her family, they recounted how her beloved grandmother used to

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caution Lyra to “look before you leap.” We came to juxtapose a Leaping Lifestyle organized by impulsivity and a Looking Lifestyle tempered by planful caution. Within this juxtaposition, we talked about the ways in which a Leaping Lifestyle created problems for Lyra and her preference to move more into a Looking Lifestyle. It is helpful to view the name we develop for an externalized problem as a work in progress. This is not an attempt to diagnosis the particular problem that is affecting a family, but a way of talking about difficulties in order to be helpful. The phrase “a Leaping Lifestyle” is worthwhile only as long as it is useful to the client and family. Although externalizing conversations represent an unconventional way of talking about problems, clients are often able to enter them without significant difficulty. Clients’ level of comfort seems to correspond with therapists’ level of comfort. As clinicians become more comfortable talking in this way, clients slip into it more easily. In this regard, it is helpful to use externalizing language from the beginning. Sometimes just talking in an externalizing fashion is sufficient to invite clients to enter this way of thinking about problems. At other times, it may be useful to directly explain the process. For an example, I often say to families something like the following: “Families that I work with have often found it helpful when we talk about problems in their lives as something separate from them and give it a name. A lot of times when we’ve done this, it seems to help them figure out how to deal with the problem in ways that haven’t emerged before. What would you think if we were to try that way of talking about problems and see how it works?” If it doesn’t work, we can move into other ways of talking about problems that are more congruent with a family’s preferred style. It can also be helpful to refer to a particular space in the room when talking about a problem. For example (looking to an empty chair in the room), “If the problem was sitting right over there, what would it be thinking about our conversation now?” This helps to concretize the problem and give it more life in the room. At other times, when a problem has a strong hold on a client, it may be useful to not give the problem so much life in the room until the client feels more confident.

A SIMPLE OUTLINE FOR EXTERNALIZING CONVERSATIONS Externalizing is a powerful clinical practice that can initially seem difficult to apply in one’s own work. In an attempt to make these ideas more accessible, this section outlines a simple framework for externalizing

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conversations, which is further elaborated in Chapter 7. Externalizing conversations can be organized around inquiry in four areas: client’s experience of the problem, effects of the problem, client preferences about the problem’s effects, and client’s preferred coping with the problem. This framework can be portrayed graphically in the following way:

I illustrate this framework with a brief clinical example. A husband and wife are referred for therapy by their son’s preschool because their escalating arguments with each other scare him. Both parents are concerned about their son and the effects their arguments have on him. Their female therapist begins by developing with them a proactive vision toward which they would like to move (a supportive home based on a loving relationship). The therapist asks them about why that is important to them and elicits times when they’ve had more of a loving relationship. She then inquiries about things that can pull them away from a loving relationship. They mention continual arguing as a problem, and she begins by thinking in her own head about the arguments as an externalized sequence in which the parents become trapped. After learning that the arguments are mutual, have not escalated to violence, and are seen as a problem by both parents, she moves into an externalizing conversation about the Arguments.

Questions about Clients’ Experience of the Problem The therapist begins by asking about the couple’s experience of the arguments. Examples of such questions include:

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“You’ve both talked about the Arguments that come into your relationship and your family. When are they most likely to happen?” “How do they enter your life?” “Do they build slowly or come in quickly?” “What’s it like having the Arguments in your life?” “How is your life together different when the Arguments intrude into your life together than when it is just the two of you at home?” In the process, she listens for metaphors that might capture their relationship with the Arguments, and together the therapist and couple come to regard the Arguments as a sneak thief that is stealing away their hopes for their family. The mother captures this metaphor when she says, “You know the arguments happen so fast, it’s almost like we both get mugged by them and then we really don’t know what happened afterward.” The purpose of these questions is to develop a rich appreciation of the couple’s experience of this problem and their relationship with it.

Questions about the Effects of the Problem Effects questions seek to understand the ways in which individuals and relationships are affected by the problem being discussed. Examples of such questions include: “What toll have the Arguments taken on each of you individually?” “How have the Arguments affected your son?” “What effects have they had on your relationship with each other and your respective relationships with your son?” In tracing out a story of these effects, the therapist learns that the Arguments have left the mother depressed and fearful about further disruptions in their marriage, and the father both angry at his wife and ashamed of his own behavior in the Arguments. The parents are talking less to each other and worried sick about the effects of the Arguments on their son, who has become increasingly fearful. Learning about effects of a problem helps us further enter client experience and begins to shift the blame for those effects from the people to the problem. We can imagine the Arguments as a separate entity that has moved in with this couple and overtaken their relationship. In this context, the mother’s sadness and the father’s anger make sense. Effects questions invite compassion and help position us as appreciative allies in clients’ lives. They provide a way to understand problematic experience without problematizing the people affected by problems.

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Preference Questions Preference questions invite clients to reflect on the degree to which the 2 effects of a problem fit with their preferences in life. Examples of such questions might include: “As you think about the Arguments’ effects on each of you and your relationship, how do those effects suit you?” “Would you say that’s a positive or negative experience? Something you’d like more or less of in your life together? Or would you say both or neither?” Although these may seem like obvious (perhaps even slightly inane) questions, they are important ones. They help ensure that we are staying close to client experience and not getting out ahead of clients. They invite clients to take a stand on a problem and give voice to a preferred direction in life. As Karl Tomm (1989, 1992) has pointed out, they also mobilize emotional energy in the direction of that stand. Finally, these questions provide an opening for follow-up questions that elicit a richer explanation of that preference. The couple in this example responded that they did not like the effects of the Arguments on their family, and the therapist continued with questions like “What about those effects don’t you like?” “Why isn’t that okay with you?” “What does it say about your hopes for your life together?” These questions draw attention to people’s preferences for their lives and the intentions, hopes, and dreams behind those preferences. They can lead into rich and meaningful conversations. And they provide a segue into coping questions.

Questions about Preferred Coping with the Problems After the couple has taken a stand asserting that the efforts of the Arguments don’t fit with their preferences in life, the therapist can move into questions about how they have resisted or coped with those effects. Examples of such questions include: “How have you stayed together as a couple?” “How is it that the Arguments haven’t completely destroyed your relationship?” “What abilities, intentions, values, and commitments have you drawn on to stay connected to each other despite the devastating effects of the Arguments?”3 Whereas questions about people’s experience of problems and the effects of those problems often elicit readily available information, questions

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about preferred ways of coping often elicit new information. People struggling with a problem are typically more aware of the toll the problem has taken on their life than on the ways in which they are coping with or resisting the effects of that problem. In the process of responding to questions about how they have coped with a problem, new ideas and experiences are often generated. As clients begin to examine their coping with a problem, they often follow their responses with remarks such as, “Wow, I never thought about that before.” In the process, they begin to experience themselves differently. We can then follow up with questions that extend and elaborate these new experiences and the meaning for people’s emerging identity and experience of self. In asking about how clients are coping with particular problems, it is important to anchor that conversation in their preferences. One way to cope with a problem is accommodation (e.g., “I cope with the despair that the Arguments bring by going down to the basement and drinking until I pass out”). Another way of coping with a problem is resisting the problem’s effects (e.g., “I remember the kind of relationship I had with her when we married and I refuse to give that up. When I remind myself of the relationship we used to have, the anger eases a bit, and that’s when I realize how important she is to me and why I want to make this work”). The process of keeping our questioning grounded in preferred coping helps to ensure that we are on the same track with clients and that our assistance is helping them address constraints in ways that move them closer to desired life directions. This outline provides a simple framework for organizing externalizing conversations. We can seek to elicit clients’ experience of constraints and the effects of those constraints on them and on their relationships. Then we can inquire about their preferences about those effects. Subsequently, as we learn about how they are coping with those effects, we can support them in developing different relationships with those constraints and moving toward preferred directions in life. The next section examines the broader context within which problems exist.

INCORPORATING THE SOCIOCULTURAL CONTEXT IN EXTERNALIZING It is important to use language that facilitates consideration of the broader social context of problems. Developing externalizations that are more easily anchored in cultural prescriptions helps to further separate problems from people and access taken-for-granted cultural beliefs that support those problems. For example, Marie, a young white woman who initially came to therapy complaining of depression, began to talk about Self-Doubt. As we examined her experience with Self-Doubt, she

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described a persistent feeling of not living up to various expectations. She described profound expectations, such as “I’m not thin enough, I’m not attractive enough, I’m not making enough money to suit my middleclass parents, and I’m not sexually satisfying enough to my boyfriend.” Inquiring about the Expectations that encouraged Self-Doubt allowed us to explore together the pernicious effects of traditional gendered assumptions about how women should be. We talked about where Marie’s life would be headed if Expectations were to set the direction for her life. She said she thought Expectations would encourage her to “starve myself, get plastic surgery, get a job I hate to satisfy my parents, and become a sexual slave to my boyfriend.” When asked if this seemed fair and whether Expectation’s ideas for her life fit with Marie’s ideas for her life, Marie resolutely declared no. From there, we began examining what direction Marie would prefer to set for her life. Placing Expectations in a larger cultural context had significant effects on Marie. It more clearly located the problem outside of her and helped her to escape the additional burden of self-loathing. Earlier, she had rebuked herself, saying, “Only a real idiot would doubt herself so much.” As she began to focus on Expectations rather than herself as the source of these difficulties, she began to develop a sense of her own agency in refusing to go along with those Expectations. In many ways she began to move from an object that Expectations acted upon to a subject in her own life who began making more and more decisions about where she wanted her life to be headed. Acknowledging the cultural context of Expectations also allowed Marie to develop a more charitable view of her boyfriend and parents as also falling under the influence of Expectations. As she put it, “They’re just caught up in that middle-class success thing, and he’s just worried that he’s not gonna be a real man without some Barbie Doll on his arm.” Marie’s parents were invited in to a session that examined the ways in which Expectations drove a wedge in their relationship. Questions to bring out their hopes for her allowed her to hear the positive intent behind their complaints and helped her to reconnect with them. Her boyfriend refused to come to sessions, but Marie continued in that relationship. Although she had mixed feelings about the relationship, she became significantly stronger in her interactions with him.

DISENTANGLING BLAME AND RESPONSIBILITY At times concerns have been raised that externalizing conversations might collude with clients’ avoidance of responsibility. Some have asked whether, in our attempts to minimize shame and blame, we’ve become

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lax in promoting personal responsibility. This concern requires particular attention to the language we use in examining the relationship between people and problems. In my experience, when people think about being in a relationship with a problem rather than having or being a problem, they often experience both an ability and an accompanying responsibility to begin to address the problem. A colleague once said to me: “When I thought of Procrastination as characterological, it was a great excuse. I always told myself one day I’d get around to dealing with it, but because I saw myself as a procrastinator it felt natural to put it off. Now that I see I can push through it, I realize I don’t have that characterological excuse any longer. Not only do I feel more able to do something, I feel like I need to do something about it. Thinking about it this way has been a welcome kick in the butt for me.” In our culture, there is a tight interconnection between blame and responsibility. Although it is important for people to take responsibility for addressing problems in their lives, blaming them for those problems has never seemed particularly helpful. I do not believe blame is a good motivator for change. The process of externalizing allows a separation of blame and responsibility. By thinking of problems as external entities that try to invite, seduce, or trick us into particular responses, we shift the blame from individuals to problems. Problems can be seen as trying to invite particular ways of being. However, externalizing conversations also open space for clients to consider accepting or declining those invitations. Our language becomes crucial here. It is important to avoid causal language that frames problems as causing or making clients do things (e.g., “How does the Problem cause you to or make you do X?”) and to draw on invitational language (e.g., “How does the Problem encourage you or try to get you or try to convince you to do X?”). It is important to use language that highlights client choice and accountability. Questions that invite clients to consider how the problem’s influence in their life fits or does not fit with preferred directions in life represent powerful invitations to responsibility. These questions offer clients an opportunity to decide for themselves whether to continue to live within a problem-saturated story or to make changes in their life. When clients are invited to take a position in relation to a problem and make their intentions and values known, the process mobilizes emotional energy behind that position. In this way, we can promote responsibility by irresistibly inviting it rather than by demanding it. Attempting to force clients to deal with the issues we think they’re

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avoiding may actually be more likely to “let them off the hook.” As outlined in Chapter 3, our attempts to make clients take responsibility may lead to an overresponsible/underresponsible sequence that rigidifies a client stance of “This is not a problem.” In addition, we run the risk of losing therapeutic focus and providing openings for clients to focus on our “lack of manners” rather than the concerns that brought them to therapy. The use of questions and invitational rather than instructive interaction has the potential to minimize blame (and resulting resistance) and maximize responsibility (and resulting action). The next sections examine this process in more detail with a focus on externalizing conversations in situations of abuse and violence and alcohol and substance use.

EXTERNALIZING CONVERSATIONS IN SITUATIONS OF VIOLENCE AND ABUSE Working with people who have been physically or sexually abusive of others calls for considerable care in externalizing conversations. It is important that our conversations in no way excuse people of responsibility for their actions, and there is general consensus among clinicians who use externalizing practices that it is inappropriate to externalize violence or abuse as a problem (Elms, 1990; Jenkins, 1990; Russell & Carey, 2004; White, 1995). Although externalizing is an attempt to separate people from problems and open space to examine a problem’s cultural context, it does not seek to separate people from their own actions or the real effects of those actions. Thus, although it is problematic to externalize violence or abuse itself, there are some powerful ways in which externalizing can be used to explore relevant ideas, beliefs, and practices. We can think about a man4 who is violent or abusive as being in a mutually influencing relationship with cultural beliefs and practices that may constrain him from relating more respectfully (e.g., ideas such as “I should be the king of my castle,” “My woman should listen and obey me,” “Children should be seen and not heard,” and “I have a right to sex in my marriage” and the practices that accompany these ideas). Although we can hold these beliefs and practices to blame in situations of abuse, we can also hold men who are violent or abusive responsible for the choices they make in accepting or declining these encouragements. Externalizing conversations can become powerful invitations to reflect on the choices one is making in life and the consequences of those choices. There are two important shifts in this way of approaching men who have been violent or abusive. The first shift moves from focusing on

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what causes a man to engage in abusive acts to what constrains him from facing up to his violence, taking responsibility for it, understanding its impact, and developing more respectful relationships (four common goals in working with men who have abused). The second shift moves from the helper challenging those constraints to the helper “irresistibly inviting” the man to challenge those constraints. Alan Jenkins (1990, 1996) utilizes a series of carefully crafted questions to help men who are violent and abusive reconsider their relationship with ideas and practices that constrain more respectful ways of relating. Some of these questions are briefly outlined here, with a particular focus on application to men who are abusive to their women partners.5 In the spirit of believing in possibilities and resourcefulness, we can begin our work with men who have been violent or abusive with the assumption that they would prefer nonabusive, mutually respectful, and caring relationships with their partners, but are constrained from developing those types of relationships by deeply entrenched traditions, habits, and beliefs that influence the ways in which they make sense of and participate in the world (Jenkins, 1990). Examples of these include cultural traditions, habits, and beliefs that promote an imbalance between men and women, encourage men to hold an exaggerated sense of entitlement and status in relation to women and children, and encourage men to look to women to take responsibility for the social and emotional climate of relationships. Chapter 3 highlighted ideas for engaging people who hold a stance of “This is not a problem” by eliciting their intentions, hopes, and preferred view of self in order to develop a proactive focus. Assuming we have done this and there is a discrepancy between a man’s preferred view of self and the effects of his actions, we can pose questions that amplify that discrepancy, such as: “Do you want your relationship with your partner to be one with violence in it, or would you prefer a violence-free relationship?” “Do you want a relationship in which your partner feels safe around you or frightened around you?” “Do you want a relationship in which your partner tells you what she really thinks or one in which she only says what she thinks you want to hear?” From here we can work with a man to externalize constraints to a more respectful, violence-free relationship and offer “irresistible invitations” for the man to challenge those constraints. Examples of questions that offer irresistible invitations for abusive men to examine and challenge these constraints include:

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“Could you handle a relationship in which you control your own violence, or do you need your partner to try to control it for you by walking on eggshells around you? Are you sure? It might be easier to leave it up to her. Why do you want to take control of your violence?” “Could you handle a relationship in which you stand on your own two feet and face pressures when they arise, or do you need to lean on your partner by getting her to look after your feelings for you and calm you down?” “Could you handle the pressure of leaving the old-fashioned blueprint about men and marriage behind and deciding your own future for yourself? Are you sure you’d rather try to build a new relationship or go the easier route and settle for something more acceptable to the guys at the bar?” “Is it important for you to try to earn back your partner’s respect and trust, or do you think she should give it out of duty? How important is it for you to try and earn it back? Would you settle for trying to beg for it back? Demand it back? Con it back?” With each of these questions, it is important to not simply accept the man’s initial response or fall into arguing for an acceptance of responsibility. The goal is to invite him to really reflect on the questions and respond himself to these invitations. After there is a commitment and some energy for moving in a new direction, we are positioned to then help a man begin to consider his readiness to take new steps and begin to develop a plan to promote safety and nonviolence, take responsibility for past abusive behavior, and practice respectful ways of relating. We can return to the simple outline for externalizing conversations and externalize constraints to responsibility, examine their effects on a man who has been violent or abusive, as well as their effects on his relationships, inquire about the degree to which those effects fit or do not fit with the man’s preferences in life (with particular attention to ways in which they may not fit), and stand in support of the man as he begins to shift his relationship to these constraints and live more respectfully.

EXTERNALIZING CONVERSATIONS IN SITUATIONS OF ALCOHOL AND SUBSTANCE ABUSE Externalizing conversations can also be useful to help people reflect on and shift their relationship with drugs and alcohol. Numerous authors have offered ideas about the use of externalizing practices with drugs and alcohol (Crowe, 2006; Man-kwong, 2004; Sanders, 1997; Smith &

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Winslade, 1997; West, 2003; White, 2000). The rest of this section focuses primarily on alcohol, but offers ideas applicable to the misuse of other substances as well. The idea of a person being in a relationship with alcohol rather than being an alcoholic or having alcoholism runs counter to many conventions in substance abuse treatment, but can be very useful. For some people, taking on the identity of a recovering alcoholic has been very useful and, in some cases, lifesaving. I do not wish to diminish those beneficial effects in any way. The following ideas are offered in the spirit of expanding our available options in responding to substance use and misuse and in further examining ways to invite responsibility without fostering blame. We can personify alcohol, using wording that reflects client language (e.g., an older man calls it The Drink, a teenage boy refers to it as Likker, a young woman calls it Seductive Chardy, and a college student calls it My Roommate Al). After developing a name with clients, we can follow the simple externalizing conversation outline, examining the clients’ experience of their relationship with alcohol; its effects on them, others, and relationships; their preferences about those effects (as well as the preferences of important others), and their attempts to resist and cope with the influence of alcohol. It is important to note that although alcohol is very powerful, there are always areas of life that fall outside its influence (days when a person has managed to stay sober or drink moderately, parts of life that have not been taken over by its influence, and relationships that have not been polluted by it). These exceptions provide “windows of opportunity” to develop a different relationship with alcohol (Smith & Winslade, 1997). In the process of examining the relationship between a person and alcohol, it is important to acknowledge the significant support alcohol receives in our culture and the ways in which taking a stand against alcohol in one’s life can be a significant countercultural stance. An appreciation of the cultural support for alcohol brings an awareness of the ways in which a person’s shifting his or her relationship to alcohol can be a major life change, place enormous pressure on the person’s sense of personal identity, and profoundly affect that person’s sense of belonging in his or her particular community. We can think of the process of shifting a relationship to alcohol as a major life transition and turn our attention to helping clients develop communities of support in that process. There are several important considerations in the process of helping a client renegotiate a relationship with alcohol. We can approach an examination of a client’s relationship with alcohol as a process of collaborative inquiry in which we jointly examine all facets of that relationship and approach the project with curiosity rather than preconceived

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conclusions. Generally, the negative effects of substance abuse outweigh the beneficial effects, but if we are going to ask a client to reflect on negative effects of alcohol in his or her life, it is crucial that we are also convey a willingness to consider its potentially beneficial effects. Second, in examining effects, it is crucial that we also examine the effects of a person’s relationship with alcohol on important others in that person’s life (e.g., children, spouse, extended family, work colleagues, other drivers, etc.). We need to actively ask clients how others might describe the effects of their current relationship with alcohol on them and find ways to bring others in to obtain that information directly and provide clients with an opportunity to hear it without needing to respond in the moment. When a person’s relationship with alcohol exacts a devastating toll on those around him or her, it is important that we offer irresistible invitations for that person to reflect on the discrepancy between those effects and his or her intentions, hopes, and preferred view of self. Chapter 3’s clinical example of a no-problem stance highlighted this process in detail. Finally, it is important to appreciate alcohol’s chemical, psychological, and cultural strength and to approach it with caution. The process of helping clients renegotiate their relationship with alcohol rather than prescribe a preordained definition of that relationship opens the question of moderation versus abstinence. In my experience, clients have been able to develop different relationships with alcohol, some characterized by moderation, some by abstinence, and some by a periodic alteration between the two. I wouldn’t want to dictate a priori what is or isn’t possible for clients. However, one of the wonderful things about a focus on abstinence in sobriety is its clarity. In examining different possible relationships that a client struggling with alcohol may develop, there is a danger of minimizing the hold that alcohol has on that person. As a result, it is always important to keep in mind that a client’s preferred relationship of moderation may not be possible and to keep a fallback plan on the table. This ties back to the importance of keeping a focus on both possibilities and risks and taking seriously our professional responsibility to address risks to others as well as to clients themselves.

EXTERNALIZING “STRENGTHS” AND SUSTAINING ELEMENTS IN LIFE Historically, externalizing conversations have been used primarily with problems and constraining elements. However, they can also be productively applied to strengths, resources, and sustaining elements. The ideas in this book are, in many ways, compatible with strength-based

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approaches. However, although a focus on strengths offers more possibilities than a focus on deficits, I think we can take this even further. We can move from thinking about strengths as “belonging to people, as being inside them, as being lacking in some people or as being amenable to growth, harvesting, mining, or extracting” to thinking about them as “achievements, qualities, skills of living, values, hopes, dreams, beliefs, and activities” (Swartz, 2004, p. 61). This shift has been described as a movement from internal states of identity to intentional states of identity (White, 2004). For example, we ask a mother who has a long history of involvement with Alcoholics Anonymous about how she copes with her adolescent son’s outrageous behavior. She replies, “For me, it’s all about serenity. I want to accept the things I can’t change, change the things I can, and be able to know the difference.” Rather than simply accepting her serenity as an internal quality or strength, we can externalize Serenity in order to develop a richer appreciation of how it works for her and its impact on her life and relationship with her son. We can inquire about the abilities, skills, and know-how that constitute Serenity. We can trace the history of the development of this Serenity. We can explore the important people in the mother’s life who have contributed to the development of Serenity. We can ask about the meaning that Serenity holds for her and explore the values and commitments that are linked to it. We can then elicit a rich description of the history of those values and commitments and the existential stance that underlies them. Here are some examples of questions we might ask in this regard: “Can you tell me more about this Serenity?” “If Serenity was not a quality that you have, but something you do, what are the skills that go into it? What, for you, are the practices of Serenity?” “How did you develop those practices?” “How would you like to use Serenity in your life?” “Why is it important for you to use it in that way?” “What values are important here?” “When you think of those values, what hopes or dreams do they reflect?” “What do those hopes and dreams say about what you are committed to or what you stand for in your life?” “As you think back across your life, who do you think might particularly appreciate your pursuit of Serenity in the face of your son’s provocations?” “How have those people contributed to your development of Serenity?” “If they could witness your practice of Serenity, what do you think it would tell them about you?”

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These are just a few of many questions that could be taken up and provide entry into a rich and meaningful conversation. Although externalizing conversations about problems help people to gain some distance from the problems in order to better address them, externalizing conversations about “strengths and resources” can help people develop a richer appreciation of capacities in order to more fully draw on them.

EXAMINING THE RELATIONSHIP BETWEEN PEOPLE AND PROBLEMS Once a problem has been externalized, we can then begin to look at the relationship between that problem and the people affected by it. We can juxtapose the relationship that a problem currently has with a person or family with the relationship that a person or family would prefer to have with the problem. In this examination of the relationship between a problem and a person, we can shift from focusing on the person or the problem to focusing on the relationship between the problem and the person. To quote Sallyann Roth and David Epston (1996): It’s not the person who is the problem; it’s not even fully The Problem that is the problem. It is, to go the whole way, the relationship of the person with The Problem that is the problem! (p. 151)

Focusing on a person’s relationship with the problem as problematic rather than the problem as problematic has a number of advantages. Some problems cannot be eliminated. For example, many chronic medical conditions, such as hypertension or diabetes, cannot be defeated, but they can be managed, kept in their place, or taught better manners. This also holds true for neuropsychological problems, such as autism or developmental delays; for human emotions, such as fear, worry, or anger, that often emerge in everyday life; and for problems such as substance abuse that often make persistent reappearances in people’s lives. Conveying the idea that such difficulties can be eliminated or expelled from our lives may set people up for disappointment and inadvertently support the problem. However, we can acknowledge that people are in an ongoing relationship with particular problems and help them to keep those problems in their place or continue to lead the lives they’d prefer in the face of those problems. In addition, some problems may have positive as well as negative effects. For example, the problem of Evaluation may have potentially positive effects as well as disabling negative effects. In writing this book, I’ve been very aware of the voice of Evaluation. Sometimes, it speaks as

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a paralyzing tyrant with accusations that my ideas are trite, unclear, and irrelevant. At other times, Evaluation has offered thoughtful and provocative comments that have helped me to clarify and sharpen my thinking. Although I wouldn’t want to respond to every criticism offered by Evaluation, some have proven extremely useful. I wouldn’t want to kick Evaluation out of my writing, but I might want to develop a relationship with it in which Evaluation is a supportive editor rather than a scathing critic. Similarly, the following questions could be useful in examining a client’s preferred relationship with Worry: “When is Worry an old friend with good judgment who is looking out for you, and when is it perhaps a bit over cautious and needlessly concerned?” “Which of Worry’s concerns would you like to take seriously, and which would you like to just view with bemusement?”” “When have you been in charge of what you take of Worry’s advice, and when has Worry been in charge of that? Which do you prefer?” In highlighting the potential positive effects of certain problems, I am not talking about problems serving a function for those persons involved with them. There’s an important difference between acknowledging that problems are complex and may have positive as well as negative effects, and contending that those problems then serve a function in someone’s life. The original rationale in seeing the Problem as the problem was that it constituted a counter-practice designed to help us move away from internalizing metaphors (the problem is the person), structural metaphors (the problem is the family organization), and functional metaphors (the problem serves a function for the person or family). If we can clearly separate the problem from the person, a relationship metaphor that focuses on the relationship between the Problem and the person is useful. In this metaphor, the goal is to embrace a both/and position in which we can both help clients and families to hang on to the positive effects of problems and shift their relationship with the negative effects of those problems. In examining the relationship between people and problems, it is important to consider the kinds of metaphors we use to describe that relationship. It is easy to fall into metaphors that tend to foster an adversarial or aggressive relationship between people and problems. Western culture is steeped in dichotomous, oppositional thinking, and when we are supporting someone in redefining his or her relationship with a problem, it is easy to engage in dichotomous thinking (e.g., up/ down, on/off, win/lose). There are two cautionary notes I want to raise here. First, dichotomous thinking can lead clients to experience anything

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short of victory as defeat. For example, in response to the question, “How have you been able to keep Depression in its place this week?” a young woman struggling with Depression might immediately focus on the ways in which Depression has continued to be a presence in her life and experience a sense of failure in response to the question. We need to move beyond polarized binaries and, as Johnella Bird (2000, 2004) has put it, find a “language for the in-between.” In that light, we may want to pose questions such as: “What little bits of movement have you noticed in relation to Depression?” “It’s easy to minimize those bits of movement, but in the face of Depression’s continual onslaught, what do those little bits of movement tell you about yourself?” “How have you managed to accomplish that, and what has helped you to accomplish that?” A second danger is the use of metaphors that foster an adversarial or aggressive relationship between people and problems. It is easy to fall into conversations that seem to be attempts to externalize and then expel or kill off a problem. For example, we can work with clients to silence Critical Voices or kick Depression out of their lives or beat Worry. A number of authors have highlighted the ways in which aggressive metaphors in the externalizing process are anchored in a “power over” metaphor, expressing concern that such metaphors draw on and may encourage tendencies toward domination, competition, and aggressiveness (Freeman et al., 1997; Freeman & Lobovits, 1993; Roth & Epston, 1996; Stacey, 1997). Many of these authors have suggested a shift from confronting and struggling against problems to compromising and coexisting with problems. Militaristic metaphors such as beating, kicking, or thrashing a problem fit with patriarchal ways of being in the world and have the potential to replicate those ways of being at the same time that we are seeking alternatives to them. In our fervor to stand against social injustice, we risk becoming intoxicated with righteousness and replicating ways of being we initially opposed. A central focus of this book has been a movement away from problems and toward life outside of problems. In line with this focus, we can move to a stance that is explicitly pro-person rather than anti-problem. Although this reflects a subtle language shift, it has powerful repercussions in helping to keep clients focused on moving toward preferred lives rather than moving away from problems. An oppositional metaphor of resistance also obscures other forms of resistance. An oppositional metaphor is anchored in patriarchal

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notions about how people resist the influence of problems. Stacey (1997) quotes Aptheker (1989), who critiques the patriarchal notion that resistance to injustice has always required oppositional politics and a struggle for power against those responsible for maintaining social injustices. Stacey suggests the usefulness of expanding metaphors of resistance beyond a protest metaphor and draws on feminist literature to celebrate small daily acts of resistance, such as refusing to submit to others’ pejorative definitions of oneself or continuing to endure in the face of problems. For example, a woman’s continuing to care for her children in the face of depression is an act of resistance to depression. Recognizing small daily acts as resistance to problems helps us to more clearly recognize life outside problems. Finally, our habitual use of oppositional metaphors in the relationships between problems and persons may not fit with families’ preferred metaphors and may be experienced as impositional. For example, Elliot (1998) notes an interaction with a client in which she suggested “standing up to depression” and the client replied, “Couldn’t I sit down with it instead? When I have a disagreement with someone, I prefer to sit down, have a cup of tea, and sort it out.” In this way, it is crucially important to check out the effects of the metaphors we use with families. We can ask clients questions such as whether this way of talking about the problem is working for them, and if not, whether there is another more fitting way that we could use. Our preferred relational metaphors are also deeply embedded in our broader culture. Tomm, Suzuki, and Suzuki (1990), in examining the application of externalizing conversations in Japan, found that Western metaphors of confrontation and struggle against problems were “inconsistent with a basic Japanese orientation of compromise and coexistence with problems” (p. 104). Perhaps we can come into better harmony or balance with problems rather than banishing them. Tomm et al. (1990) contrast outer and inner externalizations. They use outer externalizations to describe conversations about problems that can be defeated, escaped, and left behind, and in which themes of conflict, power, and control tend to prevail. They use inner externalizations to describe conversations in which problems are not necessarily viewed as negative or removable, but are talked about as if some kind of ongoing coexistence may be necessary. They suggest that in situations of inner externalizations, a protest metaphor may work to the detriment of the person and work in favor of the problem. Freeman et al. (1997) suggest that we may want to fit our metaphors to the degree of oppressiveness of a problem, noting that we may want to use more aggressive metaphors with problems that have more serious effects (such as anorexia) and less aggressive metaphors with problems that are less immediately

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threatening. Focusing on the relationship between people and problems opens new possibilities in externalizing conversations. It offers us more flexibility and helps us to better explore the complexity of those relationships. The next section examines some of the difficulties that can be encountered in externalizing conversations.

WHY ISN’T THIS AS SIMPLE AS IT SOUNDS? When clinicians initially try externalizing conversations, they often run into difficulties. They may start by externalizing problems, but can’t seem to sustain the process. Clients don’t “get it” and reject the idea of the problem as something separate from them. Or, despite seeing the problem as separate, clients seem so reluctant to let the problem go that clinicians end up believing that maybe it does serve a function for them. Let’s examine each of these difficulties.

How Do I Keep This Going? Many clinicians initially find externalizing conversations awkward to start and difficult to sustain. Externalizing conversations represent a very different way of thinking. They begin not with what we say but with how we think. Sometimes I have been asked, “But what if the problem really is in the person?” Seeing people as separate from problems is a conceptual device that organizes our work. The question is not “Where do problems really lie?” but, rather, “What are the consequences of thinking about problems as internal or external to clients?” Externalizing is not a technique but a conceptual stance that we take to organize our work in particular ways. As a new stance, it can take a while to fully enter into it. The earlier section “Beginning an Externalizing Conversation” offers a number of concrete suggestions that may prove useful in starting this process. And the simple framework that orients externalizing conversations around four areas (experience, effects, preferences and coping) provides a road map to focus our efforts. It can also be useful to practice this way of thinking in our own lives. As a reader, you might find it useful to view issues that come up in your own life through this conceptual framework: posing questions about your experience of a problem, interaction, belief, or situation; the effects it has on you; how those effects fit for you in your life; and how you cope with them in ways that you prefer.7 This way of thinking and talking about problems can be viewed as akin to learning a new language. No one would expect to develop fluency from brief or intermittent exposure. Fluency often requires deep immersion and time.

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What about When Clients Refuse to See Problems as Separate? Sometimes the invitation to view problems as separate entities is too distant from clients’ experience. Some clients seem to cling to a notion that problems are an integral part of them. For example, Barry was a devoted single-parent father who evaluated his parenting quite harshly and balked every time I raised questions about the voice of Evaluation (even though the phrase came from him). He would typically reply, “This is not something being said to me, this is me saying it. I’m a complete failure as a parent, and I have to come to grips with that.” Barry had previously been in a traditional therapy for many years and had emerged as a self-defined failure because, as he said, “I’m passive–aggressive and refuse to deal with my core issues.” Although Evaluation as an externalized problem did not suit him, he resonated with the idea of a Critical Part that spoke in a very harsh tone. As we talked about the Critical Part of him, Barry was able to talk about its voice, what it wanted for him, and the harshness with which it pursued those aims. We were able to talk about the relationship between Barry and this Critical Part and worked together to help him develop a different relationship with it. Throughout the work with Barry, I continued to view (in my own head) that Critical Part as an externalized entity. Rather than attempting to impose such a view on Barry, I used a language that worked better for him. However, I held onto a conceptual framework (externalizing) that anchored me in a different relational stance with him. My view of Barry as someone who was under attack by this Critical Part (which perhaps had good intentions for him but pursued them with vindictive zeal) helped to position me in a more understanding and compassionate way than if I had simply viewed him as passive–aggressively refusing to address core issues. Externalizing can be helpful as a conceptual device regardless of the language we ultimately use with clients.

What about When Clients See Problems as Separate, but Continue to Cling to Them? Sometimes people view problems in their lives as separate from themselves but have great difficulty shifting their relationship with those problems. They seem trapped in their existing relationship with problems and don’t seem to want to leave that relationship. This can be particularly true in situations in which the problem–person relationship is an abusive one in which the problem’s dictates for the person are oppressive and unjust. For example, Carla was besieged by Bulimia, which took a significant toll on both her mental and physical health. She

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described feeling abused by Bulimia, believed she would always be subjected to its dictates, and showed little apparent interest in shifting her relationship to it. Although I never directly encouraged Carla to “leave” Bulimia, I certainly hoped that she would “file a restraining order” against it. As I became increasingly frustrated with her continued involvement in an abusive relationship with Bulimia, I began to think about the parallels to abusive interpersonal relationships. As Virginia Goldner and colleagues (Goldner, 1998; Goldner, Penn, Sheinberg, & Walker, 1990) have pointed out in their examination of violence in couples, there is often a powerful bond between the partners in abusive relationships. Usually, others view this bond as shameful, sick, and regressive. Often, the bond remains a secret hidden from the world. Paradoxically, attempts to separate the partners in such a relationship tend to strengthen this bond. As the bond goes underground and becomes more shameful and yet compelling, its secretive nature increases its binding power. In their work with couples, they found that acknowledging the power of this bond without pathologizing the partners undercut the bond’s power. In their work with women in violent relationships, they would listen for positive descriptions of the relationship and encourage that description as part of the conversation. They found that when they were able to do that, the shameful bond had a much lesser hold on the women and they were freed up to more easily leave or alter the relationship (if they chose). It is fruitful to apply these insights from abusive interpersonal relationships to abusive problem–person relationships. As I shifted from attempting to “separate” Carla and Bulimia to becoming more curious about their relationship and listened for positive descriptions of aspects of it, I began to develop a better appreciation of the “bond” between them. As Carla put it, “Bulimia is the only thing I can count on. It’s always there. It’s the constant in my life.” As I began exploring positive and negative aspects of her relationship with Bulimia, she was freed up to more openly examine that relationship. As we examined the cultural messages that supported her continuation in that relationship, Carla began to focus on ways in which she felt she was perhaps ready to move on. In this examination of positive and negative aspects of the relationship between a person and a problem, it is important to emphasize that I do not see the positive aspects of a relationship as akin to that problem’s serving a function for the person. Saying that people’s relationships with problems are complicated and have positive and negative aspects is quite different from implying that those people somehow derive secondary benefits from or need such relationships. The first acknowledges the complexity of people’s relationships with problems; the second has the tendency to blame them for the continuation of those relationships.

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SUMMARY This chapter has focused on externalizing conversations as a way to help clients experience themselves as being in a relationship with a problem, rather than having or being a problem. This shift provides clients with some room to move in relation to problems and opens space for the consideration of previously obscured alternatives. Externalizing conversations are an important component of the broader clinical framework I’ve outlined in this book. Once we have gotten to know clients and helped them envision preferred directions in life, we can identify and externalize constraints as “potholes on the road to preferred lives.” We can focus on problems, feelings, interactions, beliefs, lifestyles, life stories, dilemmas, difficult situations, and broader cultural expectations as constraints to desired lives and externalize any of these. The chapter offered a simple outline for externalizing conversations that focused on clients’ experience of a problem or constraint, the effects of that constraint on them, their preferences about those effects (whether or not they like the effects and why), and the ways in which clients cope with or resist the effects of problems. We can view externalizing conversations as a collaborative endeavor to investigate these areas. In focusing on the relationship between a person and a problem, we moved from attempts to externalize a problem and get rid of it, to an effort to examine a problem’s current relationship with a person in order to help that person develop a relationship with the problem that better suits him or her. This gives us more flexibility in our work and in the stances we hold in relation to problems. This chapter outlined a number of special considerations and challenges in externalizing conversations, a process that continues in the next chapter in more depth. NOTES 1. When a particular problem such as Anxiety is described as an externalized entity, it is capitalized to set it off. 2. Within the narrative literature, preference questions have been discussed in the context of “statement of position maps,” in which clients are asked to evaluate the effects of a problem and then justify their evaluation (Morgan, 2000; White, 2005). I refer to them here as preference questions. 3. This item lumps abilities, intentions, values, and commitments into a single question for illustrative purposes. In actual practice, it would consist of multiple questions, exploring each in significant detail. 4. For brevity, this section primarily focuses on abuse by men in heterosexual relationships. 5. A thorough description of this questioning process is beyond the scope of

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this chapter. For readers interested in a more detailed outline of the questions and their development, please consult Jenkins’s (1990) Invitations to Responsibility. 6. This section examines the use of externalizing conversations with alcohol and substances as a way of highlighting considerations about disentangling blame and responsibility. For a fuller description of the actual use of externalizing conversations around alcohol and substances, please consult any of the references mentioned here. 7. Jill Freedman has a very nice exercise that consists of a series of internalizing questions to pose to oneself juxtaposed with a series of externalizing questions (Freedman & Combs, 1996a, pp. 49–50). I have found this exercise very helpful in developing an experiential understanding of the process of externalizing conversations.

CHAPTER 7

Helping Clients Shift Their Relationship to Problems and Develop Preferred Lives

Once we have externalized a problem, we can juxtapose the problem’s influence on the person with the person’s influence on the problem. The simple framework for externalizing conversations in Chapter 6 highlighted four areas of inquiry: experience of the problem, effects of the problem, client preferences about those effects, and preferred coping with the problem. Questions about effects fall into a broader category of questions that attempt to map the influence of the problem on the person, his or her family, and community. Questions about preferred coping fall into a broader category of questions that attempt to map the influence of the person, his or her family and community on the problem. Michael White (1993, 1995) has referred to these two broader sets of questions, respectively, as deconstructive questions and reauthoring questions. This chapter offers a more detailed map for externalizing conversations with a particular focus on these two sets of questions. Deconstructive questions examine a problem’s influence and tactics and attempt to take apart unspoken assumptions and ideas that support the problem’s influence. The story of the problem’s influence on the person is often more evident and can be referred to as the dominant story or plot. This story is often deeply embedded in a client’s life and receives strong cultural support. Deconstructive questions do not directly challenge the problem’s influence, but attempt to bring to light gaps or inconsistencies (exceptions) in the story of the problem’s influence. Reauthoring questions 215

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put together the person’s influence on the problem. These questions seek to bring forth an alternative story or counterplot of the client’s coping with and resistance to the problem. The word “reauthoring” emphasizes the active construction of stories of coping and resistance. The overall flow of externalizing conversations then consists of inviting a separation of people from problems (externalizing questions); taking apart the influence of problems on people, their families, and communities (deconstructive questions); and putting together the influence of people, their families, and communities on problems (reauthoring questions). This chapter examines broad areas to explore in deconstructive and reauthoring questioning. The ideas in this chapter have been profoundly influenced by the writings of numerous authors and build on their work (Dickerson, 2004a; Dickerson & Zimmerman, 1992, 1995; Freedman & Combs, 1993, 1996a, 2002; Freeman et al., 1997; Monk et al., 1997; Morgan, 2000; White, 1995, 1997; Russell & Carey, 2004; White & Epston, 1990; Winslade & Monk, 1999; Zimmerman & Dickerson, 1993, 1994, 1996). In practice, externalizing conversations seldom proceed in a stepwise process from deconstructing to reauthoring. Often the questioning process moves back and forth between an examination of the problem’s influence on the person (the dominant story) and the person’s influence on the problem (the alternative story). The Externalizing Conversations Map (Figure 7.1) identifies areas of inquiry and provides a flexible way to move between them. The left-hand vertical column highlights areas of inquiry for deconstructive questions, and the right-hand vertical column highlights areas of inquiry for reauthoring questions. In a strictly linear flow, one might proceed top to bottom through the areas of inquiry in the left column, move into preference questions, and then proceed top to bottom through areas of inquiry in the right column. However, reality is seldom so neat and tidy, and this map provides a framework that allows us to move more flexibly between topics while retaining an organizing focus. In this way, we can balance focus and flexibility to have a conversation that is well organized and yet does not feel formulaic. We can easily incorporate this map into our work through the notes we take. I routinely, with permission, take notes in sessions and often organize them by drawing a vertical line down the middle of a sheet, highlighting the dominant story (or the problem’s influence on the person) on the left-hand side and the emerging alternative story (or the person’s influence on the problem) on the right-hand side. The map provides a framework that organizes our inquiry. Our notes provide a way to highlight important components of this framework, allow us to underscore important points by reading them back, and provide a foundation for writing therapeutic letters (described further in Chapter 9).

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Questions about the Influence of the Problem on the Person/Family

Questions about the Influence of the Person/Family on the Problem

Tracing the History of the Problem

Identifying Exceptions to the Problem’s Influence

Learning about when, where, and around whom the Problem is most and least likely to show up in the Person’s current life. Learning about the Person’s relationship with the Problem over time; in the past and in the anticipated future.

Mapping the Effects of the Problem Learning about the effects of the Problem in different areas of the Person’s life (e.g., on thoughts, feelings, and spirits; on emotional and physical health; on relationships; and on sense of self and view of the future). Learning about what story the Problem would tell about the Person and his or her life.

Identifying Supports for the Problem

Eliciting events or experiences (however small) that fall outside the Problem’s influence. Finding times or situations in which the Person has some influence and participation in his or her life despite the Problem’s efforts.

Developing an Alternative Story about the Person’s Influence on the Problem Combining exceptions and elaborating details to collaboratively develop a story about the Person’s influence on the Problem with a particular focus on who, what, when, where, and how. Learning about this emerging story over time; in the past, present, and anticipated future.

Elaborating the Meaning of the Alternative Story

Eliciting and elaborating what the alternative story suggests about the Person and what it reveals about the Person’s intentions, purposes, values, Learning about the supports the Problem hopes, dreams, and commitments for his draws on in convincing the Person of its or her life. story. Learning about taken-for-granted cultural assumptions, social practices, and internalized standards that support the Problem.

Exposing the Tactics of the Problem Learning about the strategies the Problem uses to exert influence on the Person and its intentions and plans in those situations. Learning how the Problem convinces the Person of its story and the voice in which it speaks.

Identifying Supports for the Person Learning about who might stand with the Person in developing a new relationship with the Problem and further examining intentions, purposes, values, hopes, dreams, and commitments.

FIGURE 7.1. Externalizing Conversations Map.

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For the purpose of clarification, each area of this map is considered separately here, with specific examples of questions to explore each area. The purpose of laying out specific examples of questions is to concretize the flow of the questioning process rather than provide a recipe of exact questions to ask. Having a set of possible types of questions in mind can be useful, but seeing those questions as a step-by-step recipe results in an unnatural and awkward process. We need to attend to the person with whom we are talking, as well as the questions we ask. The power of externalizing conversations lies in the attitude we hold with clients (reflected in our voice tone, gestures, and stance). The overall flow of the conversation is more important than the specific questions. Although the questions are powerful, they can come off as shallow, forced, and not especially helpful when approached as a technique (Freedman & Combs, 1996a). The questions are more powerful when the person asking them really views clients and problems as separate entities. We need to actively orient ourselves to what might be small openings to life outside the problem’s influence. Thus, examining the influence of the client and his or her community on the problem requires a leap of faith that there is life outside the influence of the problem and that there is always some degree of resistance to that problem’s influence.

DECONSTRUCTIVE QUESTIONS The process of deconstructive questioning has been captured in a bumper sticker that states: “Subvert the dominant paradigm.” In this instance, the dominant paradigm is the story of the problem’s influence in the client’s or family’s life. The goal in deconstructive questions is to undermine the problem’s influence by taking apart the taken-for-granted assumptions and ideas that support it. We can organize deconstructive questions in four broad areas: • • • •

Tracing the history of the problem’s influence on the person/family. Mapping the problem’s effects on the person/family. Learning about cultural and other supports for the problem. Learning about the problem’s tactics and strategies.

A fifth class of questions that are used throughout this process are preference questions. Preference questions can be used to explore a client’s opinions regarding the problem’s influence in his or her life and how that influence fits with the person’s preferred directions in life. Preference questions can be interspersed throughout those other questions and

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help the questioning process become richer and more personally meaningful to the client. Each of these areas is examined in turn.

Tracing the History of the Problem’s Influence on the Person/Family To learn about the problem’s influence, we can begin by finding out about the current context of the problem and, in particular, when, where, and around whom the problem is more or less likely to make an appearance. Using this information as a foundation, we can then inquire about the history of the problem’s influence on individuals and those around them. In the example of Matt and the Itchies, described earlier, we could begin by asking Matt and his mother some of the following questions: “When are the Itchies most likely to show up in your life together?” “In what situations are they more apparent?” “Do you notice them more at home or at school?” “Are you more vulnerable to the Itchies in the morning when you have lots of energy or in the afternoon when you’re tired?” “Are there particular situations in which you might expect the Itchies to be more active?” “Are there particular people around whom the Itchies are more or less likely to show themselves?” “How long have the Itchies been around?” “How has the Itchies’ influence changed over time? Has it gotten stronger, weaker, or stayed about the same? When have you felt stronger in your relationship with the Itchies?” In examining the influence of a problem, we can use scaling questions to get a better sense of the ongoing relationship (e.g., “On a scale of 1–10, how strong would you say the Problem’s influence in your life was 6 months ago? Three months ago? Today?”). This can help therapists develop a better sense of the ongoing relationship between clients and problems. With younger children we can use drawing (e.g., “Could you draw me two circles showing me how big the problem is and how big you are when the problem is at its strongest? Can you draw me two more circles, showing how big the problem is and how big you are when you are at your strongest?”). It’s also possible to use clay or puppets to help children highlight their relationship with problems. Learning about the history of a person’s relationship with a problem is helpful in a number of ways. It helps to elicit the dominant

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story of the problem’s influence over time. In tracing that history, we can develop a richer appreciation for the theme and influence of that story. In addition, when a problem is examined over time and the ebb and flow of its influence is noticed, the problem can seem less fixed and more changeable. Tracing the historical relationship between a person and a problem can also illuminate times when the problem has been less influential and open space for a description of exceptions and consideration of life outside the problem. The word “exceptions” is used here to refer to those events that might fall outside the dominant story line that can serve as openings for an alternative story. The usefulness of exceptions is examined shortly in the section on reauthoring questions.

Mapping the Effects of the Problem on the Person/Family Effects questions seek to understand the toll that a problem has taken on a family’s life. We can explore a problem’s effects on a person, on important others in the person’s life, and on relationships. John Winslade and Gerald Monk (1999) have suggested the usefulness of learning about a problem’s effects in the three dimensions of length, breadth, and depth. Length refers to effects over time (How long has the problem had these effects? Have those effects been getting worse or better? If these effects were to continue, what would the future look like?). Breadth refers to the extent of a problem’s effects (How widely has the problem spread its effects? How many areas of a person’s life have been affected by the problem? How many people and relationships have been affected by the problem?). And depth refers to the intensity of the problem’s effects (How strong have the problem’s effects been? How heavily have those effects weighed on the person? Are there times when the effects have been more or less intense?). Continuing with the example of the Itchies, we could combine these three dimensions with questions for Matt’s mother such as the following: “What kind of toll have the Itchies taken on Matt’s life [e.g., at school, at home, at play]?” “How long have the Itchies had those effects?” “When have you noticed those effects being more or less intense?” “If the Itchies were to continue growing stronger in Matt’s life, what effects do you think they might have by this time next year? How would that affect his education and his future?” “I imagine that the Itchies have also taken a bit of a toll on your life. What’s it been like for you having them in your house?” “How has that affected your emotional health, your physical health?”

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“How has it affected your relationship with each other? Have the Itchies brought you closer together or pushed you further apart? What effects have they had on other relationships?” “If the Itchies were to grow stronger in your family, what do you think might happen to relationships in your family over the next year?” While these are questions for Matt’s mother, we could also ask similar questions of Matt or intersperse questions for both. In posing effects questions, it is helpful to ask about effects across many areas of life (e.g., personal life, school or work life, hobbies and leisure time activities, thoughts and feelings, physical health, mood, energy, relationships with friends and family, and, finally, relationship with one’s self). Broad examples of questions intended to elicit the effects of a problem on one’s relationship with self could include: “What story might this problem try to tell you about what kind of person you are?” “If this problem talked you into believing that story, what kind of future would it hold for you?” “What would it try to get you to notice and not notice about yourself?” “What important things would it try to keep others from noticing about you?” Effects questions support a further externalization of problems and increase the distance between problems and people. As clients consider a problem’s effects, they often find themselves annoyed with the problem and wanting to hold it at bay. Effects questions can help to cast relational strains in a different light and support connectedness among family members. For example, Fred and Ray, the father and son caught in a pattern they described as “that Fast/Slow Thing,” were invited to examine the effects it had on their relationship. Fred described it as “dragging their relationship right down the toilet.” As he and his son talked, they moved from volatile reactivity to connection and compassion. As Fred put it later, “I felt like we moved from attacking each other to attacking that stupid Fast/Slow Thing.” There is often a hot potato of blame that gets tossed around in families (e.g., “It’s your fault.” “No, it’s your fault.”) Effects questions help family members shift from blaming each other to blaming the problem. This shift helps them come together against the problem rather than against each other. When individuals are not feeling accused, it’s much easier to be less reactive and more reflective. In this way, effects questions help to build a containing environment for conversations.

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Effects questions also support the development of empathy and connection in therapeutic relationships. As we listen to the stories that families may tell about the devastation wrought by problems in their lives, we can fall into shell-shocked support (“Oh, you poor thing”) or become instrumental and try to offer solutions or reassure clients that they have strengths and resources. Clients can experience our reassurance as minimizing their experience and respond by trying to get us to see how bad things really are. Effects questions can offer families an experience of someone understanding the pain in their situation in a way that removes blame. In this way, effects questions help us to stay connected to clients’ experience, fully acknowledging it while simultaneously shaping their experience of that pain in a less stigmatizing manner. Finally, questions that explore anticipated future effects have the potential to heighten clients’ resolve to reclaim their lives and relationships from problems. In a conversation with Fred and Ray, I summarized what they had told me about the effects of that Fast/Slow Thing on their relationship and asked them, “If that Fast/Slow Thing continues to get stronger, what do you think will happen to your relationship?” FRED: Kiss it good-bye. Just kiss it good-bye. BILL: What do you think about that? Are you ready to have that Fast/ Slow Thing just kiss your relationship with your son good-bye? FRED: No way. He’s my son. We’ve gotten into some messed up stuff here, but I’m not willing to give up on him. Gregory Bateson (1979) relates a quasi-scientific fable: If you take a frog and drop it into boiling water, it will jump out. However, if you put a frog in room-temperature water and slowly heat the water, the frog will accommodate to the temperature increases, not jump out, and eventually boil to death without really noticing it. This story is an apt metaphor for the growing influence of problems in people’s lives. As we live with the presence of problems, we accommodate to their debilitating effects. Anticipated future effects questions can be useful in exploring with families whether the water that is their life is getting hot.

Preference Questions Although questions about a problem’s influence, effects, supports, and tactics can proceed in a stepwise fashion, preference questions are usually interwoven with the other questions. Preference questions can help a client and therapist learn about whether these effects suit the person or not. Examples include questions like:

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“As you think about the effects this problem has had on your life, what’s your reaction? Would you say these effects are good, not so good, mixed, neither?” “Are these effects something you would like more of or less of?” “How well would you say these effects fit with the kind of life you want for yourself?” These questions help to ensure that we are not making assumptions and getting ahead of clients in our efforts to help them shift their relationships to problems in their lives. If a client’s response indicates that the effects of a particular problem are not problematic for him or her, it’s clear that we need to inquire further before moving ahead and trying to help the person with that problem. If the effects of problems do not fit with clients’ desires for their lives, we have a foundation for further inquiry into clients’ purposes and intentions, values and beliefs, hopes and dreams, and commitments in life. For example, in response to Fred’s statement that he would not want to let that Fast/Slow Thing just kiss his relationship with Ray good-bye, I asked, “Why is that? What is it about this relationship that makes it so important to you?” That question opened up a long, impassioned story about Fred’s disappointing relationship with his own father, the effects that had on his life, and Fred’s hope to develop a different kind of relationship with his son. Fred talked about his desire to have Ray one day look to him as a role model for parenting and his commitment to becoming a father that could serve as a role model for future generations. The process of voicing preferences, intentions, values, hopes, and commitments out loud can be powerful. Preference questions can mobilize and align a person’s emotional responses behind a preferred direction in life and invite poignant reflection on how that person’s actions fit with his or her best intentions and values. Fred’s declaration of his intentions and commitments as a father brought forth a particular pride in his parenting, along with a sense of responsibility to hold to those commitments. The rest of the examples of areas of deconstructive questions will have preference questions sprinkled throughout.

Learning about Cultural Supports for the Problem Problems are embedded in a cultural context and often receive significant support from prevailing cultural ideas and practices. Marie’s struggle against Self-Doubt and the effects of Expectations, described in the last chapter, provide a good example of this support. Expectations’ accusations that Marie was not thin enough, attractive enough, or sexually satisfying enough are all embedded in cultural assumptions about how women should be and look. Although many of these cultural

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specifications have come under increased scrutiny and are being challenged, they continue to have a strong and complex influence. Exposing and critically examining cultural assumptions that support a problem help to further undermine the influence of that problem. Our stance in raising such questions is very important. Virginia Goldner (1992) draws a distinction between raising moral issues in therapy and being moralistic in therapy. She suggests that raising moral issues (asking people about the effects of how they act) is a mark of clinical integrity, whereas being moralistic (telling people how they should act) is a self-indulgent misuse of therapeutic power. This distinction is also useful in examining cultural supports for a particular problem. The goal in illuminating cultural ideas that support a problem is not to substitute some other set of prescriptions for how to be in life (i.e., countercultural specifications rather than cultural specifications). Rather, the goal is to make visible the taken-for-granted assumptions that organize our lives so that clients can examine those assumptions and decide how they actually fit for their lives. To quote Zimmerman and Dickerson (1996): Our intention is to explore the ideas that influence people, not to destroy them; to question them, not to leave persons without an anchor or without some sense of constancy in their lives. Our experience is that discourse can take us away from our experience, or get us to make sense of our experience only against some standard or norm. We believe that by questioning the discourse of influence, we allow people to consider their preferences more clearly, and to decide whether or not the ideas that influence them “fit” for them. (p. 69)

Here is where the idea of being in relationship with a cultural discourse can become particularly useful. The goal is not to sever that relationship but to develop a relationship that best “fits” for the client, as determined by the client. Examining the cultural supports that problems receive helps to put problems in a broader perspective and minimize self-blame. It also makes the difficulty of redefining our relationship to a particular problem more understandable. An example of the process of examining cultural supports for a problem comes from an individual meeting with Fred, the father dealing with that Fast/Slow Thing. FRED: I hate it that I end up lecturing him so much, but when I tell him to do something, he needs to do it. BILL: And what’s it like for you when he doesn’t? FRED: It drives me crazy.

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BILL: I can understand that he should listen to you, but I’m thinking about shifting this a bit and asking about you rather than him at that moment. Would that be okay? FRED: Yeah, I guess. BILL: When he doesn’t listen to you and it drives you crazy, how does that get you to think about yourself? FRED: Like I’m an idiot. I feel like a jerk. BILL: And this voice that’s saying you’re a jerk—what’s it saying you should be able to get Ray to do? FRED: I should be able to get him to listen to me. I should be in control of my son. BILL: And this idea that you should be in control—do you know other men who hear that voice saying that they should be in control? What stands behind that voice? FRED: Oh, you know, that stuff about men needing to be in control and all that. We went on to explore Fred’s thoughts regarding the gender discourse about men and control. He traced some of his experiences growing up, with the idea that “a real man is always in control and doesn’t take crap from anyone.” After a bit, I brought the discussion back to his relationship with his son. BILL: Do you think that Ray as a young man coming of age is influenced at all by that same idea, that men should be in control and not take crap from anyone? What do you think that voice says to him when you get to lecturing him like you described? FRED: (laughing) It probably says the same thing to him, you know, like, “Are you going to let this old fart diss you like that?” It’s a sneaky son of a bitch, that voice of control. BILL: So, if this voice had its way with your relationship, what would happen? FRED: We’d be like two bulls butting heads. But that’s what men do. BILL: It may be what men can do. Is that how you want to spend your time with Ray? [Preference question] From here we moved into a discussion that externalized the cultural idea that “real men are always in control,” looked at the effects of that cultural idea on Fred’s relationship with Ray, and examined how that fit

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with the relationship Fred would like to have with Ray. Fred began to get angry and declared that he was not going to let the “voice of male control” control him. We both laughed at the irony and moved on to talking about exceptions, when their relationship had been more anchored in connection rather than in control battles. I asked which he preferred and which he thought Ray would prefer (he thought they’d both prefer connection). We ended with Fred expressing an interest in talking next time with Ray about how they could move from control battles to connection. In this conversation, the problem moved from that Fast/Slow Thing to the cultural idea that “men should be in control.” In the process, we recycled through a deconstructive questioning process, learning about the new problem’s influence, effects, supports, and tactics, as well as Fred’s opinions and preferences regarding them. In this process, preference questions were particularly important to help me position myself beside Fred and ensure that I was seeking his ideas about the political questions I was raising rather than simply imposing my ideas about his life choices.

Learning about the Tactics of the Problem If we think about problems as separate from people, we can attribute intentions, plans, and strategies to problems and examine the tactics that problems use to exert influence on people. As people are invited to consider a problem’s strategies, they move into an observing position and shift their relationship with the problem. Clients, observing how a problem operates, often describe a certain distance from its influence. As they stand further outside the problem’s influence in an observing position, they can develop a different perspective and experience of the problem. This shift in perspective and experience supports the development of agency in addressing the problem. For example, in Marie’s struggle with Expectations, I asked the following questions: BILL: You’ve described Expectations’ ideas that you are not thin enough, attractive enough, wealthy enough, and sexually satisfying enough. You’ve also talked about how you don’t appreciate those accusations and think they’re, as you said, crap. When Expectations tries to lay that crap on you, do you have a sense of how it does that? MARIE: No. BILL: Does Expectations come up and tell you that it’s going to try to lay that crap on you? Does it give you some warning? MARIE: No, it’d be stupid to be that direct.

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BILL: Why would being direct be stupid? MARIE: Well, if it was direct, I’d know what it was trying to do and then I’d tell it to just shove off. BILL: So, would it be helpful for us to get a better sense of how Expectations tries to lay that crap on you? MARIE: That’s an intriguing idea. I like that idea. 1

BILL: So, if it had a voice, what would it be saying to you? How does it try to build its case for this crap? In talking about a problem’s tactics, it is useful to include the word “try,” which implies that a problem is not always successful and opens space for consideration of exceptions. As this conversation continued, Marie described how Expectations continually made comments that compared her to other women who passed by, particularly when she noticed them catching her boyfriend’s eye. She described the voice of Expectations “running that line that they’re prettier than me, dressed better than me, made up better than me, and all that crap.” We began to talk about Expectations trying to “run that line” on her and the support Expectations gets in our culture. I asked Marie if she’d be willing to do some research on how Expectations “runs that line.” She agreed, and at the next session came in with detailed descriptions of Expectations’ tactics. She also described how studying the tactics of Expectations took away much of its power. As she put it, “Now, when Expectations tries to run that line on me, I can see it coming and I just laugh at it.” An important support in this process came from a woman friend whom Marie told about the research project on Expectations. That woman became excited and joined Marie in an informal support group in which they shared their respective discoveries about Expectations. Marie proclaimed that Expectations didn’t have a chance when they were working together. This again highlights the importance of people drawing on the power of supportive community in shifting their relationships with particular problems. The process of examining problems’ tactics and strategies often brings out clients’ agency in coping with and resisting the influence of problems. For example, as Marie talked about Expectations’ loss of influence over her, I asked if Expectations was losing its influence over her or if she was taking that influence away from Expectations. She paused thoughtfully, and we began to move into a discussion of her influence in relation to Expectations. In the process, a number of exceptions to Expectations’ influence began to emerge. Those exceptions allowed us to move into the kinds of reauthoring questions that are examined next.

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This section has outlined questions to examine the ongoing and changeable relationship that problems have with people—exploring areas of influence, effects, preferences, cultural supports, and tactics. The actual questioning process often does not follow this sequence in a step-by-step progression. It is useful to think about these areas as domains to be considered in a conversation that fits a client’s pace and style. Deconstructive questions take apart the influence of the problem on a person and set the stage for reauthoring questions. Sometimes we can spend little time taking apart the influence of a problem on a person and move quite quickly into reauthoring questions. At other times, when a problem has a significant hold on a person, it is important to take more time and fully examine the problem’s influence in order to open space for the emergence of the person’s influence on the problem. As we have seen in Marie’s situation, the process of taking apart the influence of the problem may open space for an easy transition into reauthoring questions.

REAUTHORING QUESTIONS Problems are often deeply entrenched in people’s lives. They may take up so much space that they begin to define people’s identities and convince them that there is little or no life outside the problems. However, despite the apparent strength of a problem, there are always areas of life that fall outside the problem’s influence. Often these exceptions are small and easy to overlook. The dominant story of a problem’s influence consists of “events in a sequence across time organized according to a theme or plot” (Morgan, 2000, p. 5). The theme or plot of the story line provides a framework for organizing our experience of this sequence of events over time and renders it understandable and coherent. At the same time, events that don’t fit within that theme or plot are “pruned from experience” (White & Epston, 1990). The dominant story of the problem’s influence promotes selective attention to some experiences at the expense of others. Those events that don’t fit within the dominant story are, in a phenomenological sense, nonexistent for people living within the problem’s story. In this way, stories shape our experience and constrain our access to abilities, skills, and know-how that have been obscured by the dominant problem story. At the same time, no single story can adequately capture the complexity of clients’ experience. There are always events that fall outside any story. Reauthoring questions build on these outlying events to help clients develop and live out alternative stories. Based on the assumption that problems are not happening all the time and that people handle

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problems better some of the time, a reauthoring process begins by eliciting exceptions (events that would not have been predicted by the dominant story) and giving them enough attention to make them noticeable. As multiple exceptions are organized in a sequence across time according to an alternative theme or plot, we have the beginning of a broader alternative to the dominant story. The purpose of this process is not to make up new positive stories to replace old problematic ones, but to help clients to develop richer stories that fill in gaps and highlight previously edited-out events and experiences in their lives in order to help them find places to stand in their lives in which they can better access previously obscured abilities, skills, and know-how. We can organize reauthoring questions in four broad areas: • Opening space for alternative stories by examining life outside the problem. • Combining exceptions to the problem’s influence and expanding that story. • Elaborating the meaning of this emerging story. • Developing support for the enactment of this alternative story. The process of reauthoring begins with a search for a point in time, a point in space, or a point of view that falls outside what would have been expected within the context of the dominant, problematic story. Points in time or space are moments or situations in which something different happened and/or clients experienced themselves differently. Points of view are others’ perspectives on clients that fall outside clients’ dominant stories. These points are usually referred to as exceptions, unique outcomes, or sparkling moments, and they provide the foundation for openings that can be developed into alternative stories or counterplots. These moments often emerge and are visible during deconstructive questioning. As we learn about a problem’s influence over a client, we also learn about situations in which the problem’s influence wanes and the client’s influence grows. We can note when exceptions spontaneously arise and begin to build on them, or we can actively elicit exceptions. As we notice exceptions with a client, it is useful to find out whether that exception is preferred by the client, and if so, why. Inquiries about clients’ preferences help to ensure that the newly developing alternative stories fit with their preferred directions in life. These questions are important both to ensure that our work is supporting clients moving in directions that fit for them and as a way to solidify their commitment to those directions. Once we have elicited some exceptions that are in keeping with client preferences, we can begin to work with clients to elabo-

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rate these exceptions into an alternative story by co-evolving a counterplot that links exceptions in time, space, and perspectives within a new theme. In the next sections, two reauthoring situations are described, one taken from ongoing work with an individual and one from a consultation interview with a family. These examples are used to concretize the process of reauthoring, with multiple examples of questions.

THE GIRL WHO COULD Fran was a 31-year-old white secretary who was referred by her employee assistance plan after a run-in with her boss in which she became distraught and angry. She described herself as depressed, disorganized, and intimidated by her boss. She had trouble sleeping and couldn’t focus at work. She was initially reluctant to come for help. In the first session, it was apparent that Depression had a strong hold on her. It had convinced her that she was worthless and unlikable, an accusation supported by an abusive father and a painful school history of being teased and taunted. She felt intimidated by Depression and was convinced she couldn’t deal with it directly. She was also adamantly opposed to taking medication, which had been previously suggested. Depression’s hold on Fran was very strong, and the few exceptions to its influence that emerged were immediately dismissed by her as inconsequential. Fran was also an avid science fiction fan who read voraciously and had seen hundreds of science fiction movies. At our second session, she came in looking very tired after attending a 24-hour science fiction movie marathon. Even though she was exhausted, there was a sparkle in her eyes that contrasted sharply with how she looked at the first session. In the first session, she had mentioned coping with the taunting and teasing as a child by watching hours and hours of science fiction movies on TV. At the time, I had thought of her fascination with science fiction as an escape from painful reality, but I now found myself wondering what science fiction might be an “entry into” rather than an “escape from.” As I was contemplating this shift, Fran talked with anticipation and excitement about an upcoming science fiction conference. In response to a number of questions, she began to describe important responsibilities she would hold at this conference and the crew she would supervise. I asked her to describe the Fran that one would see at this conference, and she replied, “A big kid, a nut who has fun, wears outrageous costumes, and enjoys herself; a girl who is confident and not afraid of people, someone who is friendly and open.” I asked what the members of her crew would add to that description, and she thought they’d see her as

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“in charge and inclusive, fair, kind, and fun to work for.” We moved into a discussion about what she appreciated about those descriptions of her and why that was important to her. I asked Fran for a good title for this story, and she replied, “The Girl Who Could!”2 I was moved and found her a quite different person from the one whom Depression had brought in the previous week. We talked about the conference as sort of a depression-free zone, and the following conversation ensued: FRAN: You know, it’s like I live in a Sea of Depression and there are these Islands of Sanctuary where it can’t get me. Some, like the conference, are bigger islands and some are very small. Some aren’t even islands. They’re like coral reefs where I can just keep my head above water. BILL: Do you like it better when you’re on the islands or out in the sea? FRAN: The islands, definitely the islands. BILL: What is it that you like better about the islands? FRAN: I’ll drown out in the sea. The sea will kill me. The islands sustain me. We moved into a conversation about the hopes and commitments behind this choice for life and anchored it in her struggle against teasing and taunting throughout grade school. Eventually, we returned to her metaphor of islands and coral reefs. BILL: You talked about wanting to get more solid places to stand, like islands. What do you think would need to happen to build some of those coral reefs into islands? FRAN: I need to do what always happens to coral reefs, add sediment— the sediment is the people around me who will help me remember who I am and not get washed away by Depression. This metaphor of Islands in a Sea of Depression shaped our future work together. We mapped the terrain of the Islands of Sanctuary and added the sediment of people around her. The goal in this endeavor was to enlarge and solidify the land mass on which she stood in her life as a foundation for helping her develop a different relationship with the Sea of Depression. In this way, the work juxtaposed Depression’s influence on Fran’s life and Fran’s influence on the life of Depression. All too often in our work as therapists, we focus on the sea of problems rather than the islands of client abilities, skills, and know-how. It is

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an ironic and tragic paradox that our attempts to help often result in therapists and clients learning more about problems’ influence and less about clients’ resistance and coping. Again, it is important not to ignore the influence of problems but to juxtapose the dominant tragic story of the problem’s influence with a heroic counter-story of client agency.

THE FAMILY WITH A SOLID FRAME A spontaneously emerging exception led to a reauthoring process in the first situation. In this second situation, the initial exception was elicited through questioning. The Smith family was a blended white workingclass family with a long history of involvement with multiple helpers. The identified client was Joe, a 14-year-old boy who had spent the last 7 years in and out of residential treatment. He was his mother’s only son, and she had raised him alone after her first husband abandoned the family shortly after his birth. When Joe was 7, his mother married a divorced man with three older children. As the two families came together, significant tension arose and various children’s behavior escalated out of control. For the past 7 years, the family members had been unable to all live together. At the point of this consultation, the intact family consisted of stepfather Bob, mother Jane, and son Joe. The three older children were living with their biological mother. The family had been referred to a home-based family therapy program upon the son’s latest discharge from a residential facility. The family’s dominant story emerges in the following excerpt from a consultation interview: BILL: What was your reaction to the idea of this consultation? JANE: I thought it’d be an excellent idea, because I have to say we’re a very complicated family. I mean we’ve been through so many counselors and therapists, years and years of it, and nothing seems to help. This is the last straw, right here, and there’s gotta be some resolution. BILL: Okay, when you say that you’re a very complicated family and you’ve been through a lot of therapy, what’s your experience of that been? Do you feel that the helpers who have been involved with your family understand who you are as a family? JANE: Yes, they say we’re very complicated. BILL: So, you’ve heard that from other people. JANE: Yeah, in fact there was one counselor who said this family was

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never going to make it. We had worked with her for years and years and she said, “You’re not going to be together much longer because none of you are cooperating.” BILL: What was your reaction to that? JANE: I had to agree with her. I mean there was a time when I said to myself, you know, I’m not much for this marriage either, because things were getting to a point where I just couldn’t stand it. The entire family shared Jane’s story: “We are a complicated, uncooperative family who can’t make it together.” This dominant story had undermined the family members’ life together and was supported by a number of previous family–helper interactions. The following segment highlights the emergence of an exception elicited through questioning: BILL: You talked before about the harder parts of being a family. If there are the easier parts of being a family and the harder parts of being a family, you guys have certainly had your share of the harder parts. How have you hung on to the connection that you just described? JANE: Love, commitment. BILL: But how do you explain that this love and commitment haven’t been washed away with the difficulties? JANE: Believe me, it’s been washed away hundreds of times, but it’s still there. I mean, I love Bob and I love Joe. BILL: So, it’s taken some knocks, but somehow it hasn’t been completely washed away? JANE: Right. BILL: What does that tell you about yourselves as a family? JANE: It just says come hell or high water no one’s gonna stop us, and you know you can be as stubborn as you want, but I’m still gonna stick by you and I’ll be here if you need me. BILL: Whew. You’ve gotten a lot of help from lots of different people and you’ve had a lot of people tell you you’re a very complicated family. If there is one thing that the professionals haven’t understood about you as a family, what would you say it is? JANE: I think they’ve seen everything. BOB: I disagree. I think they’ve seen what’s on the surface, but they haven’t seen the family bond. They’ve missed the fact that the family bond is there. Otherwise, under no circumstances would this

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family have survived this long anyway. What they saw were the changes that they thought needed to be made, and they were very substantial changes. We made an effort to make the changes as best we could, considering who we are. If I attempted to present any more of a change, based on their suggestion, I would stop being who I am. BILL: You know, it’s interesting. I live in a house that’s about 90 years old, and when my wife and I bought this house, it was in disrepair and there were a number of people looking at this house, and what people were seeing was peeling wallpaper, this, that, and the other thing. And what we saw was this house has got a solid foundation. These walls are sound and . . . JANE: It’s got potential. BILL: It’s got potential, yeah, and it sounds like what you’re sort of describing is a number of people have seen the peeling wallpaper in the house that is your family, but they haven’t . . . BOB: That’s right, they seem to miss the frame. I mean, they have valid points. There are a lot of shortcomings in my personality, and there’s a lot of shortcomings in Jane’s personality, but what they failed to see were the offsetting benefits between Jane’s personality and mine. BILL: Well, that makes sense. To go back to that wallpaper, I know in our house that wallpaper was peeling and it looked hideous, but . . . JANE: You took it off and it was fine. BOB: Yeah, when you peeled it all the way down, the frame was still solid just like our family. We went on to examine how they had developed this Solid Frame, in what situations they were most likely to see the Solid Frame, how that Solid Frame had been developed initially in their early years as a family, how it had weathered the ravages of the past 7 years, and what it suggested about their hopes for their family. This developing story, “We are a family with a solid frame that is going to stick together come hell or high water,” holds many more possibilities than the previous dominant story, “We are a complicated, uncooperative family who can’t be helped.” It holds an acknowledgment of difficulties with an appreciation of simultaneous coping and provides a stronger foundation for further work. If we refer back to the social constructionist assumption that identity is constructed in social interaction, we can see the ways in which richer identities for the Girl Who Could and the Family with a Solid Frame are being developed in the course of

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the work. These two examples provide a foundation to explore the process of helping clients develop new lives.

OPENING SPACE FOR ALTERNATIVE STORIES BY EXAMINING LIFE OUTSIDE THE PROBLEM The process of reauthoring begins with focusing on events or experiences in clients’ lives that contradict or fall outside the dominant story. These events often emerge spontaneously. The trick is to listen for them. The beginning of Fran’s alternative story of the Girl Who Could is an example of an exception that could have been easily overlooked. I almost glossed over Fran’s reporting of the movie marathon but was tipped off by the sparkle in her eyes that something important was occurring. That sparkle alerted me to listen to her description of the science fiction convention in a different way. David Epston (1996) has described this as listening with two ears, one attuned to the dominant story and the other attuned to exceptions. If we actively listen for exceptions, we are more likely to hear them.

Discovering Times, Spaces, and Perspectives outside the Problem If we haven’t noticed an exception that spontaneously emerges, we can inquire about events or experiences from other times, other contexts, or other perspectives that fall outside the prevailing influence of the problem. We can focus on past successes or times when clients’ lives were less organized by the dominant story. Joe, in the Family with the Solid Frame, had spent most of the last 7 years in placement. We could begin with a focus on why he couldn’t live at home, or we could begin with a curiosity about times when he had lived at home and how his family had remained connected to him in between those times. This second line of inquiry opens space for the emergence of experiences that don’t quite fit within the story of “We are a complicated, uncooperative family who can’t be helped.” Following are some examples of other questions that use exceptions in time to open up space for the emergence of new possibilities: “Have there been times when Depression has taken less of a toll on your life?” “You mentioned that protective services closed your case 2 years ago, before reopening it recently. What were you doing then that got them to close it?” “How did you manage to get out of that abusive relationship?” “Over the past year, when have you two felt closer?”

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People are different in different contexts. We can search for contexts or situations in which clients act or experience themselves differently as a foundation for the development of richer stories about their lives. Fran’s description of herself at science fiction conferences was quite different from her presentation of self in the first session and provided an opening for the developing alternative story. The following are examples of questions that might be used to inquire about space outside a problem: “In what situations does this problem have less influence on your son? What do you think he is doing differently in those situations?” “You say this problem is the strongest at work—where is it the weakest? What is different about that situation?” “In what places are you two not so caught by that pattern? What’s different there, and how is your relationship different there?” We can also elicit experiences outside the problem’s influence by asking about the perspectives of others. For example, the question about how Fran’s crew at the science fiction conference might describe her yielded further information to support the development of a broader story. Here are examples of other such questions: [In a situation in which a client says, “My grandmother was the one person whom I could always count on.”] “What was your grandmother’s view of you? What did she particularly appreciate about you?” “As your son hears you talking about how you want to develop a different relationship with him than you had with your father, what do you think it tells him about you?” “I know you were not too keen to come here and meet with me. As I think about you doing that anyway, what do you think it tells me about this idea that you’re an uncooperative family?”

What about When Clients Can’t Seem to Find Exceptions? Sometimes clients have difficulty finding exceptions. Because we are asking clients about experiences that fall outside the dominant story and may be phenomenologically nonexistent, this difficulty is not surprising. In response, it is important that we believe there are always exceptions and that we are persistent and sensitive in our questioning. For example, Turnell and Edwards (1999) suggest that we ask questions about exceptions three times before we decide there is no answer. At times, it can be

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helpful to draw on the miracle question or coping questions from solution-focused therapy (de Shazer, 1988; Berg, 1994). The miracle question, as described in Chapter 4, invites clients into imagined futures and provides a way to elicit hypothetical exceptions. The miracle question can be followed by asking the client to describe imagined changes in great detail, which can be followed by questions such as, “What would need to happen to bring that about?” and “When have you noticed bits of that happening?” These questions provide an entry into potential life experiences outside the problem. When clients feel particularly hopeless and discouraged about their plight, coping questions that seek to elicit how clients have managed their difficulties can be useful in opening up space for the development of alternative stories. The following example with another client highlights this utility: CLIENT: It’s hopeless, I feel so beaten down that there’s really no point in going on anymore. THERAPIST: It sounds really overwhelming. How have you managed to cope with all this? CLIENT: I don’t think I am coping. THERAPIST: I can imagine that feeling. But how is it that you continue to make it to work in the morning? CLIENT: I have to get to work. I don’t have a choice. THERAPIST: Well, I imagine it must be very tempting to just blow it off sometimes and just stay in bed. CLIENT: My job’s important to me. Nobody notices it there, but I’m good at it and I need to get there to make sure it’s done right. THERAPIST: If people did notice how good you are at your job, what would they see? CLIENT: They’d see that I’m very responsible and committed and I always get my work done no matter what stands in my way. I’m quite persistent. These questions open space for an examination of the importance of responsibility, commitment, and persistence as well as the skills and intentions that go into enacting these qualities on a daily basis. In searching for exceptions, it is important to start small and look for subtle openings. The direction of the opening away from the problematic story and toward alternative possibilities is more important than the magnitude of the opening. It is also important not to become caught

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up in our own excitement about the possibilities these openings may hold. It is more useful to respond with curiosity than with cheerleading. However, a stance of curiosity does not constitute a position of neutrality. In my own work, I have a definite bias against the negative influence of problems and the constraining influence of problematic stories. My attempts to open space for the emergence of alternative stories consist of a series of active invitations to take up new possibilities. An example of this is shown in my use of the metaphor of an old house with Joe and his family. As Bob talks about the family bond that others have missed, the metaphor of an old house pops into my head. I share this with them with the intention of helping solidify their appreciation of that family bond. It’s important to note that this metaphor was not a preexisting one that I brought into the session, waiting to give to them. It was the first time I had thought of it, and it emerged in the conversation. I used the metaphor to capture an idea that was developing in the room between us. At the same time, I offered it with some concern that it was my metaphor and might move the therapy in a direction that reflected my preferences more than theirs. I was reassured by the fact that both Jane and Bob grabbed the metaphor and ran with it, completing my sentences. I also checked with them a bit later to ensure that this way of talking about their situation fit for them. It is important that the direction in which we are moving in therapy fits with preferred directions in clients’ lives. Although I see myself as actively inviting families into the development of alternative stories, I think it is important to ensure that these stories reflect their preferences. Again, I want to emphasize that a reauthoring process is not a process in which we, as therapists, lead clients out of old, “bad” stories into new, improved stories, but rather one in which we help clients develop more encompassing stories in a way that respects their position as the primary authors and maintains clarity about our position as supportive in this process. The use of preference questions offers a way to ensure that our work is responsive to clients’ preferred direction in life.

DEVELOPING ALTERNATIVE STORIES Exceptions open space for the emergence of alternative stories, but they are not enough. We need to work with families to expand the elicited exceptions into a substantial and coherent alternative story. Freeman et al. (1997) draw on a nest building analogy to describe this process. The process of restorying requires painstaking work. With the ingenuity and care of birds building a nest, we create the counterplot. The therapist

Helping Clients Develop Preferred Lives collaborates with the family to gather and document past tions, hopes, and dreams that stand in counterpoint to dominated story. Strand by strand, actions and ideas are narrative convincing enough to serve as an alternative to saturated story. (p. 98)

239 events, intenthe problemwoven into a this problem-

The development of a convincing narrative occurs simultaneously in realms of action and meaning. Michael White (1993, 1995, 2005), borrowing from Jerome Bruner (1986), proposes that stories have dual landscapes: the landscape of action and the landscape of consciousness, 3 meaning, or identity. The landscape of action is constituted by experiences of events that are linked together in sequences through time and according to specific plots. This provides us with the rudimentary structure of stories. . . . The landscape of meaning is derived through reflection on events in the landscape of action to determine what those events might say about the desires, preferences, qualities, characteristics, motives, purposes, wants, goals, values, beliefs, commitments, of various persons. (White, 1995, p. 31)

As Fran (in the Girl Who Could) described her involvement in the science fiction conferences, she was moving in a landscape of action. She was describing the who, what, where, and when of that story. As she reflected on the description of herself in that story, she was moving in a landscape of meaning/identity, highlighting the intentions and purposes, values and beliefs, hopes and dreams, and commitments that are important to her. Reauthoring moves back and forth between the landscapes of action and meaning/identity. Jill Freedman and Gene Combs (1993, 1996a, 2002) draw on story development questions and meaning questions in their negotiation of landscapes of action and meaning/identity. Through story development questions, people plot the action and content of their preferred stories. Through meaning questions, we invite people into a reflecting position from which they can regard different aspects of their stories, themselves, and their various relationships. These questions encourage people to consider and experience the implications of unique outcomes, preferred directions, and newly storied experiences. In naming the meanings of these experiences, they are constructing them. (1996a, p. 136)

Following Freedman and Combs (1993, 1996a, 2002), I will refer to story development and meaning questions because I think these terms are closer to people’s everyday experience and parallel other distinctions between action and meaning that run through this book. Story

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development questions consist of the common questions of journalism, who, what, when, and where, in order to expand alternative stories. Meaning questions focus on the meaning of the newly developing story in order to further embed that story. Although it is initially helpful to discuss story development and meaning questions separately, the two realms are intertwined and are usually developed simultaneously.

STORY DEVELOPMENT QUESTIONS As we find recent actions that contradict what would have been predicted by the dominant story, we can ask about how the person or family members achieved that action and what steps they took to achieve that action. As Jane (in the Family with a Solid Frame) talked about maintaining the love and commitment that had been washed away hundreds of times but was still there, we could pose questions like the following: “How do you think it is, after these hundreds of times, that you have been able to keep that love and commitment still there?” “What steps have you taken to keep the love and commitment still there?” “If the keeping of the love and commitment still there was not something that just happened, but something that required distinct actions on your part, what steps did you take to make that happen? How did you do that?” “How did you prepare yourselves to take those steps? How did you do that? These questions pull for client agency and are often difficult to answer. They seek a description of events that fall outside the dominant story and are often unstoried. Clients may tend to minimize or discount the steps they have taken. As such, it again is important to trust that there is always life outside a problem and to be gently persistent in our questioning. We can think of this as a shared journey in which we, as therapists, and clients together search for events outside the dominant story and elaborate a thicker, richer, more comprehensive story about these events. We can then ask about other similar actions in the past or in other contexts and inquire about those actions, the steps required to take those actions, and how clients prepared to take those steps. We can also seek to learn about other people who may have noticed, helped, or appreciated these actions and seek to learn more through those people’s perspective. For example:

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“Who would notice the efforts you’re describing here?” “Would they be surprised to hear this?” [If no] “When or where have they witnessed similar efforts on your part? What do you think they might particularly appreciate about those efforts on your part? What do you think those efforts tell them about you?” [If yes] “Would this be a new development from their perspective? Have they ever witnessed your taking steps like this in the past? What do you think this new development might tell them about you?” We can draw connections between these different events in time, space, and perspectives and invite clients to reflect on how these elaborated events fit with their preferred directions in life. These preference questions help to further embed and solidify the developing alternative story. From there, we can move forward in time and speculate about similar possible steps in the future. Questions about future possibilities further invite people into an experience of new possibilities and contribute to a sense of forward motion and accomplishment. Examples of questions to examine new possibilities that were used with the Family with a Solid Frame include the following: “As your Solid Frame continues to grow stronger, what will your life together look like next year?” “Does that fit with how you would like your life to look a year from now? In what ways? What about that feels particularly important to you?” [Preference questions] “How will some of those things you describe first begin to emerge?” “What will you learn about yourselves as that happens?” “If Joe carries this family bond as a foundation with him in his head, how will it affect his return to school?” “What different things might others notice about him as that happens?” The development of an alternative story continually occurs against the backdrop of the dominant story. The pull of the dominant story is often very strong, and it is important to interrupt talk that drifts back into it. We are inviting people to stand in a different story and experience themselves in that context, and it is important that we help to hold them there for the sake of that experience. We can think about this as affirmative action for alternative stories. If we simply listen to the emergence of a fragile alternative story, it is likely to wither in the face of the solidity of the dominant story. As Winslade and Monk (1999) have pointed out, the skill and expertise in this questioning process lies in

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“carefully assembling with the client, a story line that is invigorating, colorful and compelling” (p. 44). Again, it is important to emphasize that this is a joint project. Although as therapists we have an active leadership role in posing questions that will support the development of an alternative story, it is important that this story remains the clients’ story. We need to be continually checking to see whether our work is congruent with clients’ preferred directions in life.

MEANING QUESTIONS As we elaborate the details of alternative stories in clients’ lives, we can also inquire about the meaning these developing stories hold for them. Meaning questions invite clients to reflect on the implications of emerging stories for how they make sense of and experience their lives. Examples of such questions include: “As you think about the events you’ve described, what do you think it says about you as a person? What does it mean to you that you’ve been able to do this?” “How would you describe somebody who was able to do that? Does that description fit for you?” “When you took this step, what were you hoping for? What does that say about your intentions in your life?” “What does that say about what you really care about and value in your life?” “What hopes and dreams stand behind that action?” “What’s important about this for you? What do you think it might tell others about who you are and what you stand for in your life?” “If you were to give a title to this story, what would you call it?” These are unusual questions to answer and often require a mental search for answers. The process of that mental search is very important. In the process of reflecting on particular questions, clients also have experiences of self in the context of those questions. For example, as clients ponder a question about their hopes and dreams, they are likely to experience themselves holding particular hopes and dreams. In this way, questions generate experience as well as yield answers. Meaning questions invite a person into a different experience of his or her life that can have transformative effects. In posing these questions, it is important to use language that is close to clients’ immediate experience. These questions can be very

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evocative. The power of my question to Jane, “What does that tell you about yourselves as a family [that your love and commitment haven’t been washed away]?” lies in the experience of herself and her family that is generated as she considers the question. As she responds, she experiences her family and her role in it in a powerfully different way. This is very emotional for her. Although I am not directly asking about feelings, the process invites a deep affective experience, which is reflected in the tears in her eyes as well as a strong welling of my own feelings. The questioning process can also have radiating effects on other family members. Throughout much of this consultation, the son, Joe, had sat looking bored and disinterested. As his parents began to enact a Solid Frame story, he perked up and began attending with some amazement. It was as if he had fallen into a movie that was much more involving than he had expected. People often respond to meaning questions by talking about strengths or positive qualities. In the Family with a Solid Frame, we could think about that solid frame as a strength its members have. It is clearly more useful for this family to view itself as a family with a solid frame than as a complicated, uncooperative family of people who can’t live together, and that shift alone would be a positive development. However, we can take this even further. As highlighted in the section “Externalizing ‘Strengths’ ” in Chapter 6, we can move from thinking about positive qualities as internal characteristics to thinking about them in the context of intentions and purposes, values and beliefs, hopes and dreams, and commitments and principles in life. Asking about these intentional states helps us develop a richer, more complex alternative story. Michael White (2001, 2004, 2005) developed a useful outline for questions about intentional states. This outline includes questions about the intentions or purposes that shaped a particular action, the values and beliefs that support those intentions and purposes, the hopes and dreams that are associated with those values, and, finally, the principles of living and commitments on which people base their lives. In this hierarchy, each level encompasses the previous level and extends it, contributing to a richer experience. For example, Fran (in the Girl Who Could) describes herself as a very determined person. If we simply think about determination as a strength or positive quality, the conversational possibilities are limited. As a way to further the conversation, we can inquire about the history of her determination, how Fran developed determination, who has supported her in that process, why it is important to her, and how it is connected with important intentions and purposes, values and beliefs, hopes and dreams, and commitments and principles in her life. Examples of these questions include:

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“As you think about your determination to not let yourself get dragged down as a kid by teasing and taunting, what does it tell you about yourself?” “How did you develop this Determination, and who has been helpful in that process?” “As you move forward in your life, what kind of life do you want to build with this Determination?” “Can you help me understand more about what is really important to you in this Determination? What values and beliefs stand behind this?” “What does that say about your hopes and dreams for your life?” “What do you think your stance against unfairness tells me about what you stand for in your life?” These questions help clients articulate their values, hopes, and commitments in life, lead to poignant conversations, and support preferred directions in life.

INTEGRATING STORY DEVELOPMENT AND MEANING QUESTIONS TO SUPPORT THE DEVELOPMENT OF ALTERNATIVE STORIES Story development and meaning questions often intertwine to support the development of richer stories. We can move back and forth between getting the details of a particular event (action) and then reflecting on its implications for identity (meaning). Typically, this alternation begins with an event in the present that feels relevant to a client. We can move from a momentary glimpse of an exception and enlarge and elaborate it through painstaking story development questions. Then we can move to meaning questions and invite reflection on the intentions, values, hopes, and commitments that might be present in that event. From there we can move to another moment in time, space, or perspective, eliciting and elaborating the details of another event. Following that, we can ask meaning questions about that moment. Typically, the questioning process starts in the present, moves back through recent history, perhaps back into distant history, and then forward to the near future, each time collecting details of the story and reflecting on the meaning of those details. In this process, it can be very useful to elicit a title for the alternative story, which captures the story and provides a concise metaphor imbued with meaning. To further exemplify the interplay between action and meaning here, I continue a description of the ongoing work with Fran. Building on her frame of adding sediment to Islands of Sanctuary in a Sea of

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Depression, we began by charting the terrain of existing Islands of Sanctuary from Depression in different contexts in her life. Reflecting on the meaning these events held for her, we juxtaposed her emerging story of the Girl Who Could with Depression’s story of worthlessness (Nobody likes you, and nothing you ever do is right). Moving into the past, I inquired about times when she had hung onto a sense of competence in the face of accusations of worthlessness. She described her struggle to hold onto a positive sense of herself in the face of teasing and taunting throughout grade school (action) and her determination not to get dragged down by the unfairness of teasing and taunting (meaning). Based on concrete details in each incident (action), we learned about her commitment to standing against unfairness and building a life that she believed in rather than a life that others expected of her (meaning). Moving back to the present, I asked Fran where the Girl Who Could was beginning to appear in places outside the science fiction conferences. We discussed various interactions with friends and work colleagues and emergent themes across situations. Fran stated that the common theme seemed to be, “I remember who I am. I’m around people who help me remember that. I like who I am. I’m an original. I’m definitely not a copy, and that’s okay. I don’t have to fit in with everyone else and it’s their problem if they have trouble with that.”4 Again, this led into a series of questions such as the following: “Do you prefer being an original or would you prefer to be a copy? Why?” “What do you particularly appreciate about yourself as an original?” “What helps you stay grounded in your appreciation of yourself as an original and not fall into trying to be a copy of others’ ideas for you?” “Do you think, in our culture today, people are more encouraged to be originals or more encouraged to be copies?” “What do you think gets people to copy others’ ideas for their lives rather than appreciating their own originality?” “What does it tell you about yourself that you continue to be an original in the face of all that pressure to be a copy?” At one point, Fran described herself as a work of art and commented that artists are often their own worst critics. In an attempt to expand this emerging story across perspectives, I asked Fran what she particularly appreciated about the work of art that was her life and what friendly reviews she might get from others who knew her. As we traced various reviews and she reflected on them, the development of her self-

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appreciation became visible in the creeping smile on her face, the lilt in her voice, and the twinkle in her eyes. Again, questions generate experience. After establishing a solid foundation of friendly reviews, I asked her what review Depression might offer for the work of art that was Fran. She described a scathing review, laughed, and decided she might like to keep that one around for amusement. (This was a powerful indication of the shift she was making in her relationship with Depression.) Moving into the future, I asked Fran a number of questions about upcoming possibilities, which included: “What do you think will be some of the next steps you’ll take in the emergence of the Girl Who Could?” “As you do that, what will you learn about yourself?” “Who in addition to you will first notice this?” “What new possibilities will emerge as you do that?” “As your life becomes even more grounded in appreciating the original that is you, what new possibilities will unfold? These questions supported her hope for and confidence in the life she was building. At the end of our five meetings together, Fran described having shrunk the influence of Depression in her life from an 8 or 9 (on a scale of 1–10) to a 1. Although she believed that Depression would always be a presence in her life, she had developed a different relationship with it. She no longer felt intimidated by it and was able to stop its accusations of worthlessness through her own development of a thought-stopping exercise.5 Although Fran wanted to quiet what she described as “Depression’s voice of accusation,” she didn’t want to lose touch with its “voice of sadness.” She had experienced a lot of sadness in her life and believed that sadness “anchored her in kindness, made her a better friend, and gave her more depth.” In containing Depression’s voice of accusation while listening to its voice of sadness, Fran shifted her relationship to Depression in a way that she found preferable. As she described it, stopping Depression’s thoughts helped her to reconnect with her sadness, and being in relationship with her sadness helped her to be less vulnerable to Depression’s effects.

NOT BY WORDS ALONE: ACTION-ORIENTED METHODS TO INVITE THE ENACTMENT OF ALTERNATIVE STORIES Narrative therapy strongly emphasizes language. However, this doesn’t mean that narrative therapy is simply a therapy of words. Many families

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with a long history of involvement with professional services are often seen as “not very verbal,” but this does not mean that they are not expressive. They are often quite expressive, and we need to find ways to interact with them that meets them through the manner in which they express themselves. We can bring more action-oriented methods into this work. For example, a therapist working with an 18-year-old who struggled with impulsivity and difficulty in making plans, began shooting pool with this young man and taught him how to shoot while thinking two shots ahead. In the process, the young man became a planful pool player who was enacting a different story about his life. The therapist was then able to help him expand Planfulness into other aspects of his life. If every interaction invites the enactment of particular life stories, how do we engage clients in ways that invite more liberating narratives? We can engage with clients in concrete activities that invite the daily enactment of different stories and then draw on preference questions and meaning questions to further embed those stories. In the same vein, the process of clients applying for welfare benefits, advocating for a school evaluation, or dealing with children on a supervised visit are all opportunities for us to help clients enact different stories in the process. This emphasis shifts our focus to include the process or ways in which clients experience themselves in an activity as well as the outcome of these activities (e.g., taking up the question of how a mother is experiencing herself and who she is becoming in the process of applying for benefits, in addition to the question of her success in getting the benefits). Similarly, our attempts to expand and elaborate alternative stories do not have to rely on words. Many of the creative attempts to help families involve activities: playing with families, taking kids out for a soft drink, shooting hoops with adolescents, and so on. These are often powerful experiences in which clients can actively enact different stories of identity. The fact that they occur outside the context of “therapists and patients” also has powerful effects. Once therapists step outside the traditionally defined role of therapist, it opens an opportunity for clients to step outside the traditionally defined role of dysfunctional patient. This is especially powerful for clients with long histories of unsuccessful treatment. I spoke with a mother whose son, after a long history of unsuccessful psychiatric hospitalizations, was involved in a home-based program that included a series of activity groups (in which kids and families went to baseball games, went on camping trips, had pizza parties, etc.). This mother found these activities more useful than any of their previous individual or family therapies because, she said, “It gave me an opportunity to see my kid as a regular kid and not a mental patient. In the process, I viewed him differently and he was able to be someone different.”

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SUMMARY This chapter has examined a questioning process to juxtapose the influence of problems on clients’ lives and clients’ influence on the lives of problems. Deconstructive questions offer a way to take apart the dominant story or plot of a problem’s influence and open space for reauthoring questions to put together a richer and broader alternative story or counterplot that includes the person’s emerging influence on the problem. As we engage in a reauthoring process, it is important that we fit the process to clients’ preferred modes of expression. Every interaction we have with clients is an opportunity for reauthoring. The process of helping clients more fully enter into alternative stories and continue their elaboration is examined in the next two chapters. Chapter 8 examines ways to help clients develop and draw on communities to support the enactment of alternative stories. And Chapter 9 focuses on the use of therapeutic letters and required documentation forms to further solidify alternative stories. NOTES 1. This idea of problems having voice and intention is more fully developed in If Problems Talked: Narrative Therapy in Action (Zimmerman & Dickerson, 1996). 2. In response to Fran’s use of the word “girl,” I asked a number of questions trying to take apart some of the cultural assumptions behind it. Fran found the process interesting but for a variety of reasons preferred the word “girl” to “woman” or some other term, and we stayed with her preference. 3. Bruner’s original term was “landscape of consciousness.” White began interspersing “landscape of consciousness” and “landscape of meaning,” moved toward more consistently using “landscape of consciousness,” and subsequently came to use “landscape of identity.” I primarily use “realms of meaning” and “realms of action” to align this section with previous chapters describing constraints in realms of meaning and action. 4. The examination of emergent themes across different situations is very much akin to the development of “grounded theory” in qualitative research and ethnographic interviews (Glaser & Strauss, 1967; Lincoln & Guba, 1985). In this way, this process very much fits with an anthropological metaphor for the interviewing process. 5. Fran had never been exposed to the cognitive therapy technique of “thought stopping,” but her description of what she was doing to stop depression’s accusations constituted one of the clearest descriptions of thought stopping I had ever heard. Her development of a thought-stopping technique highlights the value of eliciting clients’ knowledge before imposing our own. Whereas teaching her thought stopping could have been a useful intervention, honoring her development of it had much more impact.

CHAPTER 8

Developing Communities to Support New Lives

The African proverb “It takes a village to raise a child” could also be applied to the solidification of alternative stories. From a social constructionist perspective, life stories or narratives shape our lives. We live out the stories of our lives in our interactions with others, and those interactions solidify our narratives and further shape our lives. As we begin to enact an alternative story, the presence of a community to witness that enactment takes on great significance. The development of a village to “raise” new stories can be a crucial piece of our work with clients and families. This chapter examines ways to help clients develop supportive communities that nurture the enactment of alternative stories. It focuses on ways in which problems can disconnect people from others who have been important to them and examines concrete ways to develop appreciative audiences that can support the enactment of alternative stories. It explores ways to evoke the presence of important others through reconnection or re-membering conversations, considers the use of reflecting and witnessing practices to develop actual audiences, and concludes with an examination of ways to embed the work of therapy in a broader community of support. 249

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HELPING CLIENTS RECONNECT TO COMMUNITIES OF SUPPORT Often, the presence of problems in people’s lives disconnects them from their social networks. Consider the following examples: A family whose daughter is being discharged from a residential program is concerned about others’ reactions to her return home. They don’t know what to say to their friends and neighbors and dread dealing with the inevitable questions about where she’s been for the past year. The girl, in turn, is convinced she’ll never be able to return to her old school and is pleading with her parents to move to another town. A young woman who has been in therapy for 3 months following her boyfriend’s abrupt ending of their relationship confides to her therapist that he is the only one who knows her boyfriend left her. She feels ashamed and embarrassed that he left her, wonders what people will think, and is finding that there are fewer and fewer places she can go for fear of running into friends who might ask about her boyfriend. A woman calls a crisis line, saying a panic attack has forced her to leave work and come home. Even though she has a loving, supportive extended family, she’s embarrassed to let them know that she couldn’t “tough it out.” She desperately wants to talk with someone, but doesn’t know to whom to turn. In each of these examples, stigmatization, embarrassment, and shame contribute to the effects of other problems by separating people from potential sources of support. The resulting disconnection and isolation strengthen the influence of problems. When people are disconnected from others who have known and loved them over time, it becomes easier to be ensnared in a constraining problem story and lose sight of exceptions to that story. This process of disconnection often receives strong support from dominant cultural ideas about what it means to be a valued person (e.g., strong, independent, and achieving), which can encourage people who are not living up to those ideals to turn away from others at a time when contact with others might be most useful. If problems gain influence when people are disconnected from others, then efforts to reconnect people with a concerned community can powerfully support their efforts to renegotiate their relationship with problems. Recruitment of a “community of concern” can counteract the isolating effects of problems and help people stay in touch with alternative, preferred versions of who they are in their lives (Madigan &

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Epston, 1995). This emphasis on community at times may feel a bit odd for some clients and therapists. Traditionally, therapy has been seen as a place in which clients can disclose and work through painful issues in a private and protected sphere. In this context, confidentiality has been an important protection against exposure and shame. Privacy becomes particularly important when problems are seen as internal to the individual or family. When people are their problems, it is understandable that they would not want others to know about those problems. However, as people experience themselves as separate from problems and as bringing abilities, skills, and know-how to their relationship with problems, they may feel more openness to reconnecting to important others and seeking their assistance. The process of circulating stories of coping and resistance to problems, building support for those efforts, and working in conjunction with others can powerfully enhance therapeutic efforts. In this context, therapy can take on a different connotation. The next section begins an examination of ways to help clients evoke the presence of important others through re-membering conversations.

EVOKING AN APPRECIATIVE AUDIENCE THROUGH RE-MEMBERING CONVERSATIONS As we move through challenging situations in life, it can be very helpful to carry the presence of important others with us. A quick example of this concerns a friend and associate of mine who was accused by a colleague of not being a “real psychologist” because of her unconventional ways of doing therapy. As she listened to this accusation, she thought of a group of associates from across the country whose work she admired and respected, and who in turn highly valued her work. Her reflection on these other unconventional associates brought fond memories and evoked the presence of a supportive community that helped her to stay in touch with a version of herself as a psychologist that she valued. That experience shifted her relationship to the accusation that she was not a “real psychologist.” She became intrigued by the comment and felt as though she had a solid place to stand while reflecting on it. Similarly, our work with clients can benefit from evoking the presence of significant others in their lives. Helping clients connect to and internally hold the voices of an appreciative audience shifts their relationship to problems and supports them in being more the people they would prefer to be. In referring to an appreciative audience, I don’t mean simply a collection of congratulatory cheerleaders, but rather the presence of allies who “get” clients’ struggles in a complex and nuanced

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fashion and are experienced as a supportive presence and potential resource for them. A questioning process to aid in this comes from narrative therapy and is commonly referred to as “re-membering conversations” (Morgan, 2000; Russell & Carey, 2004; White, 1997).1 Re-membering conversations are based on a metaphor of “life as a club with members.” This metaphor originally came from the work of anthropologist Barbara Meyerhoff (1978, 1982, 1986) and is grounded in a view of the self and identity as consisting of an internal community that we each carry with us. Re-membering conversations consist of a questioning process that helps clients choose whom they would like to have more present as members of this internalized community. It is an attempt to help clients recruit members for that community, upgrade or perhaps downgrade particular memberships, and help clients reconnect or deepen their connection to that community. The next section highlights principles of re-membering conversations as I have adapted them through a clinical example.

LIFE SUCKS AND YET YOU SURVIVE Maura, a poor, white, single mother of three children (6, 4, and 3) was in her mid-20s, yet appeared to be in her late 40s. The careworn lines on her face and her smoker’s hack reflected a hard life. Her parents divorced after her father turned to drinking when his career as an air traffic controller was prematurely ended by then-president Reagan’s firing of the striking union members of the Professional Air Traffic Controllers Organization (PATCO) in 1981. Her mother subsequently became an embittered recluse, and Maura spent her adolescence living with an abusive uncle who constantly reminded her of her worthlessness. During that time, her father died of liver cirrhosis. She lost contact with her mother and escaped from her uncle’s house into an equally abusive marriage that lasted only a short while. Maura’s work as a waitress in a local diner was often interrupted by calls from the day care center, complaining about her two younger children’s disheveled appearance, empty lunch bags, and out-of-control behavior. She’d respond to these calls by laying the phone on the diner counter and continuing on about her business. Her response infuriated the day care center staff, who had long since given up on her. I met Maura when she was referred for family therapy as a last step to avoid placement of her children. Her protective worker was skeptical that change could occur and saw the referral as a requisite step before placement. Maura’s outlook on life was summarized in her oft-used phrase,

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“Life sucks and then you die.” Our conversations came to focus in particular on Bitterness and its effects on Maura and her family. In her better moments, Maura believed that Bitterness was an understandable response to a long history of setbacks and defeats, but didn’t like its presence in her life and worried about its effects on her relationship with her children. We searched for exceptions to the influence of Bitterness, and she spoke movingly about her commitment to her children. When asked how she maintained that commitment in the face of Bitterness, she replied, “I may be bitter, but I’m not giving up. Having a life of crap is no reason to stop trying.” We began to talk about her determination to keep on trying to build a better life for herself and her children and moved into juxtaposing a “Life of Bitterness and Resignation” with a “Life of Hope and Determination.” These two phrases captured a much richer set of experiences for her. Then we moved into a re-membering conversation to recruit allies who could support her in developing a Life of Hope and Determination. The following three broad steps provide a conceptual map to organize re-membering conversations with clients: • Finding allies in the client’s past or present who would recognize and appreciate aspects of client life outside the problematic story and/or client life within the developing alternative story. Eliciting the details of the relationship between the client and each ally, the importance of that relationship to the client, and the ways in which the client’s life has been affected by that relationship. • Finding specific times when the ally witnessed examples of the client living outside the problematic story or within the alternative story. Eliciting a detailed story of those events (e.g., who, what, where, when, and how) and their meaning, and inviting the client to hypothesize about the ways in which the ally’s life might have been affected by that witnessing. • Linking the conversation about past events to the present situation and to future possibilities. Attempting to bring the ally’s presence more into the client’s current life to help the client draw on that presence to support the development of a preferred direction in life. The rest of this section uses the conversation with Maura to highlight these steps as they were applied to the recruitment of one ally. It is often helpful to elicit multiple allies in order to develop a community of support that clients can carry with them. The steps illustrated here can be used in conversations about each ally in that process.

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Finding an Ally and Learning about the Importance of That Relationship The re-membering conversation with Maura began by identifying potential allies. BILL: If you think back across your life, who would most appreciate your determination to keep Bitterness and Resignation in its place? MAURA: My grandfather. He had been a labor organizer in the 1950s who stood up against the blacklisting of the McCarthy era. He believed the measure of a person was how that person held onto their beliefs when times got tough. I haven’t thought about him for years. He used to tell me stories about Mother Jones [an anarchist labor organizer who was active from 1900 to 1930] when I was a kid, and he never forgave my father for giving up after Reagan busted PATCO. I asked Maura a number of questions to learn more about her grandfather and their importance to each other (and to determine with her whether she would like to draw on his presence as an ally). Maura described her grandfather as someone who also had a right to be filled with bitterness and resignation, but always found a way to hang onto hope and determination to fight for a better life. She spoke about his importance to her and how she found his Mother Jones stories inspiring. I asked what her grandfather might have hoped to pass along to Maura in telling those stories, and she ventured a guess that he probably knew she had a hard life as a kid and might have been trying to help her find ways to stay hopeful and determined. She talked about how important he had been in her life and became misty-eyed as she thought about him. Learning about the importance of a client’s relationship with an ally evokes that person’s presence and brings the client’s experience of the relationship more vividly into the room.

Eliciting Specific Events and Their Meaning through an Ally’s Perspective Finding particular moments when an ally may have witnessed aspects of a client’s life outside the dominant story or within the alternative story helps to concretize the conversation and make it more meaningful for the client. The conversation with Maura sought out moments when her grandfather might have appreciated Hope and Determination in her life. In response to my questioning, she related a story of getting braces along

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with a friend and the two of them being teased mercilessly by some girls at school to the point of their not wanting to go to school. She talked about finding comfort in the Mother Jones stories and how the stories helped her to keep going. As I asked more about how she responded to the teasing, she described standing up to the girls and telling them to leave her friend alone. After getting multiple details of the story, I asked her what her grandfather might have particularly appreciated about her in that instance. MAURA: (pause) Well, probably that Hope and Determination we were talking about. BILL: He saw that in you then? MAURA: Yeah. BILL: What do you think it told him about you? MAURA: Well, (pause) that I was a pretty strong kid. BILL: That you were a pretty strong kid. What more do you think he would say about that? [The purpose of this question is to invite Maura further into her experience of being that strong kid.] MAURA: I don’t know. I think he was pretty proud of me. BILL: He was proud of you. As you look back on yourself at that age through his eyes, what stands out for you? MAURA: Well, I see a little girl who took a lot of crap but didn’t let it get her down. She just kept going. You know, that’s been the story of my life and I still keep going. This exchange moves back and forth between story development questions and meaning questions to elicit the story through the ally’s perspective and examine the meaning it might hold for that ally. Stringing together multiple stories through the ally’s perspective helps to enrich and elaborate the alternative story.

Linking to the Present and Drawing on the Ally’s Presence for Support As we elicit the details and meanings of multiple events, we can link them to the present situation and future possibilities and consider ways in which clients might want to bring the presence of allies more into their life. These efforts with Maura are illustrated in the following exchange:

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BILL: And if your grandfather were here with us right now, listening in on this story of your life, what would his reaction be? MAURA: It’d be mixed. He’d be angry that I’ve had to put up with so much crap, and he’d be really proud that I haven’t given up. You know, as I’m thinking about him, I realize how much I miss him and his stories. BILL: And if he heard how the message of those stories have continued on with you and had such an effect on your life, what would his reaction be? MAURA: He’d feel like he’d done some good in the world. (smiling) He’d be really happy. BILL: And this commitment to Hope and Determination, is that something you also want to pass along to your children? MAURA: I’m trying. Or at least sometimes, I’m trying. When I get caught up in my moods, I think, “Why bother?” but it’s what I’d like to pass on to them. BILL: Would it be a good thing for your grandfather to learn that the Hope and Determination that he’s passed on to you is continuing to be passed along to your kids? Maura nodded, and when I asked why, she recounted a story about the cutoff between her father and grandfather after her father’s descent into alcoholism following the PATCO strike. She described her grandfather’s disappointment with her father (as well as her own) and talked about how she was now seeing her father as being “beaten up” rather than “giving up.” This made a big difference for her, and she thought that if her grandfather could see his spirit living on in her and her feisty children, it would redeem his faith in the power of Hope and Determination. We talked about ways in which she might reconnect with her grandfather and catch him up on these events. Her grandfather’s virtual presence helped Maura greatly in her relationship with Bitterness and Resignation and in her interactions with other helpers, particularly the day care workers. Maura came to hold her grandfather and Mother Jones as members of a negotiating team in her head as she bargained with Bitterness and Resignation in her life. That helped inoculate her from some of the effects of Bitterness and Resignation and move her life in the direction of Hope and Determination. She became less reactive to the day care workers, began to think about them as fellow workers struggling with difficult jobs, and began to take their concerns more seriously. As she did, they became less reactive to her and were able to develop a more constructive relationship with her. As

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Bitterness and Resignation had less of a hold on her, she developed a stronger relationship with her children and became even more committed to helping them foster Hope and Determination in their lives. This outline is one way to proceed with a re-membering interview. It is offered to exemplify the flow of such a conversation and highlight the thinking behind these questions. It is not offered as a recipe. It is extremely important that clients experience these conversations as a collaborative process engaged in with them rather than a series of questions directed at them, and that clinicians develop a language that fits their own style. Re-membering conversations can be useful in helping clients to develop an actual community of support. In this example, Maura went from carrying her grandfather around in her head to recontacting him and developing an ongoing relationship with him.

What about When People Can’t Seem to Identify Potential Allies? Clients sometimes have difficulty identifying potential allies or team members. Our belief in the availability of possible allies is an important factor in these conversations. It is important that we think broadly and creatively in this process. We can draw on people who have been important to clients in both the present and the past. We can turn to important people who have passed away (the next section offers an example of this). We can search for pets, stuffed animals, or toys that are important allies. For example, an isolated woman who had taken in a number of stray animals was asked about how her animals might experience her compassion and connection; a beloved teddy bear and his worn stuffed rabbit friend became an important team for a young girl struggling with night fears. We can draw on singers, sports figures, movie stars, or other celebrities who are admired by clients. A young boy who transitioned through numerous foster homes was asked re-membering questions about his favorite baseball star who had endured numerous trades over his career. We can draw on historical figures as well as characters from novels or movies. In talking with Maura, who was inspired by her grandfather’s stories about Mother Jones, I asked a number of questions about what Mother Jones might have appreciated about her struggle with Bitterness. This led into a moving conversation about the integrity of Maura’s existential stance of “carrying on in the face of adversity” and her eventual decision to get a picture of Mother Jones, which she began carrying around with her and consulting in difficult times. Finally, re-membering conversations that draw on spiritual aspects of clients’ lives can lead to poignant and powerful conversations.

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USING RE-MEMBERING CONVERSATIONS TO WEAVE TOGETHER MUTUAL CONTRIBUTIONS IN LIFE Re-membering questions often move back and forth between eliciting an account of an ally’s contribution to a client’s life and the client’s possible contribution to the ally’s life (Russell & Carey, 2004; White, 2005). In the first instance, we can pose questions such as: “Can you tell me about your relationship with your grandfather and what made it important to you?” “What contributions did he make to your life?” “How did those contributions affect how you think and feel about yourself?” “As you look at your life through his eyes, how do you think he would describe you?” “What’s it like to be invoking his presence here and thinking about your life through his eyes?” “What of his ‘warm feelings’ for you do you want to hang onto, and what will help you to do that?” In the second instance, we can pose questions such as: “Why do you think your grandfather showed so much interest in you?” “What do you think you might have contributed to his life?” “What do you think your time together might have meant for him?” “How might your presence in his life have affected how he thought and felt about his own life?” “As you think about all that he’s gotten from knowing you, what does it tell you about the person you are?” “If he were here now, listening in on this conversation, what do you think might be going through his mind?” Each of these sets of questions moves through an initial inquiry about one person’s contributions to the other’s life and then examines the meaning of those reciprocal contributions for the client’s developing identity story. The first set moves to “How has your grandfather’s presence in your life shaped who you’re becoming in your life?” and the second set moves to “What do your contributions to your grandfather’s life suggest about who you’re becoming in your life?” The next section highlights this weaving together of reciprocal contributions with another clinical example.

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STILL GOING FOR EACH OTHER Maya is a 16-year-old white girl with a long history of substance abuse who is currently living in a residential treatment program. Her mother, Nina, was HIV-positive, with a long substance abuse history, and passed away within the past year. In her last 2 years of life, Nina entered a rehab program and subsequently became an important presence in Maya’s life before she passed away. In a consultation interview 6 months after her mother’s death, Maya talked about rebuilding a relationship with her estranged father and other family members and her efforts to move toward independent living and an eventual health care career. She identified Cravings as a pothole on the road to this preferred direction in life, and we moved into a conversation about her resistance to Cravings and her work to let others help her with these efforts and make it a communal process. She believed the process of letting others into her life began with letting her mother back in her life. We examined some of the ways in which she accomplished that and then moved into the following conversation: BILL: What effects did letting your mom back into your life have on you? MAYA: A lot of good ones. She was my mom, and because she was a really heavy alcoholic I never had a mom. I never had a parent there, and it was just really nice and I didn’t have to take on a role of being the adult in the situation and it was kind of a nice vacation, I guess. And also, just feeling love from her really affected me because just having her in my life, even for that short period of time, made me what I am today. I learned a lot from her. Like with the potholes, even if you fall into them, you still have to get back up and keep going. I realized she’s done that way more than once, and I think that her being in my life is what has given me my strength today. BILL: When you started to let her back into your life, what effects do you think that had on her? MAYA: I think, I hope, it made her happy. I think that really we helped each other. I think that she really enjoyed being in a mother role, and I think it affected her in a big way. It affected both of us in a big way and a lot of different ways. But, I really couldn’t tell you. BILL: And you said one of the things you had learned from your mother was about picking yourself up from potholes. In what ways did you see her do that? What did she know about picking herself up from potholes?

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MAYA: She’s been doing that ever since she was my age, you know. Her mother left when she was 9 or 10, I believe, because her mother was a severe alcoholic. She had many obstacles in her life along with alcoholism, but she kept getting back up and trying again. And, with her health, she tried to get back up, and she did and she went for it as far as she could. BILL: And if your mom was here somehow listening in on this conversation and hearing you talk about ways in which you have been picking yourself up from potholes, what do you think her reaction would be? MAYA: I think she would be happy. She would agree. She would be proud. BILL: She would be proud. What about it would make her happy and proud? MAYA: That I haven’t given up. BILL: That you haven’t given up. Would she be surprised, or would that be the sort of thing she would have predicted? MAYA: She would have predicted it, yeah. BILL: What does she know about you or has she seen in you that would lead her to predict this? Can you think of a particular situation in which she’s seen your ability to pick yourself up? MAYA: Maybe when she had left to enter rehab and I had to stay with my father. I was pretty down, and then I realized I needed to get myself together and wait for her to come and get me. I did that. I picked myself up, and I have been working my way out of that since. BILL: And as she watched you do that, what do you think that told her about you? MAYA: That I’m like she is. That I can pick myself up and keep going. BILL: So, you’ve been talking about your appreciation of her ability to pick herself up and how that’s something she’s passed along to you. And you’re talking about her seeing that ability in you and recognizing it. So, if she were here now, listening to you talk about your holding that ability, seeing that ability and your giving her some credit for it, what do you think her reaction would be? MAYA: I think she’d laugh and say, “You’re just saying that.” But deep down inside she’d say to herself that it pretty much amazes her. BILL: It amazes her. What do you think she might find most amazing about that?

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MAYA: That she’s been able to pass it on and that she’s been able to do it herself. BILL: And her passing that ability on to you, how has that touched your life? What difference has that made in your life? MAYA: It’s definitely made me a very strong person. It’s definitely made it so I can look at situations and look at the roads I could go down and be able to choose one and get around potholes. We went on to trace out with Maya and two other helpers who were also in this consultation the particular skills and know-how that have gone into Maya’s being a strong person and to explore the ways in which she had to work hard to develop that wisdom. Returning to her mother’s perspective, I inquired about what her mother might think about this hard-earned wisdom and the steps Maya had taken to develop it. This is the conversation that followed: MAYA: Well, I think she would be amazed to hear me believe that I have this ability to move forward in my life and that I was actually sharing it with others. BILL: And as she saw you believing in your ability and wisdom and sharing it with others, what do you think it would tell her about you? MAYA: That I won’t give up, that I can’t give up. Even though she’s passed, I’m still going for her. The reason I know is that after she died, she wouldn’t have wanted me to just sit there and let everything go. You have to keep on with life no matter what. BILL: When you say, “Even though she’s passed, I’m still going for her,” what do you think would happen in her heart to hear that? MAYA: I think she would smile. BILL: And as you sit here thinking about her smiling as you’re still going on for her even though she’s passed, what’s that like for you? MAYA: It makes me . . . it makes me feel good inside. It makes me feel like she’s there for me too. She’s still going for me too. I think we’re still going for each other. BILL: And as you’re still going for each other, would you like to keep her presence in your life going? MAYA: Yeah. BILL: What helps you to do that? MAYA: Just knowing that she’s there. She’s here now. She’s always with me, you know. Just knowing that she’s there.

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BILL: And how does that knowledge help you? How does that help you move forward in your life? MAYA: It just comforts me. It just helps me emotionally to know that she’s still there. She’s an amazing person. BILL: And as we’ve been talking, are there particular things you want to remember about this conversation? MAYA: I want to remember it all. It’s apparent here that Maya benefits from both remembering her mother’s contributions to her life and reflecting on the meaning of her contributions to her mother’s life. As their respective contributions become more tightly woven together, her mother’s presence becomes more available for Maya to draw on for support. As Maya continues to live into an emerging story of rebuilding relationships and developing a life in the community, the presence of evoked witnesses (like Nina) contributes greatly to the chances of this emerging story’s survival and growth. The next section moves to the recruitment of actual audiences and examines ways to utilize witnessing groups as another way to develop appreciative audiences for the enactment of new stories.

RECRUITING AN ACTUAL AUDIENCE THROUGH REFLECTING TEAMS AND WITNESSING GROUPS We can also help solidify emerging stories through the recruitment of an audience to bear witness to the telling of alternative stories and enactment of preferred lives. In this witnessing process, audiences are invited to listen in on a clinical conversation that elicits the alternative story and then offer reflections about what it was like to hear that story. The audience can consist of people who are introduced to clients particularly for this purpose or people who are already known to them. Introduced audiences have historically consisted of various professionals, but can also involve other concerned nonprofessional parties (e.g., other people who have struggled with similar issues and are willing to support a particular client). Known audiences consist of members of a client’s existing community who are asked to listen and acknowledge a story that is told. These situations can be set up informally (e.g., a couple in which one member is interviewed and the other is asked to reflect on what he or she has heard) or formally (e.g., members of a person’s community are invited to listen to a particular therapeutic conversation and are then interviewed to elicit their reflections). Utilization of reflecting teams as a professional practice was originally developed by Tom Andersen (1987, 1991) and colleagues in

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Norway. Andersen, like many in the field, was influenced by the Milan Associates’ use of a team observing behind a one-way mirror. In this format, the therapist and team would meet to hypothesize about the family and plan for the upcoming session. Then the therapist would meet with the family while the team observed behind a one-way mirror (with the family’s knowledge and permission). At some point, the therapist would take a break, go back behind the mirror, and consult with the team to develop an ingeniously constructed intervention for the family (consisting of an opinion, a paradox, a task, an assignment, etc.). Subsequently, the therapist would return and deliver the intervention. After the family left, the therapist and team would debrief the session. This format led to the development of a number of powerful and helpful interventions in family therapy and was characterized by a heady burst of creativity among therapists. Although many families found this structure to be helpful, there were also a number of concerns that arose. For example, in my own experience of providing training within this format, trainees periodically inquired about the effects of this structure on families. I typically responded within the prevailing wisdom at the time and suggested that clients knew the team was behind the mirror, had signed an informed consent form, and often found therapy to be enriched by the team’s presence. Eventually, I wondered whether families might be better judges of their experience of this structure and started to consult them about the effects of this format. To be sure, many families commented that they knew the team was there, that they had signed informed consent forms, and that they appreciated the team as a potential “safety net” for their therapist. However, there were also a number of families who confessed that they felt a little weird that a group of strangers were behind a mirror, apparently gossiping about them, and found it mystifying and disempowering. In the early 1980s, Tom Andersen (1985) and colleagues challenged the anonymous nature of these teams and begin making their deliberations more public and transparent. Andersen had become increasingly uncomfortable with what he perceived as disrespectful ways of speaking behind the mirror and subsequently summarized this discomfort. Looking back it was as if I had a consistent bodily feeling of unease. When finally this feeling found a voice it asked, “Is this the way you want to be with people?” This was a question I pushed away for some time, but it was relentless. “Is this the way you want to live your professional life?” it asked until I had to answer and I said “No.” (Andersen, 1999, p. 6)

In March 1985, Andersen and his colleagues came out from behind the mirror. During the time when a team would normally talk behind the mirror about a family, they instead switched positions with the family

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and invited the family to listen in on their speaking. Anderson described how this switching of positions changed the relationship between the team behind the mirror and the family on the other side of the mirror. We were not the hidden experts anymore. We were one of two equal parts. Many things surprised me. I thought that if we spoke out in the open we’d speak in the same disrespectful ways as we did when we were hidden. That did not happen. The reversal . . . changed the ways in which we spoke. I realized how much the context in which we speak influences how we speak. I was surprised what a difference it made to be visible. It is being hidden, being isolated professionals within a separate conversational space that makes it so easy to speak disrespectfully. If we choose to speak about families without them present, it is so much easier to speak “professionally” in a detached and disrespectful manner. If we choose to speak about families only in their presence, we are more likely to use everyday language in more respectful ways. (Andersen, 1999, pp. 7–8)

The shift from a team coming up with the “best” intervention for a family to a team offering the raw materials of their thoughts and reflections and letting the family decide what might best fit for them represents a dramatic shift in therapeutic positioning. Professionals on reflecting teams are responding as appreciative witnesses rather than as experts who know what might be best for families. This shift does not disavow professional wisdom, but suspends the imposition of that wisdom in this context. Team ideas are viewed as additions or expansions to client ideas. The process is characterized more by thoughts, images, and imaginings than by evaluations, judgments, or explanations of what was observed (Griffith & Griffith, 1994). As such, it is useful to frame reflections tentatively with qualifiers such as “I was wondering,” “perhaps,” or “possibly.” The goal is to present a family with a smorgasbord of ideas from which they can choose what best fits for them. Andersen (1999) described this as a movement from an ethic of control toward a more “democratic therapeutic relationship.”2 Freedman and Combs (1996a, p. 171) have suggested “literally changing places with clients and talking openly about multiple ideas may be the most dramatic example so far of the difference it makes to bring a postmodern worldview into the therapy room.”

THE ORGANIZATION OF REFLECTING TEAMS The general setup for the use of reflecting teams with professional audiences is one in which a therapist or consultant interviews a family while a team silently observes (either behind a one-way mirror or off to the side). Generally, the reflecting team consists of three to four people and

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can include a subset of the team behind the mirror. At some point, the reflecting team members change places with the family and have a conversation among themselves (or are interviewed by the therapist/ consultant) while the family silently observes. Finally, the family members comment on (or are interviewed about) the team reflections. This process involves an alteration of speaking and listening with a strict boundary between the two. When people are in a listening position, they are strictly in that position. When people are in a speaking position, they are strictly in that position. There is not a direct exchange between family members and team members. Although this structure can sometimes feel a bit awkward, it is deliberately designed to hold the family in a listening position and create a space for quiet reflection on team comments. The structure offers family members an opportunity to eavesdrop on the team’s conversation, take it in, and ponder the thoughts and experiences triggered for them. To support this reflective process, it is important that team members speak to each other (or to the therapist/consultant interviewing them) rather than to the family members in order to maintain a separation between the speaking and listening positions. A concrete way to accomplish this is for team members to look at each other and not make eye contact with family members during reflections. Engagement through eye contact can be an invitation for family members to respond, which pulls them out of a reflective listening experience. In introducing a reflecting team format, it is important to tell the family that the team members will be speaking only with each other and to explain the rationale for this practice. In the course of reflections, it is important for team members to ensure that everyone in the family is included in the reflections in some way and that no one is omitted. It is also important for the reflections to be short and to the point. Generally, it is useful to not exceed 15 minutes of reflections. Anything longer runs the risk of losing the family’s attention and diluting the impact. Although it can be easy for team members to become caught up in their own conversation, it is crucial to remember that the reflections are designed to serve the family and to remain disciplined in offering them. At the completion of team reflections, the family members respond and may also be interviewed about their experience of the reflections. Clients can be asked to comment on reflections that particularly caught their attention or seemed helpful and can be interviewed about the meaning of those reflections for them. The interviewer may ask futureoriented questions that explore possibilities opened by the reflections and encourage the family members to reflect on how being an audience to the reflections might affect their lives in the future. The interviewer may also share his or her responses to the reflecting team’s comments. Narrative practitioners often add a fourth part to this process,

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consisting of a shared debriefing of the experience between clients and helpers (Madigan, 1993; White, 1995, 2000). This is typically framed as an opportunity for the family to get a “behind the scenes” view of what the interviewer and team members were thinking during the consultation, and is offered as an option that a family can choose to participate in or not. Often team members ask the interviewer or consultant about the thinking behind his or her questions. The interviewer can then ask team members about the thinking behind their reflections. This usually opens into a more general examination of the interview itself. The purpose of this part is to support a more transparent process and help family members develop a richer understanding of professional thinking as well as make that thinking more accountable to the family. At the end, it is important that clients or family members have the last say about what was more and less helpful in the whole process. Generally, clients have appreciated the openness and inclusion of the debriefing section and found it additionally helpful.

THE DEVELOPMENT OF OUTSIDER WITNESSING GROUPS The use of reflecting teams and witnessing practices has been picked up by a number of therapists around the world, who have continued to adapt and expand them. One strand of reflecting practices that has particularly influenced my own work has been the development of outsider witness groups in narrative therapy approaches (Morgan, 2000; Russell & Carey, 2004; White, 1995, 1997, 2000, 2005). When Michael White was initially introduced to reflecting teams and the work of Tom Andersen by Karl Tomm in the late 1980s, he was both intrigued by the inherent possibilities and concerned that simply shifting professional speaking from a private context (behind the mirror) to a public context (in clients’ presence) would not sufficiently mitigate the embedded power of professional ways of speaking and ran the risk of replicating and extending unacknowledged power discrepancies (White, 1995). This concern parallels my own experience of introducing helpers to reflecting team practices. Initially, many professionals have difficulty in shifting their ways of speaking. It’s easy to slide back into ways of speaking in which many of us were socialized. We can find ourselves (despite our best intentions) using professional jargon, speaking in objectifying ways, devoting more attention to problems than possibilities, and attempting to help clients see something we deem important. When we fall into these ways of speaking, we can exacerbate power discrepancies and have negative effects on clients’ lives. As Griffith and Griffith (1994, p. 161) have pointed out, “Anyone who has accidentally overheard

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oneself discussed in a derogatory manner in conversation knows the power of the reflecting position for magnifying hurt.” To address this concern, White sought to shift the assumptions and practices that organize reflections. He drew on the work of Barbara Meyerhoff (1978, 1982, 1986), a cultural anthropologist who had studied an elderly and poor Jewish community in Venice, California. Many of these individuals had immigrated around the turn of the century, outlived their children, and lost their extended family in the Holocaust. They were isolated, relatively invisible to the community around them, and at risk of becoming invisible to themselves. In response, they developed a series of rituals to tell the story of their experiences and have others (referred to as “outsider witnesses”) listen to and acknowledge those stories. Meyerhoff (1986, p. 267) described these rituals as definitional ceremonies that “provide opportunities for being seen, and in one’s own terms, garnering witnesses to one’s worth, vitality and being.” White adapted Meyerhoff’s ideas to a therapeutic context and utilized a familiar reflecting team format to provide a ritual for acknowledging and bearing witness to the emergence of alternative stories and identities that were at risk for being obscured in the surrounding world.

WITNESSING AS ACKNOWLEDGMENT: THE DEVELOPMENT OF TWO-WAY SHARING Clients have reported that the use of witnessing groups has been most powerful when witnesses have commented on how they have been touched or moved by client stories, especially when those comments are explained in the context of events in witnesses’ own lives and work (Russell & Carey, 2004). An example of this type of client response comes from the consultation with Susan, the mother in Chapter 5 who worked so hard to disable the Bad-Parent Button. That consultation interview elicited both steps she had taken to disable that button and potential lessons for other parents and helpers. At the conclusion of the interview, a witnessing group spoke movingly about what they had learned from her. In response, Susan commented: “It’s amazing. I’m not alone. Someone sees the life that everyone keeps telling me I’m making up. They get it and see me as having made some progress and having something to offer others. I’m glad that what I’ve been through is useful to others. I will carry these voices around with me for some time, and my hope is they can continue to grow and crowd out those critical voices in my head.”

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Comments such as these have led to an increased focus on metaphors of “resonance” and “transport” within outsider witnessing practices. An analogy I have often used to describe these metaphors with both team members and families is to cast the interview as a pebble dropped into a still pond. Ripples emanate out and pass through the persons bearing witness. The witnessing process then is a process of acknowledging those ripples and bringing them back to clients. In acoustics, “resonance” refers to the intensification and prolongation of a sound. Drawing on this metaphor, we can intensify and prolong the ripple effects of the therapeutic interview by having witnesses share back stories of how they were moved (or transported) in the process. We can ask witnesses to attend to what resonated for them and how they were moved by what they heard. White (2005) has offered a map for this process. The questions below are an adaptation of that map that I have used in numerous settings.3 “What did you hear in this conversation that captured your attention?” “How does that connect to events in your own life or work?” “How have you been moved by hearing this conversation, and what from this conversation do you want to carry back into your own life or work?” The questions can be used as a general framework for organizing witnessing responses or as a guideline for interviewing team members. I’ve often found it useful to interview reflecting team members who are newer to this process in order to limit the tendency to slide into instructive ways of speaking that may be more professionally congruent. The next paragraphs offer contextualizing information and examine these three questions in more detail. They are followed by an example of a witnessing team conversation. In responding to these questions, it is helpful for team members to frame their comments in a way that recognizes the privilege of having clients share their stories with them, acknowledges clients’ experience of the difficulties they are describing, and honors clients’ efforts to deal with those difficulties. As professionals, we can often fall into believing that our roles give us a right to the intimate details of clients’ lives. Reflecting teams began as an attempt to create more respectful ways of interacting with families and break down the “us and them” divisions that can arise. It is important that reflections are grounded in a thorough appreciation of a family’s members willingness to share the stories of their life, along with our willingness to be moved and changed by those stories.

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The first question invites witnesses to attend to what stood out for them in the interview. It is important to be specific and concrete in responding to this question and to draw as much as possible on the particular phrases and language used by clients. Often, clients’ stories contain painful and complicated elements, and Bill Lax (1995, p. 147) has observed that reflections can sometimes have a “watered-down feel or pretend aspect with reflectors repeatedly using words such as ‘struck,’ ‘taken by,’ ‘impressed with,’ and ‘touched’ and then followed by an overly positive (and Pollyanna-like) remark.” It is important that our reflections convey an understanding of the seriousness of problems faced by clients and an appreciation for how overwhelming situations may feel. At the same time, it is important to couple the acknowledgment of difficulties with an attention to exceptions, coping, and implicit possibilities. The second question invites witnesses to place their comments in the context of their own work or life experiences. This question deserves a bit more explanation, as it goes against the grain of many taken-forgranted professional ways of speaking. Reflections are more powerful when they are explained in terms of events in team members’ own lives or work. Letting clients in on the personal and/or professional experiences that shape these reflections grounds those comments and gives them more credibility. It shifts reflections from generic comments that can hang in the air to experiential comments being offered by a real person. When team members place comments in the context of their own life experience, it is important to both be specific in describing the ways in which the story was moving or powerful, and remember that their speaking is for the benefit of the client. It is important for team members not to go too deeply into their own contextualizing experiences and to remember that the purpose of situating comments is to deepen the reflection, not to change the focus of the conversation. It is crucial that clients remain at the center of reflections. The third question invites witnesses to reflect on how they have been moved, transported, or changed as a result of hearing clients’ stories. Responses to this question let clients know that their story has affected others. In the process, it is important for witnesses to speak personally and honestly rather than come across as disingenuous or insincere. In order to accomplish this, it is helpful to listen with an openness to being transformed in the process of witnessing. The following example highlights the use of these questions to organize reflections. This example comes from an interview of a reflecting team that witnessed the re-membering conversation with Maya described earlier in this chapter. After the conversation with Maya, I outlined the ripple metaphor and reiterated the three questions. From there, they began to speak.

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ANN: I can go first. I was here for the last consultation a year ago, and the first thing that crossed my mind was how different Maya looked here. I didn’t recognize her at first, and it seemed like there were three women here [Maya and the two helpers in the consultation] rather than two staff and a teenager. I saw a woman who was growing up, who seemed very confident with herself, and I would have to use the word “fearless.” I felt like Maya bared her soul here and was honest and fearless. BILL: And what for you was that like to witness this fearlessness? ANN: It was very emotional. She really stirred up a lot for me. I work with a lot of teens in my work, and it helped me to see what a struggle it is being a teenager in placement. It’s like you want to be a teenager and say, “Leave me alone, I can take care of things.” And then you realize it’s helpful to get support. So it was powerful for me to hear her talk about that challenge. BILL: And as you listened to her description of that challenge, are there particular things you want to take back to your work? ANN: I think more of a respect for teens going though that process. I want to be more sensitive. I want to look for times when we can back off and allow them to make more decisions and better appreciate what they’re going through in their lives. BOB: You know, Ann, it’s funny that you’re talking about fearlessness because that really resonated for me as well. I thought about how incredibly frightening so many of Maya’s experiences must have been or could have been or certainly would have been for me, and how Maya was really able to deal with them and to seek out others for help. It really hits me because I’m in my 50s now and struggling with some midlife issues and thinking back on how much of my life has been controlled by fear. I heard Maya talking about alcohol and drugs and who’s in control, the alcohol or her. Some of those same areas resonate for me, not with alcohol, but fears of different things. It was important for me to hear someone so young and yet so wise be able to speak so eloquently about those experiences. It’s inspiring, and I want to remember her as I face my own fears. RITA: I guess the thing that stuck out the most for me was not only how brave Maya was, but looking back, how brave her mom, Nina, was to give them those 2 years together. I know Nina was working very hard on getting her life together, and in a lot of ways it could have been easier to do that by herself and not try to get Maya back. I worked with them during those 2 years, and I know it wasn’t easy. It was hard for both of them in different ways. And when you

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asked, “What would your mom’s reaction be hearing and seeing this today?” the word “proud” really came up. And I have to believe that hearing this, Nina might also feel successful that she raised a good girl, and would be very proud of Maya. BILL: And since you have had a special relationship with both of them, what was that like for you to hear? RITA: Part of it was hard, because Maya has her mom’s laugh and I could hear that and miss her mom. There was a vivaciousness and spirit about Nina that Maya is the embodiment of. Nina hit a lot of potholes in her life, and she dug herself out of them and kept going, and I think she would be so happy to know that ability is still alive in Maya and that maybe she had something to do with it. And Maya has learned some things a lot earlier in life than Nina did as far as getting through potholes, and I’m very moved by that. I guess the other thing that stands out for me is the value of the relationship between parents and children. As a professional, it’s easy to judge and look and say, “This isn’t healthy and you need to be the parent,” and all the clinical things we say and do. But the power and value of that relationship goes far beyond anything we’re going to say and do. And I’m reminded of the need to remember and attend to that. BILL: And as you think about carrying that realization back into your work, are there particular things from watching this that you want to hang onto and carry back with you? RITA: I guess one thing that sticks out is that families sometimes need to struggle, and our desire—or my desire—to fix things won’t solve things. Sometimes people need to go through their struggles and it brings them closer together, and I can’t short-circuit that. I want to focus on appreciating what people have been through rather than just trying to fix them, and I really thank Maya and Nina for that. At the end of the reflections, Maya was very moved by the process and glad she had participated. She appreciated that team members understood what she was trying to say, was moved that her speaking affected others, and was amazed that she had made an impact on people’s thinking. Afterward, she went into the other room where a much larger group had been observing and was further moved when it became apparent that the ripples of our conversation had also permeated that room. Six months later, Maya was continuing to move forward in her life with her mother’s accompanying presence and considered the consultation interview and witnessing comments important in that process.

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DISTINGUISHING ACKNOWLEDGMENT FROM APPLAUSE Witnessing practices based on acknowledgment represent a further shift in professional positioning. The purpose moves from trying to be helpful to the members of a family (by helping them solidify alternative stories) to recognizing the ways in which the family members have been helpful to the witnesses (by acknowledging how witnesses’ lives have been enriched by hearing their story). At the same time, the family is at the center of these reflections, which are ultimately offered to benefit the family rather than witnesses. The key issue here is not who is helped in the process (it clearly is a two-way process), but how clients and witnesses are positioned with each other in this process. White (1997) speaks about the importance of not engaging in “the applause” (pointing out the positives, congratulating people on the steps they have taken, giving positive reinforcement, etc.). Although applauding people’s positive steps in life can be grounded in good intentions, clients may experience the process as condescending or patronizing. This experience can invite a minimize–maximize sequence in which clients may perceive witnesses as suggesting, “Don’t you see how resourceful you are?” and may end up responding with a version of “Don’t you see how difficult my life is?” Although people may dismiss praise (“Oh, you are such a resourceful client”), they are more likely to accept acknowledgment (“Here is how I’ve been touched by what you’ve said”). This is not to demean applause in general (there are clearly contexts in which a standing ovation is a welcome response), but to limit it in this context. Pointing out the positives may be more useful than pointing out the negatives, but even in pointing out the positives, there is an upholding of judgment. As witnesses, we are still judging people and measuring them against our standards, which places us in a position of superiority and exacerbates hierarchy and power discrepancies. This can have disempowering effects on clients. To summarize, acknowledgment is not about congratulating people, but rather about expressing what it has meant to witness their story, why that is so, and how we have been moved, encouraged, or inspired by them. This clarification of the stance from which we speak is important both when professionals are bearing witness and when we are asking people from a client’s community to bear witness. The next section moves into witnessing practices that draw on clients’ own communities.

WITNESSING GROUPS THAT DRAW ON CLIENTS’ COMMUNITIES This section highlights a witnessing group that utilized a mother’s friendship network to support her in becoming more the parent she wanted to

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be and highlights organizing principles for similar efforts. Donna was a stay-at-home white working-class mother whose daughter, Grace (14), had been plagued by debilitating anxieties, worries, and fears for the past 5 years. Her husband, Keith, worked for the postal service and spent much of his free time alone in their basement on the computer. At one point in our work together, Donna talked about ways in which the combination of blame, frustration, and guilt made it hard for her to deal with Grace. Grace would blame Donna for difficulties in Grace’s life, Donna would respond with frustration at the accusation and subsequent guilt that she had failed as a mother. This combination was demoralizing and undercut Donna’s relationship with Grace as well as her sense of herself as a mother. The combination of blame, fear, and guilt was externalized and given the name “The BFG” by Donna (taken from the title of a Roald Dahl book that Donna had enjoyed reading to her daughter about a girl who overcame her fear of a big, friendly giant and then worked with him to vanquish other giants who were terrorizing children). Several meetings helped Donna begin to develop a different relationship with The BFG. Although she made progress in this regard, she also felt that it was a big challenge for her alone. We began to search for possible allies to support her. Keith was helpful, but often fell into trying to “fix” things in their family and then getting frustrated with his limited success and withdrawing. Donna mentioned a group of women friends who periodically met over coffee and doughnuts to share mothering stories. Keith had been encouraging Donna to draw more on this friendship network, and, while continuing to involve Keith, we explored whether the member of this group might also be helpful to Donna and decided to invite them to a meeting as a witnessing group.

Preparing for the Witnessing Group Meeting Preparation for the witnessing meeting began with talking with Donna about possibilities for the meeting and working with her to identify possible people to serve as witnesses. We began by discussing the purpose, structure, and guidelines for the meeting. I proposed a format in which I would interview Donna about her ongoing steps to reclaim her parenting from The BFG (blame, frustration, and guilt), with a focus on the abilities, skills, and know-how she had developed in the process. I framed the meeting as an opportunity to share that story with a group of concerned friends and subsequently hear their acknowledgment of the ways in which her story resonated for them in their own lives. I outlined a four-step process in which I would interview Donna while the women silently observed, followed by their reflections, followed by her comments on their reflections, followed by a wrap-up and general debriefing. Informal versions of this format had

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previously been used in family meetings in which Donna or Keith was interviewed while the other bore witness, or Grace was interviewed and her parents together were interviewed to bear witness. These previous meetings had given Donna an experiential introduction to the process. In preparation for this meeting, I told Donna that her friends’ reflections would be framed by a set of guidelines and organizing questions, which are highlighted shortly. We explored Donna’s hopes and possible concerns for the process (with a focus on what could happen both during the meeting and following it). There was a particular focus on potential hesitancies and what might prevent her from communicating those hesitancies with me. We stayed on this topic until Donna felt comfortable with the idea of the meeting and I felt assured that she was comfortable. We also discussed the issue of confidentiality, examining a variety of possibilities, ranging from complete confidentiality (the entire meeting would be confidential) to limited confidentiality (people might speak later about broad themes or the effects of the meeting on them, while holding names and details confidential), to minimal confidentiality (only topics that participants asked to be kept confidential during the meeting would remain so). It is important to have a clear agreement about confidentiality before proceeding. Although witnessing practices are grounded in an ethic of circulating new stories rather than keeping them private, it is still important that clients have final say over how information about their lives is handled. In the process, therapists have a responsibility to ensure that decisions are fully thought out. If there are mixed feelings, it is generally a good practice to be more cautious in the initial confidentiality agreement with the possibility of subsequently revisiting it. After developing a proposed structure, we explored potential witnesses to participate in the process. We used re-membering questions to discuss Donna’s relationships with various women and what they might appreciate about her efforts. I outlined some proposed guidelines for reflections (listed in the letter below) and invited Donna to speculate on whether she thought each woman could follow them. This is a crucial consideration in order for the process to go well, and I would not proceed without being assured that witnesses could stick by the agreements. The next step was to contact three friends whom Donna had identified as potential witnesses. We discussed a variety of ways to approach this and decided on an initial phone call from Donna to see if they might be interested, followed by a subsequent letter from me and a final call from Donna. Discussions about the phone calls offered opportunities to reflect on Donna’s hesitancy to “put others out” and her realization that she had a strong community willing to support her. There was also an ongoing effort to keep Keith “in the loop” through this process so as to avoid undercutting their relationship. Donna’s three friends were

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intrigued about the initial proposal, and the follow-up letter is highlighted below to further illustrate the preparation for the witnessing meeting. Dear

,

My name is Bill Madsen and I have been working with your friend Donna and her family to help their daughter, Grace, deal with a number of worries that have come into her life. In the course of this work, Donna and I have talked about some of the ways in which Donna can get caught by blame, frustration, and guilt and pulled away from the really great mother that she can be. In my work and in my own life, I have met many mothers who have had some similar experiences. I imagine you may also know some mothers who have had blame, frustration, and guilt creep into their lives. Donna has been taking a number of steps to keep blame, frustration, and guilt in their place. I believe that you could be very helpful to her in this process and would like to ask you to consider the following proposal. I would like to invite you to a meeting with Donna and several close friends. In this meeting, I would ask Donna a number of questions about the influence of blame, frustration, and guilt on her as a parent. I’d also talk with her about some of the ways in which she has been working to become a better parent. If you are willing, I would like to ask you and a couple of other women to listen in on this conversation as witnesses to it. This meeting would have a rather unusual structure. It would consist of four parts. Donna and I would talk and you and the other women would listen quietly. Then I would talk with you and the other women about your thoughts on what you heard and Donna would listen quietly. I’d be likely to ask you some questions like “What stood out for you as you listened to Donna talk? What does that evoke in your own experience as a mother? And what do you want to remember and take away from this?” Afterward, Donna would have an opportunity to comment on your reflections. Finally, we would wrap up and briefly talk about what the whole meeting was like. This kind of meeting has a different structure, in which people take turns speaking and listening rather than all talking together, and initially that structure might seem a little unusual. I will also propose some guidelines to organize your reflections. • I’d ask you to think about Donna speaking about her experience as a mother as a bit of a gift and encourage you to receive it with the appreciation that good gifts deserve.

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• As you listen to Donna, I’d ask you to listen for what captures your attention and what you find interesting and moving. When you and the other women talk with each other, I’d ask you to talk about what you heard and how it affected you. The purpose here is not to give advice to Donna about her parenting, but to acknowledge the ways in which hearing about her experiences as a mother affect you. • When you and the other women talk with each other about what you’ve heard Donna say, I’d ask you to speak with each other rather than to Donna. The purpose of this is to give her a chance to just listen in on your conversation and have an opportunity to just think about what she’s hearing rather than prepare a response. Thank you for your consideration of this proposal. If you have any questions about any aspect of this proposal, please feel free to contact me. I would particularly encourage you to contact me if you are interested in doing this and one of the guidelines feels as though might be hard for you. Sincerely, Bill Madsen This letter introduced the purpose of the meeting, outlined three questions to organize the women’s reflections, and highlighted various considerations to guide their speaking. When using witnessing practices, therapists have a responsibility for providing a structure and actively facilitating the process to ensure that it is a constructive experience. The clarity about purpose, structure, and agreements outlined in this letter contribute to that. I did not hear back from the women, but Donna reported that they were each willing to participate and touched by Donna’s request for assistance. Donna, in turn, was moved by their responses to her request.

The Witnessing Meeting The meeting began with introductions. The three women included Rosa, Dawn, and Ellie, all of whom had known Donna for some time and were familiar with her difficulties with Grace. Rosa, a 55-year-old Italian American mother of four, was the matriarch of the neighborhood. Her family had lived in the neighborhood for three generations, and Rosa’s children had babysat Donna’s kids since they were born. Dawn was a 35-year-old African American woman with two children who had

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moved in down the street 3 years ago. She was one of the first blacks in a predominantly white working-class neighborhood that was beginning to be gentrified. At the time, Donna really reached out to make her feel welcome, and Dawn held a deep appreciation for Donna’s consideration for others and willingness to extend herself. And Ellie, a 42-year-old Irish Catholic woman with three children, was an old friend of Donna’s who lived a bit farther away, but often joined the other women for coffee at the local donut place. She brought coffee and donuts to the consultation. After the introductions, I restated the purpose of the meeting, outlined the structure, and proposed the three guidelines originally described in the letter. They agreed to the guidelines for reflecting and gave me an authorization to help them stick to those guidelines. In the initial interview with Donna, we traced out the combination of blame, frustration, and guilt and described Donna’s name for it (The BFG). The rest of the interview followed a process described in earlier chapters. I inquired about Donna’s experience of The BFG, the effects the BFG had on her, her relationship with Grace, and her sense of self as a mother. We discussed the ways in which those effects didn’t fit with her preferences in life, and I began to elicit some of the ways in which she had been working to keep The BFG in its place and not let it undercut her parenting. I also inquired about the lessons that Donna’s experiences might hold for other parents. Then we took a break and shifted positions. The three women, who had been sitting off to the side, now took center stage and Donna moved off to the side to listen. I interviewed them, following the three acknowledgment questions outlined previously (and in the letter), and encouraged them to also ask each other questions in the process. Again, it is crucial for the therapist to take an active role in facilitating a constructive process, both reminding witnesses of the organizing questions and guidelines and helping them stay within them. Here is an abbreviated version of the exchange to help convey its spirit: BILL: So, as you’ve been listening to this, what stands out for you? What is rolling around in your heads and your hearts? ROSA: Well, I’ll go first here. I’ve known Grace since she was a baby and she’s always been a pretty nervous kid. Donna’s always been pretty worried about her, but I hadn’t realized until today the toll that worrying has taken on her. You know, mothers always worry. That’s what we do. My kids are all grown now and I still worry. Listening to this reminded me of all the time I’ve spent worrying about my kids. It makes me miss them ’cause kids are such a treasure. (nodding by all)

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ELLIE: You know, I thought Donna was describing my life here. When she talked about Grace blaming her, her getting frustrated with Grace and then feeling really guilty afterwards, I felt like she’d been peeking in my window and describing my family. That’s a nasty combo, and I think about all the times I go through a really similar thing, and my hat’s off to her for being able to see it and really do something about it. BILL: And as you heard Donna describe some of the ways in which she’s doing something about that, what would you like to take away from what you heard? ELLIE: Well, I want to start peeking in her window and learning more about how she does that. (laughter all around) No, really, I struggle with the same thing as a mother. I think the guilt she talked about just hangs in the air and we all breathe it in and it’s toxic, and I want to learn from Donna about ways to take better care of myself and not get poisoned by it. And, maybe next time, Donna’ll bring the donuts and I’ll have something to tell her about how I’m not letting that guilt crap poison me. DAWN: You all know Donna is the one who really made space for me in the neighborhood here, and I really thank her for that. When she talked about her daughter getting mad at her and her trying to understand that through the eyes of an upset teenager rather than an unfairly accused mother, I thought about all the ways in which she welcomed me as a newcomer on the block and I realized she’s really good at putting herself in others’ shoes. I mean she’s really good at it, and I know what it’s meant to me, and I hope she believes that it probably means something real important to her daughter, even though her daughter won’t tell her that right now. I hope I can learn more about listening to my kids that way. This is a short version of a rather lengthy set of moving and downto-earth reflections. When it came time for Donna to respond, she began by thanking me for bringing two boxes of Kleenex and ventured that she might go through both of them before she finished. She went on to talk about how much these three women meant to her and how amazing it was to hear that her life could mean so much to them. She felt, overall, proud about how she had handled what she had been through (and admitted that if she knew then what she knew now, she’d have done some things differently in the process). She described a deep love for the women who had agreed to come to this meeting, and they all proceeded to make their way through the tissue boxes together.4

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In the general debriefing that followed, there were two comments that particularly interested me. First, Dawn said that it was initially awkward to not talk to Donna directly when they were reflecting, but realized as she heard back from Donna that it probably allowed Donna to soak up ore of the meanings. She thought that if Donna had responded to each comment, the comments wouldn’t have had a chance to build on each other as much. I think this captures the potential of the strict separation between speaking and listening to support the development of richer reflections. Second, Rosa commented that it was difficult not to offer advice in the process. She put it this way: “I’ve lived a long time, and I often tell people stories about my life to help them. It was a bit startling to see how my hearing and appreciating their stories can also help them.” I think that comment captures the power of acknowledgment. This meeting had huge benefits for both Donna and her friends. They came away with a deeper sense of connection and shared values in their lives as mothers. The meeting also had radiating effects for Donna and Keith. Keith had a long habit of trying to “fix” Donna’s complaints and would often become aggravated and withdraw when he felt unable to make things better. As he heard about the powerful effects of the witnessing process, he became intrigued by the idea of responding to difficulties in a spirit of “listening” rather than “fixing.” Although that seemed like a stretch for him, both members of the couple thought it would help their relationship.

Bringing Witnessing Practices into Community Agencies The use of witnessing practices to develop appreciative audiences for change can appear time-consuming and daunting to take up, particularly for overworked helpers in community agencies. In considering these ideas, it is easy to fall into thinking, “I can’t complete the amount of work I have now, let alone take on more.” However, I encourage readers to think about ways in which these practices may save time and enrich rather than complicate your work. Re-membering conversations fit easily within existing funding structures and hold the possibility of evoking the presence of allies who can enhance therapeutic efforts. In addition, the thoughtful use of reflecting teams as a ritual to help solidify newly emerging stories constitute a clinically effective and cost-efficient approach. Informal research found that clients rated one session using witnessing teams as worth 4.7 regular therapy sessions (White, 1995). With funding flexibility, this could represent an efficient use of staff time. The use of witnesses from within clients’ own communities requires even less staff time, and much of the preparatory work is both reimbursable and has positive therapeutic effects.

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The use of witnessing teams is also a great training and socialization tool for collaborative approaches to therapy. It supports the development of a relational stance of an appreciative ally in clinical interactions and brings forward respect, connection, curiosity, and hope. If we return to the assertion in Chapter 1 that 40 years of psychotherapy outcome literature has consistently identified relational factors and hope as the biggest contributors to therapy outcome, there is ample reason to believe that the increased use of reflecting and witnessing teams in community agencies would be extremely beneficial clinically. The use of reflecting practices also has the capacity to invigorate clinicians and diminish burnout. One worker put it this way: “In my job, I see client after client and can end up feeling like my job is just fixing widgets on an assembly line. These types of meetings help me reconnect with the humanity of those widgets and remind me that they are living, breathing people. They also remind me that I’m a living, breathing person and not one of those robots that are increasingly replacing workers on assembly lines.” This rehumanization of workers as well as clients has both clinical and economic repercussions. Based on my own experience of administering in and consulting to community agencies, there is significantly less turnover in agencies when workers feel supported and stimulated. The costs of continually hiring and training new workers and the amount of time spent dealing with team disruptions that accompany ongoing turnover can be significant. Reflecting practices can be a powerful organizational intervention with important clinical and economic benefits. At the same time, the process of developing more flexible organizational and fiscal structures can be slow and tedious. With this in mind, there are a number of ways to integrate important aspects of the spirit of reflecting practices in daily clinical practice. One way is to draw on the power of acknowledgment in our interactions with clients. Clearly, therapy is a two-way street and we are often powerfully moved by our exchanges with clients. As we’ve seen, our willingness to acknowledge and share that reality with clients can have beneficial effects. Again, it is important that this is done while keeping clients at the center of attention with a recognition that such acknowledgment is for their benefit, at the same time conveying our responses honestly and authentically rather than as some new technique we’ve picked up. We can also give more attention to helping clients develop allies in their daily lives to support them. The final section addresses this process.

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HELPING CLIENTS RECRUIT AND DRAW ON ALLIES IN THEIR LIVES The process of developing communities of support can become a more deliberate focus in our work. I often ask clients, “What do you want to remember from our meeting today? What will help you keep that alive as you leave here? And with whom in your life would you like to talk more about this? One client developed a group of friends with whom she regularly expanded upon our conversations. She often returned with reports of further conversations that built on our meetings. We can think about the site of healing shifting from therapeutic meetings to interactions in clients’ natural communities and see our work as helping clients continue conversations initiated in therapy out in their real lives. Victoria Dickerson (2004a, 2004b) has highlighted the importance of helping clients to create or seek out allies. She refers to allies as people who are not only on our side, but by our side. Based on her work, we can highlight three important considerations in helping clients develop allies and communities of support. The first consideration is helping clients seek out allies. The process of finding others to support us in ways that we would prefer can be difficult. It runs counter to common cultural emphases on “finding one’s own way, becoming independent, creating one’s own life, certainly separating from one’s family” (Dickerson, 2004b). The following questions are useful to pose with clients in that endeavor: “What attributes would you like potential allies to have?” “What of your abilities, skills, and know-how would you like them to appreciate?” “Who in the past or present would be most likely to know about them?” “What would they say now about those abilities, skills, and knowhow?” “Who in your past and present would know about your values and what’s important to you in this situation?” “What would they appreciate about how you’re living your life?” Clearly, these are questions that come after some initial work on separating people from the problems in their lives and eliciting some of the abilities, skills, and know-how they bring to revising their relationships with problems. Nonetheless, these questions may yield short, rather pessimistic answers, and it is important to view such answers as “works in progress” that provide an opportunity to jointly develop constructive responses.

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A second consideration is the effective use of allies. The ways in which we turn to allies is important. Dickerson (2004a) cautions that allies can get discouraged when they hear only about problems. Many people have limited patience for story after story about others’ insecurities. It can trigger their own anxieties and sap their energy to help. It is important for clients to be clear about what they need and want from allies and to communicate that the allies’ help is important and significant. Suggestions for clients in approaching allies may include: “Rather than getting together for a gripe session, think about what you would like to hear from a friend and what would feel supportive.” “In letting others know what you’re going through, talk about your successes with a problem as well as your struggles with it.” “Ask friends whether and how similar problems have cropped up in their lives. Assure them that they are not the only ones.” “Share tips and techniques for dealing with shared problems.” “Create ways to celebrate respective successes together.” An overall guideline here is to encourage clients to think about what they want to get out of conversations with allies and what tendencies and ways of relating they would like to bring forward, or hold back, in order to accomplish the purposes that bring them to the conversation. This suggestion is not designed to help people become more strategic or put on a performance for others, but to become more deliberate about how they are with others and how they can become the people they would prefer to be. A final consideration is how clients can keep allies’ support alive and present in their lives. This can be accomplished in a variety of ways. We can ask clients what helps them to hold allies in their heads and hearts. We can work with them to develop reminders of important times with allies (e.g., photographs, mementos, or objects that evoke particular memories). It is important to draw on multiple means of communication that bring allies into our lives (e.g., cell phones, e-mail, instant messaging). And it is important to create celebrations for small and large successes whenever possible.

SUMMARY Problems do not stand alone in their influence on people’s lives. Problems are embedded in a network of interactions, beliefs, and cultural assumptions that support and strengthen them. At the same time,

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problems often disconnect people from important others in their lives, thus becoming even more powerful. Identifying cultural supports for a problem helps people better appreciate what they are facing as they renegotiate their relationship with the problem, and their efforts are more effective when people can draw on a community of concerned others. This chapter has highlighted a number of ways to help clients develop and utilize communities of support. Re-membering conversations can be used to help clients evoke the presence of others and internally hold them as an appreciative audience. I outlined guidelines and questions for this process and offered suggestions for times when clients have difficulty identifying potential allies. Reflecting teams and witnessing practices provide ways to involve actual audiences. Witnesses can be invited to listen in on clients’ stories about their lives and bear witness to those stories by acknowledging the impact of hearing them. These practices have powerful therapeutic effects and can be used with witnesses who are introduced to clients, as well as known members of their existing communities. Finally, we can more directly focus our work on helping clients find and develop allies in their daily lives. Practices to help clients develop communities of support hold the potential to dramatically shift professional positioning in therapeutic relationships. The next chapter continues this focus on building support for preferred lives by examining ways to utilize therapeutic letters and documents to help solidify alternative stories. NOTES 1. In Madsen (1999b), I referred to these as “reconnection interviews.” Here, I use the more accepted phrase “re-membering conversations.” 2. I might add that as we are working toward more democratic therapeutic relationships, we also need to acknowledge the inherent power differences that exist, take care to not minimize or mystify them, and ensure that we are continually addressing them. 3. Similar questions (though in a different sequence) have also been developed by Kaethe Weingarten (2003) in her work with witnessing of trauma. 4. One issue that I want to acknowledge, but not discuss in detail at this point, is the gender politics of this consultation. I was very aware of being a man facilitating four women sharing their experience of mothering. As an involved parent, I resonated to much of what they said and was very aware of the ways in which being an involved father in this culture is very different from being an involved mother. The women commented on their appreciation of a man’s facilitating a meeting like this, and I commented on the ways in which I felt privileged to be a witness to their conversation.

CHAPTER 9

Solidifying New Lives through Therapeutic Documents

This chapter examines ways to help clients and families elaborate and solidify newly emerging alternative stories through written documents, with a particular focus on therapeutic letters and termination reports. In addition, it examines providing a literary equivalent of witnessing practices through letter-writing campaigns. One way to enhance the development of new stories between sessions is to send therapeutic letters to clients to summarize sessions and amplify emerging developments. David Epston (1994), who is most closely identified with the practice of sending therapeutic letters, has summarized their purpose as follows: Conversation is, by its very nature, ephemeral. After a particularly meaningful session, a clients walks out aglow with some provocative new thought, but a few blocks away, the exact words that had struck home as so profound may already be hard to recall. But the words in a letter don’t fade and disappear the way conversation does, they endure through time and space, bearing witness to the work of therapy and immortalizing it. (p. 31)

In the first following section, I examine a series of therapeutic letters, used with a woman over a 2-year course of therapy, to outline guiding principles in their construction and use. I introduce the client and then move immediately into the first letter. Questions about what to include 284

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in letters and how to organize them are addressed in the commentary between letters. Broader questions, such as how to introduce the use of therapeutic letters to clients and whether it is at all possible to consider this practice in the face of overwhelming work demands, are further addressed in a subsequent section.

REGAINING SIGHT OF THE BEAUTY IN LIFE Cassandra was a spirited young woman with a sparkle in her eye and a straightforward, down-to-earth style. She was caring, thoughtful, and reflective and had struggled with Depression and Anxiety since high school. She felt as though she had been “living in a cave for the past 10 years and didn’t have a right to form relationships,” wondered whether she had “adult onset autism,” and could “barely look one day into the future.” She worked as a milieu worker in an emergency shelter for runaway youth and loved to sculpt. She was bisexual and had experienced a number of difficult relationships. She grew up with ongoing verbal and physical abuse. Her older brother used to routinely punch and verbally assault her, often on the heels of explosive fights with their father. She was left with the idea that she was somehow responsible for that abuse and had a long history of mediating between her parents and attempting to rescue her father from various self-destructive acts. When asked about the lingering effects of these various challenges, she described a pervasive sense of numbness and a history of alcohol and substance misuse. At the point of entering therapy, Cassandra had not used any substances for quite a while and came to our meeting with a mixture of hope and caution, wanting things to be different and distrusting that could actually happen. We met approximately every other week, with some periods of less frequent meetings. Two years later, as Cassandra left therapy to enter graduate school, she reported, “I feel as if I had emerged from a cave, had a right to be out in the world, knew what I wanted to be doing and was doing it!” The following series of letters documents her journey and is interspersed with her comments, along with guidelines for the use of therapeutic letter writing. The first letter summarizes our initial meeting. Dear Cassandra, It was good to meet with you this week, and I wanted to share back with you some of the notes I took as a way to keep alive the thoughts and ideas that you developed in the meeting. You talked

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about the some of the ways that Depression and Anxiety have come into your life. You described how Depression can get your mind “locked up like an engine without oil.” You said this “locking up of your mind” gets you frustrated, encourages you to disengage from others, steals away your interest in things in your life, and keeps you from enjoying your life. You also talked about the ways in which Anxiety can double up with Depression, leaving you exhausted and scattered, sidetracked from life goals, and isolated, unfocused, and desperate about your life. You summed it up with the phrase, “They leave me feeling numb and losing sight of the beauty in the world.” I was saddened to hear about the toll that Depression and Anxiety have taken in your life and especially the way in which Numbness has clouded over the beauty in a world that you seem to so powerfully appreciate. Do you have a sense of how you’ve hung onto that appreciation of beauty and how you go about finding it in your life? You talked your desire to not have Depression, Anxiety, and Numbness occupy such a prominent place in your life and your Determination to not lose sight of the beauty in life. After we talked, I found myself wondering about that Determination and what it might want for you in your life? Do you have a sense of what intentions and hopes might be behind your Determination to not lose sight of the beauty in life? We also began to talk about a number of ways you’ve managed to begin to reclaim your life from some of the devastating effects of Numbness, Depression, and Anxiety. You described Numbness as a passing cloud and contrasted times in your life when you are caught by Numbness with times when you are more able to enjoy life. In those latter times, you described making connections with others, drawing on your care and empathy, understanding others and giving back, and being more able to express yourself. We did a lot of talking about the ways in which you hang onto the hope and knowledge that you can and will get your life out from under the cloud of Numbness. If the steps you described required particular skills and abilities to take them, what do you think they might be? How do you think you’ve developed the knowledge that you can and will get your life out from under the cloud of Numbness, and what helps you remember that? As our time came to a close, we agreed to continue focusing on helping you get your life out from under that cloud of Numbness and

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build on your enjoyment of your life. I was very moved by your initial steps in our first conversation and look forward to meeting with you next time and hearing your further thoughts and ideas about this project. In support of your pursuit of the beauty in life, Bill Madsen After getting to know Cassandra, I talked with her about her presenting complaint of feeling depressed and essentially followed the fourpart outline for externalizing conversations offered in Chapter 6. We externalized Depression and examined her experience of it. We developed a fuller description of the way in which Depression, Anxiety, and Numbness came together and their cumulative effects on Cassandra’s life. Cassandra was clear that these effects did not fit with her preferences (her desire to not lose sight of the beauty in life), and we focused on the kind of relationship she would prefer to have with Depression and on some of her initial coping efforts to keep Numbness in its place and better appreciate both the beauty and pain of life. In my work, I often take copious notes that can form the foundation for therapeutic letters. I begin by seeking permission (“It would be helpful for me to take notes as we talk as a way to organize my thinking and capture your words. Would that be okay with you?”).1 I often tell clients they can have access to these notes and that other clients have often found it helpful to receive a summary of the notes in the form of a letter. We can then talk about whether they might be interested in periodically receiving letters and how they might want to make use of them. Notes help therapists to stay grounded in clients’ own language. We can write down notable phrases (e.g., “locked up like an engine without oil”) and refer back to the notes to keep our questions closer to clients’ immediate experience. The notes also help us to be more alert for the emergence of exceptions and to better juxtapose dominant and emerging stories. One way to do this is by drawing a vertical line down a page and noting elements of the dominant story on the left and emerging threads of alternative stories on the right. The process of note taking also helps us to slow down the conversation and offers an opportunity to underline important themes. For example, Cassandra says, “I’m committed to finding the beauty in life.” In response, we could ask if we could write that down and slowly repeat back her words as we’re writing. In this way, we can repeat important phrases and highlight their importance. Cassandra appreciated the care that went into note taking and commented that the process of checking out whether the notes had captured

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her words accurately contributed to building trust because, as she said, “I saw that you were able and willing to work from my understanding of things.” She described this first letter as helping her remember an important moment in the session in a way that both highlighted it and helped to build our relationship. The paragraphs in therapeutic letters typically capture what clients have said in sessions (shaped by our questions) and usually conclude with questions to continue the conversation. It is important to stay as close as possible to clients’ original language and document their words rather than inject our meaning. For example, consider the difference between “You talked about your desire to not lose sight of the beauty in life.” as opposed to “You have a desire to not lose sight of the beauty in life.” Whereas the first sentence captures client experience, the second has the potential to be experienced as an imposition of professional knowledge. When we frame sentences in clients’ words, we can follow up with questions that invite further reflection and extend the original conversation. (e.g., “Do you have a sense of what intentions and hopes might be behind your Determination to not lose sight of the beauty in life?”). Although these questions may yield additional information for us as therapists, their primary purpose is to serve clients. This is captured in Cassandra’s comment: “Reading and pondering the questions in the letters got me thinking and exploring new ideas. It gave me a sense of moving forward, seeking and creating versus going to therapy sessions in order to find out ‘what was really going on’ with me.” The closing of the letter reflects a deliberate choice of words. Depending on where clients are in their relationship with a particular problem, we can end letters in ways that signify our support for them against a problem (e.g., “Yours in antidepression”) or our support for them in favor of preferred lives (e.g., “In support of your pursuit of the beauty in life”). My own preference is to position myself in support of preferred directions in life in order to support a proactive vision and maintain a sense of forward momentum. However, if I think a client might experience that as minimizing his or her struggle with a problem, I’d shift the language to better convey support for where the client might be in his or her current relationship with that problem. The next few sessions traced out the history of Cassandra’s relationship with Depression and juxtaposed “Survival Mode” and “Feeling Mode” (Cassandra’s phrases for her tendency to slip into numbness and just survive and her intention to stay connected to her feelings and

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appreciate both the beauty and pain in life). We examined why she preferred Feeling Mode, identified things in her life that would pull her into Survival Mode, and elicited practices she was developing to ground herself in Feeling Mode (e.g., setting aside a specific time every day to play with her cat, sculpting on a regular basis, exercising, and reaching out to friends). We anticipated the ways in which Survival Mode could get hold of her and developed an action plan to resist it. Throughout, we kept a focus on who might be useful allies in her efforts and how she could draw on them. The letters helped in this process. She would often share letters with her allies and continue the conversations with them. She put it this way: “The letters offered easy starting points for conversations with my friends about this, and the feedback from those conversations helped me trust you and our work together more.” At one point, Depression made a serious comeback in Cassandra’s life and she found herself disconnecting from others and sliding back into Survival Mode. The following letters from two sequential sessions supported her during that process. Dear Cassandra, In reflecting on our meeting today, here are some of the things that particularly stand out for me. You talked about Depression sneaking its way back into your life and your 2-week plan to keep it in its place. You described a quite comprehensive plan that included running, biking, eating good food, connecting with friends, and not isolating yourself. It sounds as if you’ve done quite a bit of this already in reconnecting with your cousin and some of your old friends. You also talked about considering the use of medication in a couple of weeks if this first plan doesn’t seem sufficient. We had a very moving conversation about forgiveness and compassion. You talked about the loyalty binds you feel caught in with your parents and your compassion for their respective situations. You also talked about your frustration with your father’s apparent giving up on making changes in his life and his difficulty forgiving himself. You said that for you forgiveness is very important. As you put it, “forgiveness is the only way.” We talked about the prospect of bringing forgiveness and compassion more into your relationship with yourself and some of the positive effects that might have. You thought it would lead you to blame yourself less when Depression manages to creep back into your life in little bits. As you are able to respond more to your own life with compassion and forgiveness, what other gifts do you think that might bring?

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We talked about your relationship with Depression and the ways in which you view it with annoyance, irritation, and frustration. We explored the possibility of relating to Depression with compassion and forgiveness without submitting to its demands. You were very clear that that direction might hold some interest for you a bit into the future, but that you really didn’t want to be too charitable with Depression right now. As you said, “I’d like to respond to it decisively, but not with anger.” We examined some of the skills and know-how from your life that you might draw on for developing such a relationship with Depression, and you focused on your ability to set limits in your work. You described your reputation at work as “a woman who doesn’t take any crap.” You talked about how you don’t allow people to call you honey or sweetie and how you are “very good at sticking to my limits.” What limits would you like to define and set with regard to Depression? What would help you to do that? Who would appreciate your efforts to bring what you know from setting limits at work into your relationship with Depression? I wish you the best in the next 2 weeks and stand in support of your efforts. Be well, Bill

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Dear Cassandra, It was very moving to meet with you today. I wanted to share back some of your words and thoughts to help keep them alive. After Depression reentered your life and began to take up more space, you described some of the ways in which you are beginning to see beauty again. You described running, meditating, exercising, and eating better, and we both agreed these seemed to be solid recipes for improvement in anyone’s life. You talked about tiring of a life so focused on Depression and wanting to build more of a life outside of it. I began to ask you about aspects of your life outside of Depression, and you initially described painting and cooking as areas where you were “fearless, in the moment, feeling good, appreciating beauty, and improvising with creativity.” You talked about your commitment to ground your life in a Spirit of Beauty and spoke poignantly about why Beauty is important to you.

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You said it “fills you with awe, makes you proud to be human, feeds you, and can serve as a guide for hopes and dreams for your life.” As you are reading these lines, what other ideas are coming to mind about the important role that Seeing Beauty Again plays in your life? We talked about your faith that Beauty exists even in dark moments, and examined ways to develop daily practices for seeing and appreciating Beauty. You described consciously focusing on Beauty in your life and looking for it, even in ugly places. You described the ways in which you are committed to viewing the runaways whom you work with as still beautiful despite all their anger and pain. I was very moved by that and asked you what effect that commitment might have on them. You thought it would give them hope and help them remember what is really inside of them rather than just focusing on all the stuff piled up on them. I know there’s a lot that Depression has piled up on you. What of your own Beauty in those times do you want to remember and hold on to? Who in your life would most appreciate your commitment to doing that in your own life as well as in the lives of others? Finally, I asked you to notice and catalog some of the other ways in which you continued to ground your life in a Spirit of Beauty in the next 3 weeks until we meet again. If that still feels like a constructive thing to do, I’ll be very interested in hearing about what you’ve found. In solidarity with your search, Bill During this comeback, Depression was quite adept at clouding Cassandra’s mind and obscuring any progress she had made in her life. The letters became important to her in both documenting the plan she had developed to resist the effects of Depression and in reminding her of stated preferences for her life. In the spirit of moving from viewing Depression as the problem to viewing Cassandra’s relationship with Depression as the problem, the letters helped her reflect on the different kinds of relationships she might have with Depression. Cassandra was clear that she didn’t want to be too charitable with Depression at that moment, but might want to consider relating to it with compassion and forgiveness (without submitting to its demands) in the future. The letters helped keep alive the options available to Cassandra in her relationship with Depression and embedded the notion that her current relationship with it was ongoing and changeable. The letters also helped her remember abilities outside the problem (e.g., setting limits at work) that might be brought to bear in

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modifying her relationship with Depression. In her words, “the letters were mega-helpful at that point. At times they may have saved entire sessions from completely vaporizing from my depressed mind.” In this way, letters can be invaluable to reground clients in their experience of a session, help them remember stated intentions and preferences, and draw on them in responding to problems. Letters can also document available abilities, skills, and know-how and make them more available for use. Clinicians can position themselves as allies who are reminding clients of previously developed commitments and plans, rather than as experts trying to design and implement a plan in the moment. Cassandra commented that the closing in this last letter (“In solidarity with your search”) was very important and helped her feel supported and stronger in relation to Depression. These letters and the sessions they documented helped Cassandra get stronger in her relationship with Depression. As we began to build a community of support for Cassandra in dealing with Depression, it also made sense to examine the broader network that supported Depression. As has been emphasized throughout this book, an active consideration of the influence of the broader culture and its possible support for problems in clients’ lives can be a large part of our work with them. Cassandra’s struggles in life were exacerbated by her position in our culture as a bisexual woman. Important aspects of her life were rendered invisible by experiences that she attributed to homophobia. The following letter captures some of the ways in which this played out in Cassandra’s life and highlights one way that letters can help clients reflect on and begin to shift their relationships with broader cultural forces in their lives. Dear Cassandra, In our last meeting, we had a long talk about your recent visit with your family and the ways in which Homophobia has affected you in interactions with family members. You talked about the pressures for things to be “wonderful” and the ways in which that made important experiences of your life become invisible. You described its getting you to feel “not free” and ruminate on subtle homophobic vibes and begin to see them everywhere in the culture. You also talked about the bind that puts you in, leading you to feel angry and not be sure what to do with that anger. Expressing your anger at Homophobia in a context in which it would not be recognized, acknowledged, or understood felt like a setup, and stuffing that anger can leave you feeling like a “wimp” and supports Depression. You poetically described the result as feeling stuck in sludge and lethargy. It was clear that this is not a situation to your liking. You described the

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experience of being straitjacketed and feeling as if you were living in too small of a box. You had a couple of very poignant metaphors— feeling like a “revving engine that can’t go into gear” or feeling like a Ferrari stuck in traffic. When I asked you about your preferences for your life, you expressed a desire to feel more free, more open and expressive, and feeling as if you could use your energy efficiently and effectively. I’m struck by the amount of energy that you do have in your life (as well as the quality of it) and wonder what will happen for you and those around you as you are increasingly able to use that energy more efficiently and effectively. You expressed a desire to take some action on this, and we began to explore some of the ways in which you have already begun resisting the effects of Homophobia in your life and with your family as a foundation for future endeavors. You talked about a number of steps like preparing yourself for situations and interactions, anticipating what you might encounter while at the same time looking for positive interactions with your family, and trying to not hold things in. You talked about how your anger can be an ally for you and the ways in which it gives you energy that overcomes depression and lethargy. You also described talking about Homophobia and labeling it for what it is in your own mind and with friends. Do you think Homophobia might get a little worried about your unmasking it and naming it? Do you think it would prefer to operate underground or to be exposed in your own mind? Finally, you described visualizing putting Homophobia in a box so that you would have more influence over when and how you wanted to think about it. You described how doing that eased its effects on you. I asked you to notice the ways in which you are successful in putting it in a box and what beneficial effects that has on you. Toward the end, we began talking about who you would want as allies in your resistance to the effects of Homophobia in your life. You named a number of people and also wanted to remember to envision them and carry them with you in your life. As they are an increasing presence in your life, how do you think that will affect your efforts to keep Homophobia in a box? I look forward to our next meeting. Be well, Bill

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This letter captures the use of externalizing conversations to address broader cultural constraints to preferred lives. Cassandra came in very upset after a visit home in which she tried to talk about an important girlfriend in her life and was met with questions mainly about her friend Malcolm and what prospects there might be for that relationship. In our conversation, Cassandra came up with the word “homophobia” to capture what was going on here, as shaped by questions I asked (e.g., “As you think about trying to talk with members of your family about a relationship with another woman who is very important to you and their responding by asking about possible futures with another male friend, how do you make sense of that? What do you think might be influencing them to respond in that way? How powerful do you think that is in our culture, and what kinds of support does it get in our culture?”). In conversations like this, it is important for therapists (who are in a significantly less vulnerable position) to not wait for clients to raise concerns about broader cultural contributions, but to take the lead. Cassandra put it this way: “When you first asked about cultural considerations, I was not willing to come out to you, but it planted a seed of trust for me to later open up to you. Your introducing the topic helped me to know that you were sensitive and aware of these issues and to consider that it might be safe to talk with you, after having several negative experiences with therapists in which I felt pathologized and stigmatized around issues of sexual orientation.” At the same time, recognizing the power discrepancy in therapeutic relationships, it is important not to impose a particular meaning on the situation. Johnella Bird (2000, p. 91) has highlighted that, as therapists, we can position ourselves as “the holders and conveyors of knowledge or as the negotiators of the possible meanings that can be made of experiences, feelings, and ideas.” I have a strong preference for the latter stance. I believe it is useful for therapists to raise questions about cultural beliefs that impact clients, learn about their current relationship with those beliefs, invite reflection on what type of relationship they would prefer to have with those beliefs, and support them in developing preferred lives. However, as therapists with a certain degree of position power, we can slide into misusing that power when we begin specifying what kind of relationship a person should have with a particular cultural belief. Examining cultural supports for a particular problem places that problem in a broader perspective, makes the difficulty of redefining a relationship to that particular problem more understandable, and minimizes client self-blame. In this instance, examining the degree of support

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that Homophobia receives in our culture helped Cassandra to appreciate its power and feel less like a “wimp” in sometimes being reluctant to take it on. It also helped her develop more empathy for her family as people who were caught by Homophobia than as people who were homophobic. Externalizing Homophobia also helped her take action in addressing its effects on her life. Numerous writers have emphasized helping clients move beyond reflection to take concrete steps in addressing political, economic, and cultural factors in their lives as an important therapeutic step (Belkin Martinez, 2005; Freire, 1971, 1994; MartinBaro, 1994). Accessing a community with which to take action also becomes an important step in clients’ lives. This letter provided us with an opportunity to further examine existing and potential allies for Cassandra in building the life and relationships she preferred in the face of Homophobia. This letter was one that Cassandra returned to from time to time, which highlights the fact that letters can have enduring utility. Following this session, we began to examine Depression in the context of Cassandra’s often being recruited into a position of OverResponsibility in her life. We explored Over-Responsibility in the context of her history of bring abused, her position within her family of origin, and her cultural standing as a woman. The following letter summarizes a session in which Cassandra developed utter clarity that she was not responsible for the abuse that happened in her life. Although that clarity was striking in the session, there was a danger that it could slip away afterward. This letter helped Cassandra hold onto that clarity and highlights ways in which letters can help clients solidify initially tentative realizations. Dear Cassandra, Here is a rendering of some of the things you said in our last meeting along with some questions and reflections. You described a common situation as a child of your brother hitting you, your mother responding with “Why can’t my kids get along?”, and you then feeling responsible and needing to do something to fix it. When I asked you to describe your current take on that situation, you replied, “That’s not the way it should be. It’s not a situation of kids not getting along. The boy is hitting the girl. The boy is responsible for the hitting, not the girl. The parents are responsible for addressing the situation, not the girl.” You described your current clarity as a cut-and-dried situation, saying it used to be fuzzy, but isn’t anymore. When I asked you how you had arrived at this clarity, you described how you have decided to “deal with the anxiety that comes up in these kinds of situations and not let my mind complicate things for me.”

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We went on to talk about the ways in which you have been encouraged into Over-Responsibility in your family and in this culture and began to examine what stance you would like to take in relation to Over-Responsibility as it shows up in your current life. I asked you a number of questions toward the end of helping you develop a preferred stance in relation to Over-Responsibility, and you told me that you wanted to think about that some and come up with a word or phrase that could serve as a metaphor to capture your preferred stance in relation to Over-Responsibility. I look forward to hearing your thoughts on this. As you begin to clarify your preferred relationship to Over-Responsibility, how do you think it will affect OverResponsibility’s effects on your life? You also spoke about wanting to reexamine the ways in which you can come to view many events in your life as manifestations of “being essentially screwed up.” I think there are many ways in which you have been mistreated, and I think that is very sad and wrong. I’m also struck by all of the ways in which you have resisted and continue to resist mistreatment both by actively protesting it and by pursuing a good life for yourself in the face of that mistreatment. As we discussed, I would encourage you to think some about ways in which events in your life could also (also, not instead of) be viewed through a prism of coping with and resisting injustice and mistreatment. As you look through this double lens of “mistreatment” and “protest against mistreatment,” I wonder how it affects the stories you tell about yourself. I look forward to meeting with you in 2 weeks. In appreciation and support, Bill Cassandra found this to be an important letter, as evident in her subsequent reflection: “It helped me feel understood and believed. I can’t stress that last part enough. The both/and approach was important. I remember appreciating the prism metaphor in a very profound way. It helped me start to hold two storylines at once—even ones that might contradict each other at certain points. And it was a moment when I breathed a huge sigh of relief that I was not dealing with an overly silver-lining person.” This comment highlights the importance of fully acknowledging difficulties in clients’ lives while simultaneously introducing possibilities. Letters

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can become an important vehicle for holding the complexity of such a message. The letter also reminded Cassandra of her interest in thinking more about her relationship with Over-Responsibility and developing a metaphor that could capture her preferred stance with it. She came to the next meeting having developed three different metaphors for how she wanted to respond to invitations for Over-Responsibility in different contexts, and we spent significant time elaborating these three stances and focusing on how she could implement them. She found the development of these three metaphors particularly helpful and believed the process of coming up with her own metaphors was crucial. In this way, letters can stimulate important work between sessions and help to link meetings. Near the end of the session, Cassandra came back to a deep-seated belief that she was “essentially screwed up” as the reason that she had so many difficulties in life. She briefly mentioned a desire to reexamine this belief. Although that could have been a passing comment easily forgotten by the next session, placing it in a letter helped us to subsequently return to it. In this way, letters can highlight particular issues and keep them on the table. The last letter to be considered here documents a session in which we externalized the belief that Cassandra was “essentially screwed up.” It represents ways in which letters can be used to take apart particular beliefs and offer opportunities for clients to further step into a different relationship with them. Dear Cassandra, I wanted to share back some of the developments that came out of our meeting today. You began by describing a number of developments in your life that include being more social, having a better mood, and noticing a distinct absence of the Critical Voice. Congratulations on the work you’ve done to make that all happen. We focused on that “deep-seated belief” that can get hold of you, that you’re screwed up. While I am personally not inclined to agree with this belief, it is clearly one that has gained a lot from events in your life and your family and from your position in this society. Given all the supports that you listed for this belief, is it any wonder that it might have a bit of a hold on you? Because exposing Critical Voices seemed to have a beneficial effect, we decided to talk more about this belief. Here are some of your thoughts and my reflections. We examined this idea’s accusations and the situations in which they arose. You described it as accusing you of being selfish and trying to convince you to be selfless and not do anything for yourself. You

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talked about its trying to get you to “not take what I want, punishing myself, making myself uncomfortable, not setting time aside for myself, and dropping everything for others.” You mentioned a small, but important time when you stood up to the expectations of selflessness. You described a request from your friend Dawn to which you replied that you could help her out after you finished something else first. You described a struggle in your head to respond in that way and thought it represented “trying something new and being willing to take a chance to free yourself from OverResponsibility.” What do you think it took on your part to take that chance? If that decision to take a chance was intentional, what were the hopes for yourself in making that decision? We talked about what might be some of the commitments or guiding principles in your life that are revealed by taking a chance in that situation, and you described a Commitment to Being Happy. I inquired about how your life is different when it is grounded in this Commitment to Being Happy, and you related that you do things for fun rather than out of obligation, that your choices and priorities are different, and that YOU are making decisions about your life rather than operating on autopilot. We contrasted some times when your life is guided by autopilot rules with times when YOU organize your life, and you described the latter situations as “much better.” You said, “I’m more able to handle things, I’m more relaxed, I’m living the life I want to be living, and I’m more in control of my life.” You also said, “My life feels different, it is more of an open lens, and I’m able to see more things. I like it a lot better.” From there you painted a picture of the life you want to be developing for yourself. It held going to a job you like, living in a family you’ve created, and feeling relaxed in your life. You said that future felt exciting, but also intimidating, and you were unsure how to develop the road to get there. We can certainly talk more about that, and I imagine there are many people who would join you in developing that road. Finally, there were a number of things you wanted to keep in mind. They included: • Your experience with Dawn and the conviction that you can choose to do things that you want to be doing. • The fact that you are currently feeling good and the realization from that fact that it’s possible to feel good. • The realization that the Voice of Screwed Up Belief is different

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from YOUR voice and that the Screwed Up Belief’s voice would be happier if you just accepted its accusations and didn’t question them. • The realization that YOUR voice and your life will be happier if you don’t just accept the accusations of the Screwed Up Belief and continue to question it. Writing these notes gives me an opportunity to reflect on our meetings together. As I write this one, I am very moved by your courage to confront and question the accusations of the Screwed Up Belief and your ability to utilize your encounter with the Screwed Up Belief to reconnect to your Commitment to Be Happy. I wish you thoughtful traveling in your continued journey. Be well, Bill This letter captures an externalizing conversation that deconstructed a particular belief’s claims and helped Cassandra shift her relationship to the voice of that belief. It highlights ways in which letter writing can support clients in gaining distance from beliefs that have spoken quite compellingly to them in the past. The shift in phrasing from a “belief that you’re screwed up” to the “Screwed Up Belief” was a gradual one that occurred over the course of the meeting and highlights the way in which language is a dynamic process that can support the development of new relationships with problems. I often end sessions by asking clients what they want to remember from the particular meeting. Cassandra mentioned four things that were included in the letter. The reiteration of these four things illustrates ways in which letters can be used to keep alive the thoughts and experiences that clients find most important. The last paragraph of the letter includes some witnessing on my part, acknowledging some of my own responses to working with Cassandra. She found this portion of the letter to be particularly important. We can also involve clients in letter writing. In my work with Cassandra, we had a particularly poignant session at one point that called for a letter. It came during a very busy week in my life, and I was aware that I couldn’t promise to write a letter, but also aware that it would be important to document that meeting in some way. At the end, I asked Cassandra what three things she would like to remember from the meeting, wrote them down, and, briefly explaining the circumstances of my schedule that week, encouraged her to write a paragraph about each phrase. She went home, briefly wrote out something

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about each phrase and later wrote more. She reported, “It helped me remember the things we talked about and take action on them, which helped a bunch.” Barry Duncan and Jacqueline Sparks (2005) have highlighted that asking clients to write about their therapy demonstrates respect for their expertise concerning their own lives and gives therapists an opportunity to learn about what is important from client perspectives. This process can support clients as a resource for themselves and for therapists. Cassandra’s application to graduate school also became an opportunity to use written documents therapeutically. She needed to write a personal statement and wanted to write about her own personal journey. We met to review an initial writing of that statement and used it to reflect on our journey together. In preparation for our ending, I sent her a list of questions that we might discuss in a consolidation interview (the format of which is described in a subsequent section). Cassandra responded to the list of questions and essentially wrote out her own termination summary, which we reviewed and discussed. As is evident here, our efforts toward the end increasingly shifted to Cassandra’s doing the “work” outside of sessions and our sessions becoming witnessing opportunities for that “outside work.”

Effects of the Letters on Cassandra I conclude this section with some comments from Cassandra about the effects of letter writing in general. I discussed using these letters from our work together and sent her initial drafts of this chapter for review after we completed our work together. In addition to the comments about each letter that have been interspersed throughout, she had a number of thoughts about the whole process in general. “In general, when I read your letters, I felt important and got a warm feeling in knowing you were thinking about me. The letters were important in keeping a thread of continuity between the sessions. I didn’t have to start from zero every time I walked into your office. Reading previous letters helped me realize that I was making some serious progress. The documentation was particularly helpful for me while I was depressed –because of its effects on memory—and in general during the first year, when I was nervous just talking to you and had memory problems because of that. Because of the nervousness inside the therapy room, my mind wasn’t able to be as open and creative as it would be when I was relaxed. Of course, as I learned to trust you more, I could do more actual thinking and

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responding inside the sessions. But for a while I had to rely on the letters to remember what we talked about and to think about your questions. “The letters were really helpful in reminding me that you had understood me accurately, and respected and worked from my understandings. This was particularly helpful for me, given my penchant for overthinking things and distorting things—usually in the service of self-doubt. Later on when we started talking about the abuse, the letters served as assurance that you believed me. This last part is vital. Without the letters, I definitely would have had major recurring doubt that you believed me. I can’t emphasize that enough. “Reading and pondering the questions in your letters led to my constructing my own questions using similar formats. In other words, I started asking myself questions like, Hmm, I wonder what Dawn would say about my ability to write this paper? Or, wait a minute, would Depression be psyched if I decided not to go out for dinner with friends or would it be worried? (Yes, I actually do this sometimes.) An offshoot of this is sometimes this way of thinking inspires me to ask my friends questions like this if they are experiencing a problem. I’ve gotten positive feedback from them and I like how the questioning has affected how I view others and become curious about them.”

CONSIDERATIONS IN THE USE OF THERAPEUTIC LETTERS There are a number of considerations in using letters. It is important that we have conversations ahead of time with clients about how we will convey letters to clients. They can be sent by postal mail or e-mail, and it is important to inquire about who else might see them and whether there are particular individuals whom clients would prefer to see or not see these letters, and then arrange for their delivery accordingly. We can also engage clients in a conversation about the use to which they might want to put the letters (e.g., are there particular places they might want to keep letters, are there particular times or situations in which they might want to pull them out and reread them, are there particular allies with whom they might want to share them?). Finally, we can engage clients in conversations about how they might want to respond to letters. It is possible that clients might want to write something back, bring reflections from letters back to the next session, use letters to bridge sessions. It is important to have some clarity about our availability to respond to

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responses from the letters we have sent out and to avoid implicit expectations. Throughout, clarity and transparency become important guidelines. There are also a number of considerations for clinicians who are thinking about the use of therapeutic letters. These letters are powerful and valuable tools. Their value has been informally studied by David Epston. He asked clients how many sessions of therapy a letter was worth and what percentage of positive outcome from therapy could be attributed to letters. Clients reported that a therapeutic letter was worth four to five sessions of therapy and attributed 40–90% of positive outcome to the letters (Freeman et al., 1997). In a similar study of 40 clients, David Nylund and John Thomas (1994) found that clients in an HMO (health maintenance organization) clinic rated therapeutic letters as being worth an average of 3.2 sessions, with 52.8% of the positive outcome attributable to the letters alone. These figures suggest that letters have enormous therapeutic potential and can significantly enhance therapy. Though therapeutic letters hold the promise of supercharging therapy, many clinicians under the pressure of demands for high productivity complain that they could not begin to find the time to produce such letters. Given the potential for therapeutic letters to increase the efficacy and cost-effectiveness of therapy, it becomes important for funders (such as HMOs and state agencies) to become better informed about creative applications such as the use of therapeutic letters and begin to incorporate it as a reimbursable activity. Articles such as the one by Nylund and Thomas (1994) on the economics of narrative therapy need to be read by more people than just clinicians. At the same time, we can use required paperwork in a similar fashion. Most clinicians in agencies have to complete progress notes on each session. These notes could easily be altered to a format similar to that of the preceding letters and then shared with clients. Conceivably, the last 10 minutes of a session could be devoted to co-constructing a note that documents the session, which could then be copied and given to a client to take home. Given the therapeutic efficacy that clients attach to letters, such an allocation of time would certainly be worth everyone’s while. In addition, many clinicians are required to complete quarterly updates that summarize the work with a client every 3 months. These reports, if handled in a manner similar to the letters, could be opportunities to have our paperwork actually support the work we do rather, than be experienced as administrative requirements that detract from the “real work.” Of course, it requires a shift in how we handle both what we write and the process through which we write it. This shift can be initially threatening to clinicians, but many who attempt it report significant changes in their work as well as their experience of report writing.

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DEVELOPING COMMUNITY THROUGH LETTER-WRITING CAMPAIGNS Chapter 8 highlighted some powerful ways in which witnessing practices can support the enactment of preferred lives. We can expand witnessing practices into the written domain through letter-writing campaigns, initially developed by Stephen Madigan (1997; Madigan & Epston, 1995). In letter-writing campaigns, important members in a client’s life are asked to send letters that outline memories of their relationships together outside the problem’s influence. The process is often described as “re-remembering” to emphasize the way in which it brings forth other remembrances. One goal of letter-writing campaigns is to assist clients to re-remember aspects of themselves that have been obscured by the problematic story. The process of collecting, reading, and rereading letters elicits experiences and evokes relationships that can help solidify alternative stories. A second goal of letter-writing campaigns is to help clients who have been disconnected from natural networks or communities to reconnect to them. Letter-writing campaigns often develop out of reconnection interviews and can extend their impact by providing tangible mementos that invoke the presence of important others in clients’ lives. Madigan (1997) provides a thorough description of the mechanics of letter-writing campaigns. In brief, therapists can begin by asking clients to identify others who would view them differently from the problem’s description of them. We can then juxtapose the problem’s description and these alternate descriptions and inquire about the possibilities that each description might hold for clients. As we elicit client preferences, we can generate a list of people who would stand in support of their preferred stories, and construct a letter of invitation to seek letters highlighting memories of their relationships that are more consistent with emerging alternative stories. As letters come in, we can engage in a process of reading and reflecting on the letters that arrive. Sessions can also elicit emergent themes across letters in an attempt to weave together a more substantial counterplot. There are many ways to integrate practices such as letterwriting campaigns, and the following section highlights one adaptation of this idea by a home-based worker with a teenage client.

DIANA’S BOOK Diana was a wonderfully engaging 17-year-old girl who was voted Queen of Suspension in her junior high school yearbook (fittingly, she was suspended from school on picture day and the yearbook ran the title

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under a blank space for a picture). She struggled with substance abuse, as well as school and family difficulties, beginning in 7th grade, and she moved out of her house a year later to live with a friend. She entered her first treatment program at age 14 and, over the next 20 months, had 13 different placements in hospitals, halfway houses, and residential treatment programs. She became involved with a home-based community support program in an effort to reunite with her family. Although initially skeptical about services, she built a strong relationship with her outreach worker, Anya, and made significant changes in her life. Much of their work together revolved around a letter-writing campaign. When Anya initially suggested the idea of a letter-writing campaign, Diana was skeptical, but with Anya’s gentle persistence, decided to give it a shot. Anya framed the experiment as an opportunity for Diana to read how people viewed her outside her reputation of “drinking, drugging, and not caring.” They began to generate a list of possible letter writers, which included a college volunteer who helped her transition home, her psychiatrist, a therapist, a friend from work, her department of mental health worker, and her brother. Diana described her initial steps in this process: “I was very nervous to ask anybody. I was worried they would reject me, but with Anya’s help, I took that chance. The first person I asked was Kira, an older friend who helped me move home from the residence. Anya described our project to Kira and explained the guidelines of writing about how she knew me outside of my reputation. I was very nervous to hear what she would say. She wrote the letter and we made a plan to meet. Kira picked me up from school, and we met Anya at the mall. We headed to the pizza store and sat down. My heart was racing and I was so anxious. Kira began to read the letter to me and I relaxed. I listened to every word she read, and I stored the letter in my mind. I was so surprised and she was so honest. It was wonderful. We talked for a long while afterward, and it was a whole new experience to be hearing such good things about myself. It was the first of the letters, and I had survived.” This description brings home Diana’s tentative mixture of excitement and trepidation. The chance she takes in asking others to join her in this process is nerve-racking and yet an important step in building a community of support. It is important to carefully consider whom to include in such a project and to frame the invitations clearly. For example, Diana initially decided not to include her mother or stepfather. At the time, Diana and her mother had a very conflictual relationship and

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her stepfather had little involvement with her. Diana believed her mother “knew the old story about me, but couldn’t see the changes I was making” and was worried that she would “either just write about the old stuff or not be real.” As letters began to accumulate, Diana left the book out for her mother to see. It provided an opportunity for her mother to view Diana through others’ eyes and invited her mother into Diana’s newly developing identity. The book became a way for Diana to communicate with her mother and stepfather and gave them a vehicle through which to connect. They later made up an award certificate for her to celebrate 90 days of sobriety, and she put that in her book. Diana made some interesting choices in her development of a letterwriting campaign. One choice was to include both helpers and people from her natural community. Because she was “systems kid,” much of Diana’s community had been helpers. She began by primarily asking helpers for letters, but then began getting letters from friends and nonprofessional contacts. The process of the letter-writing campaign both mirrored her transition back into the community and supported that move. A second choice was Diana’s decision to meet personally with each letter writer. Often in letter-writing campaigns, a letter of invitation may be sent out by the therapist (examples of such letters are contained in Madigan & Epston, 1995) to solicit a number of letters that can be sent to the client’s home or the therapist’s office, depending on the client’s preference. Typically, the therapist and client read and discuss the letters and may periodically invite the letter writers into the office. Diana insisted on personally contacting each letter writer (initially with Anya’s assistance). This led to a ritual in which she would talk with each letter writer about the process and they would then meet over a snack or meal to read the letter together, put it in her book, take a photograph together, and add other appropriate mementos (e.g., tickets, poems, prayers, etc.). The ritual strengthened the symbolic value of the letters. The process was time-consuming and labor-intensive, but provided an ongoing framework for Anya’s work with Diana.2 Anya explained: “It reinforced what I thought would make a difference and gave me a specific tool to practice day in and day out. We had the opportunity to talk about each letter beforehand, to experience getting the letters, and watch and listen to what people said. We would hear the effect that writing had on the letter writers, which was amazing, and then Diana and I would talk about it again. Each letter represented a chance to have those experiences over and over. It reinforced our work together and gave me an invaluable tool to use.”

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A Sample Letter Diana graciously offered to share some of her letters. The one included here is from Diana’s coworker and friend, Abby. Along with the letter, Abby included a poem by her boyfriend, Dale, who had died in a car accident while Abby was driving. Shortly before his death, Dale had written a poem about his struggle with substance abuse and had given it to Abby. When Abby passed the poem along, Diana felt it must have been written specifically for her because it so captured her own experience. Here is the letter. (The poem is not included.) Dear Diana, I feel lucky to know you. You have this amazing ability to always sparkle and your positivity rubs off on everyone around you. You possess such a wonderful spirit and your ability as a “survivor” is powerful. Diana, you have a wonderful heart. You look out for others, including me, and I respect that. When you asked me to be part of your letter album, I knew exactly what to do. I went to my most treasured shoebox and pulled out Dale’s poem. He told me that one day I would know who to read it to. Well, that was 6 years ago and nobody but myself has read it. Dale died next to me in a car accident one month after I got this poem. His strength and memory I know and trust I will now pass on to you. I have chosen not only to read his poem, but to give it to you. Stay strong, be true to yourself, and remember you are never too far from people who love you. Love, Abby The ritual around the letter and poem strongly affected Diana, Abby, and their relationship. After reading the letter and putting it in the book, they cried and talked for hours. Diana began sharing things with Abby about her life that few people had ever heard and developed a much deeper friendship with her. The process also affected Abby. Here are Diana’s words: “When Abby gave me the poem, it allowed her to let go of the pain and move on. No one had seen it and now others know about it and she’s no longer alone. Now Dale’s poem helps others.”

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In this way, letter-writing campaigns become community interventions with a potentially wide-ranging impact. Overall, the letter-writing campaign had a profound effect on Diana. She was “blown away” by the response from others and appreciated the Diana she saw through their eyes. The consistency with which various people viewed Diana outside the previously dominant story of “drinking, drugging, and not caring” powerfully supported her in the development of a life outside of drugs and programs. Diana put it this way: “This book is like everything to me. When I’m having a bad day, I just whip it out and read it. I remember where I was the day I got the particular letter I’m reading and it makes me feel better and keeps me going. It makes it easier to go on and I’m not alone with those troubles.” In this way, the letter-writing campaign contributes to Diana’s holding a community of support close to her and drawing on it in times of need. Diana’s words movingly convey the effects of letter-writing campaigns. However, in a human service world concerned with measurable outcomes and concrete results, consider the following. For the first 20 months of Diana’s involvement with the mental health system, she was in 13 programs (including hospitals, detox centers, and residential programs) and had (by her estimate) more than 20 different workers. For the second 20 months, beginning with Anya’s involvement with her, Diana lived at home with no readmissions and significantly fewer workers in her life. Although that time was not consistently rosy and troublefree, the savings in treatment costs was enormous.

TERMINATION AS AN OPPORTUNITY TO CONSOLIDATE ALTERNATIVE STORIES I conclude this chapter by examining ways in which we can use the end of therapy as an opportunity to solidify alternative life stories. The review process that accompanies required quarterly reports and termination summaries can be an important time of reflection and consolidation. This section examines a different way of thinking about termination, illustrates an interview outline to consolidate new stories, and highlights the use of termination/consolidation summaries that document the process. Traditionally, the process of termination has been organized around a metaphor of loss in which the ending of therapy is a painful process

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that evokes other unresolved losses. This metaphor promotes attention to how a client is grieving the loss of the relationship and encourages the therapist to view the client’s handling of this loss in the context of other unresolved losses. Although we must appreciate the importance of therapeutic relationships for many clients and acknowledge the sense of loss that can be evoked in endings, a sole reliance on this metaphor runs the risk of making therapeutic relationships more important than other relationships in clients’ lives and contributing to a narrow view of helping efforts. In the process, we can lose sight of the healing potential in clients’ natural communities. We could also frame termination within a rite of passage metaphor and view it as a ritual to celebrate and consolidate the development of new identities (Epston & White, 1995). Termination then becomes less about an ending with a focus on looking back and more about a transition with a focus on the future as well as a review of previous work. Epston and White (1995) have proposed a series of questions that can be posed to a client or family in a special meeting to elicit and document the changes made and the knowledge gained in the process of therapy. I have adapted these questions into a broader format that has been used in a number of different contexts. A consolidation interview consists of a specific interview that reviews the work a client or family has done and the progress made in therapy. The interview can be seen as an invitation to reflect on a client’s journey toward a preferred direction in life and can be used to solidify the integration of a new identity. A consolidation interview can be organized around five broad areas of questions, as outlined below and included in Appendix D. • • • • •

Reviewing-the-journey questions. Reauthoring questions. Circulation questions. Problem resurgence questions. Client wisdom questions.

A consolidation interview begins with discovering whether the client or family members would be interested in taking some time to review the work they have done in order to better understand and solidify that work. This can be proposed ahead of time and discussed with the family members. Usually, families are very interested in the idea. Reviewing-the-journey questions capture the story of developments in a family’s life during the course of therapy. Reauthoring questions elicit the meaning of those developments and the alternative story that has emerged in the course of joint work. Circulation questions help to identify and recruit an audience that can bear witness to changes that clients

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have made in their lives. Problem resurgence questions are used to anticipate and develop contingency plans for the possibility of problems reappearing in clients’ lives. And client wisdom questions solicit what clients have learned from their engagement of problems that might be helpful for others addressing similar problems, as well as for therapists trying to help others in similar situations. The next section utilizes a consolidation interview with a couple to highlight this practice.

FROM UNFAIR FIGHTING TO LOVING FRIENDSHIP Manny (32) and Ellen (31) were a Latino couple with two children, Raquel (11) and Juan (9). They were referred for couple counseling by Juan’s pediatrician after Juan expressed his fear of their verbal fights in a checkup examination. Manny had a dark complexion, spoke with a thick accent, and worked in an auto parts store. Ellen sold real estate and looked, dressed, and acted more like an Anglo. They often had verbal fights over their children’s education and future. Ellen wanted them to go to private school and get out of the neighborhood, whereas Manny saw that as economically impossible and wished Ellen had more pride in their culture. In their fights, Ellen would berate Manny with stinging attacks on his lack of drive and ambition and he would respond with disparaging verbal assaults that shocked Ellen into stunned silence. The fights, though never physical, scared Ellen, and both parents were worried about the effects of their fighting on their children. We met for 5 months until a change in Manny’s employment situation brought our work to a halt. However, at the end of our time together, the couple had made a huge shift in their relationship. Although they still had periodic fights, the fights were about “real-life things” and didn’t feel out of control or emotionally abusive. The couple had a foundation of deep love and close friendship, and our work together juxtaposed metaphors of “Unfair Fighting” and “Loving Friendship.” We examined what pulled them toward Unfair Fighting and the ways in which that was embedded in their experience of racism in their lives. As Colorado, Montgomery, and Tovar (1998) have pointed out, violence in Latino homes is contextualized by the violence Latino people experience from the North American dominant culture through pejorative messages from the privileged toward the poor, from citizens toward immigrants, and from white people toward persons of color. For example, Manny described experiences of people mocking his accent and thinking he was stupid because of his faltering English. He reflected on his original dream to make a better life in the United States and his shame that he hadn’t been able to accomplish that goal. He

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described feeling out of control in his life and losing it when he got teased at the auto parts store for not being able to keep his “little woman” in line. Placing Manny’s explosions in a broader cultural context of racism and internalized gender expectations did not excuse his explosions, but helped to develop a fuller understanding of the explosions so that our work could be more effective. Ellen’s experiences of racism also affected their relationship. She lost a real estate deal after she introduced herself with her last name and subsequently tried to pass as an Anglo in order to keep her job. When we examined Ellen’s stinging attacks on Manny’s “lack of drive and ambition” in the context of her response to discrimination and cultural expectations of upward mobility, they became less personalized and lost much of their sting for Manny. Although Manny and Ellen still fought over schools and the neighborhood, the personal intensity of the fights eased considerably and they had a shared sense of allying together against broader cultural messages.

Reviewing-the-Journey Questions Questions in this area, which examine the ways in which clients have redefined their relationships with particular problems, may include the following: “What were you most concerned about at the beginning of our work together?” “What problems were you struggling with?” “How strong were those problems (on a scale of 1–10)?” “How strong would you say those problems are now (on a scale of 1–10)?” “When you compare the problems’ influence at the beginning of our work and their influence now, what do you notice? The first two questions are different ways of acquiring similar information. The second two questions allow a comparison of where clients were at the beginning and at the conclusion of therapy. The process of attaching numbers to these points in time concretizes the magnitude of the shift and provides a basis from which to inquire about clients’ reactions to that shift. We don’t need to be wedded to numbers as a way to mark the transition, the point is to highlight the significance of the shift in some way. In their consolidation interview, Manny and Ellen said they were initially most concerned about Unfair Fighting and the effect it had on their relationship and their children. When asked to rank Unfair

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Fighting’s hold on their relationship on a scale of 1–10, they gave it a 9 at the beginning and a 4–5 at the end of our work together. They both agreed that this shift was significant. Ellen described the shift: “It was huge. Before, it was out of control, and if we hadn’t made this shift, our relationship would be over. It’s not like we’re completely out of the woods yet. We still have some big fights, but the fights are much different now. I’m not afraid of his anger and I don’t feel emotionally abused by him.” In situations in which clients report very little change, we can stay focused on the direction rather than the magnitude of change. Even if the reported change is minimal, we can inquire about how clients have begun to move their lives in that direction and what they think about that movement. In situations in which clients report no change or that the problem is getting stronger, we can examine their coping in the face of the problem’s strength. In this examination, it is important to allow space to acknowledge potential discouragement. This is not a process of putting a positive spin on a bad situation, but rather being open to threads of coping and resilience amid pain and suffering.

Reauthoring Questions From the foundation established by reviewing-the-journey questions, there is a natural segue into reauthoring questions such as the following: “What steps did you take to bring about that change in the problem’s influence?” “How did you do that?” “What does it mean that you’ve taken these steps?” “What does it tell you about each other and about your relationship?” “What does it say about what you care about and value in your life together?” “With these new achievements as a foundation, what changes might follow next?” These questions are familiar as story development questions and meaning questions, discussed in Chapter 7. These questions elicit the details and meanings of alternative stories and are constructed to highlight clients’ roles in bringing changes in their lives (or in the event of few or no changes, continuing to cope amid difficulties). Many clients have described this reflective process as validating and promoting of self-appreciation.

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With Manny and Ellen, I both acknowledged that they were still working on their relationship and wondered how they had made “huge” progress in only 5 months. Manny replied that he had begun to listen more to Ellen. MANNY: When she used to criticize me all the time, I felt it just wasn’t fair. Here I was working my ass off for her and my family and all I’d hear from her was how it wasn’t enough. That was just not fair. There’s been so much in my life that’s been not fair that I just couldn’t take it. But then, as I heard how my explosions devastated her, I thought that’s not fair either, and I couldn’t believe I was doing the same thing that upset me so. I felt horrible about that. BILL: It sounds like hearing that from Ellen was really important for you. You said that it was hard to hear, and I respect your ability to meet that head-on and take it in. How were you able to do that? What does it tell you about yourself that you were able to do that? MANNY: Oh, I don’t know. She was right about what she was saying. BILL: Ellen, what does it tell you about Manny that he was able to set aside his discomfort and really listen to you even though it was hard? ELLEN: Well, one part of me feels like he should listen and it’s about time. But another part feels like finally he’s being a man. I don’t mean like his buddies at the auto parts store who think they’re so big because they can boss their women around. I mean like a real man who can stand for something. BILL: And what does it tell you that he stands for? ELLEN: That he’s a man who respects his wife and family, and that’s important to me. From there we moved into a discussion of respect and family as powerful shared values and their commitment to building a family of respect even though their family got little respect out in the world. We talked about Ellen’s spirituality and Manny’s sense of humor and ferocious cultural pride.

Circulation Questions The development of an audience that can witness and honor changes strongly supports the solidification of those changes. Circulation questions help identify and recruit such an audience. The following are examples of such questions:

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“Now that you’ve accomplished these changes, who else should know about them?” “What difference do you think it would make in their attitude toward you if they had this news?” “Would it be better to go along with people’s old ideas about you or to catch them up on these new developments?” “What would be the impact of those people hearing about these developments?” “What would be the best way of letting them know about these accomplishments? When asked who should hear about these changes, both Manny and Ellen identified their mothers. Manny’s deceased father had been quite abusive of both Manny and his mother, and Manny was often in a position of having to comfort his mother. She used to say to him, “Wives stick by their husbands no matter what. When you marry, treat your wife right because she will be the only one that you can always count on.” He thought his mother would be comforted to hear about the husband he was becoming. Ellen thought her mother should also hear about the changes in their relationship. Ellen’s mother had disapproved of their relationship and had not come to their wedding, which was a cruel blow for Ellen. When Ellen and Manny began to have problems, Ellen found herself wondering whether her mother was right and now felt it was important to let her mother know about the changes.

Problem Resurgence Questions Problems can often make reappearances in people’s lives. The questions below can be used to anticipate such possible reappearances and develop contingency plans. “If this problem were to attempt a comeback, how would you first notice that?” “What might give you an indication that this problem was coming back?” “What might be the first sign of that indication?” (Continue to trace back.) “What have you learned about managing this problem in the past?” “What of that knowledge could you bring to addressing its attempted comeback?” Questions like these help further solidify the abilities, skills, and wisdom that clients have developed in dealing with problems. Having

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a preexisting contingency plan in place should problems reappear helps clients to remember those problems as difficulties they have effectively managed in the past. It is useful to help families develop plans that draw on their own natural networks rather than reengage with services. Often, the simple fact of having a contingency plan in place provides enough reassurance that clients may not need to recontact therapists. Manny, Ellen, and I reflected on factors that might pull them away from Loving Friendship. Ellen observed that she would notice herself beginning to hang onto her resentments and not sharing them with Manny. We examined how that might begin to occur and what they both had learned about building an atmosphere in which Ellen would not be silenced. We also examined what might pull Manny away from Loving Friendship, and he admitted that when Ellen raised concerns with him, he sometimes heard the voice of his buddies at the auto parts store teasing him about being such a “wimp” around his wife. He acknowledged that those voices could pull him back into trying to assert his “authority” over Ellen, and they both agreed the results would be disastrous. As he reflected on what had helped him move toward more Loving Friendship in the first place, he decided to put a picture of his mother in their bedroom as a reminder of the way his father had treated her and his desire to be a different kind of husband. Ellen decided she wanted to use her best friend as a sounding board to make sure she was neither minimizing concerns nor holding onto resentments.

Client Wisdom Questions Client wisdom questions seek to capture the important lessons clients have learned in their experiences with particular problems. Examples of such questions include the following: “I periodically meet with other families struggling with the same kind of problem you described. From what you now know, what bits of wisdom would you have to offer them?” “If they were to ask you about what you’ve learned in dealing with this problem, what would you say to them?” “Much of what I’ve learned about helping families comes from my work with families. Based on what you’ve learned in your accomplishments, what thoughts would you have for professionals trying to help other families with similar issues?”

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These questions have many beneficial effects. They bring forth wisdom and expertise that can be helpful for other clients and therapists. They also elicit ideas from clients that can be brought back into their own lives. One family remarked, “You know, these are great ideas we’re coming up with. We should remember them.” These questions open space for further investigation of how the wisdom that emerges might be relevant in clients’ own lives. In this process, the focus is not on simply soliciting sound bites of advice, but rather on eliciting more nuanced reflections. Finally, these questions have empowering effects on clients and set a foundation for a more mutual and emotionally powerful ending. Examples of reflections by Manny and Ellen are highlighted in the section on using termination/consolidation summaries. However, when I asked them about their wisdom for other couples who might be working to reclaim their relationships from Fighting, they built on each other’s ideas in a way that exemplified a Loving Friendship. The process invited the enactment of their newly developing couple identity. In this way, the questions can be seen as an invitation to live into and solidify preferred alternative stories of identity. The process of soliciting lessons for therapists serves a further dual purpose. When I have asked clients these questions, I have invariably found their responses interesting, useful, and moving. Their input has enriched my practice, and for that I am grateful. However, I am primarily interested in the effects of this process on clients. Clients have been pleased (and at times surprised) to be asked about their thoughts and have responded eagerly. The process of consulting with them shifts their status from that of a recipient of services to that of a more equal participant in the therapeutic relationship. It legitimizes and honors their knowledge and expertise and breaks down the barriers between professionals and clients. It decreases a “less than” experience of self for clients and invites increased participation in both therapy and their lives. Questions that solicit client expertise in this way have empowering effects and enhance clinicians’ work with clients.

Other Applications of Consolidation Interviews This interview format can be used in a variety of situations. It is easily adapted to quarterly reviews or other transition points in therapy. I have often used this format for midcourse corrections (in agencies these are often structured in as quarterly reviews). In one instance, a couple were unsure whether to continue or take a break from therapy. I asked them a number of questions from this format, and they recommitted to therapy with a different focus. Another example of an initial interview

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using this format involves a family with an adolescent girl returning home from a residential placement. Rather than begin with an inquiry into why she had left home and entered a residential program, I began with a focus on the family goal of making reunification work. Following the consolidation interview outline, I elicited and documented the changes that all family members had made during the residential placement, the wisdom and capacities they had developed in that time, how they had accomplished those changes, who should now know about these changes, and lessons learned that might be applicable to other families who were reuniting after a residential placement. The family members were particularly taken by the questions about their lessons for others. As they responded to those questions, they reflected on the progress they had each made and the things they had learned. In this way, we began our work together grounded in their knowledge and expertise, which was a better foundation from which to examine their doubts and fears about living together again. Many clients and families have remarked on the power of these types of interviews. Their significance can be amplified when they are marked by a document or symbol that concretizes them. These interviews can be videotaped, and clients can be given a videotape. They can also be documented in therapeutic letters. Finally, we can utilize symbols or rituals that extend the interview. The couple who recommitted to therapy rewrote their wedding vows to mark a new chapter in their relationship. The family whose daughter returned from residential placement sponsored a welcome-home party, inviting friends and family to mark not just her termination from the program but the beginning of a new life at home. At this party, her father, normally a shy and reserved man, gave a speech reflecting on their changes and honoring his daughter’s return. This shift to reunion parties as a way to mark the transition out of residential programs has been elegantly developed and described by Nichols and Jacques (1995). We can also mark interviews such as these through required paperwork, such as termination summaries.

USING TERMINATION/CONSOLIDATION SUMMARIES TO DOCUMENT NEW STORIES Clinicians who work in community agencies are routinely required to write termination summaries. Traditionally, licensing agencies require that these summaries contain the following information:

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Presenting Problem and Diagnosis Treatment Goal and Plan Client Condition and Level of Functioning at Termination Reasons for Termination Follow-Up Recommendations

Drawing on the information that emerges in a consolidation interview, we can reformat a termination summary to derive a termination/ consolidation summary that is both useful to clients and fits licensing requirements. The following outline highlights a format for a termination/consolidation summary that can be coauthored with clients: Initial Concerns • Client/family’s initial concern • Level of concern (1–10) • Effects of problem(s) on family members Therapy Goals and Plan • Agreed-upon focus of therapy • Therapy plan (Who did what to address that focus) Course of Therapy • Current level of concern (1–10) • Comparison of initial and current levels of concern • Client/family contribution to changes Status at Termination • Rationale for termination • Early warning signs of possible problem resurgence • Client/family plan to solidify progress and address possible problem resurgence Follow-Up Recommendations • Family/therapist recommendations for family • Family recommendations for other families and therapists working on similar problems An example of a collaboratively derived termination/consolidation summary, based on the work with Manny and Ellen, is highlighted below. Appendix E also outlines this format.

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Termination/Consolidation Summary Initial Concerns Manny and Ellen Rodriguez sought counseling for help with “Unfair Fighting.” Although Unfair Fighting erupted over a number of different issues, the couple described the following fairly consistent pattern: Ellen would have concerns that she had trouble articulating and Manny had trouble hearing. As these concerns grew, Ellen would begin criticizing Manny in ways that he perceived as “stinging.” Manny would not respond to her criticisms until he became infuriated and would then verbally “explode.” His strong explosions would shock Ellen into stunned silence. As her resentments began to build again and she felt silenced and unable to talk with Manny, the pattern would repeat itself. Manny and Ellen were both very concerned about the strength of Unfair Fighting and agreed it had taken up 90% of their relationship. Even though Unfair Fighting had never become physical, it took a significant toll on both Manny and Ellen, who felt very cut off from each other, and on the children, who were quite fearful when it occurred. The couple sought counseling to address these concerns.

Therapy Goals and Plan In reflecting on the foundation for their relationship, Manny and Ellen agreed that they loved each other and valued the times when they were close friends. The agreed-upon focus of therapy was to help them better anchor their relationship in Loving Friendship by reconnecting to the foundation they had developed over the years and examining the forces and pressures that pulled them away from relating to each other in ways that reflect Loving Friendship. We met every other week for 5 months to accomplish this.

Course of Therapy Our work in counseling together compared and contrasted the couple’s prior relationship overtaken by Unfair Fighting and their developing relationship anchored in Loving Friendship. We explored gendered beliefs and the couple’s experiences of cultural violence as Latino people as a context for the violence in Unfair Fighting. The couple reported that considering the broader context helped to depersonalize the fighting between them and shift their perspective on each other. At termination, Manny and Ellen agreed that they had reduced the presence of Unfair Fighting in their relationship from 90% to 50%. They saw this as a “huge” shift in their relationship. Although they still have fights, they describe the fights as much different now. Manny’s outbursts are much less explosive, Ellen is not afraid of his anger, and she no longer feels emotionally abused by him. The couple reports the following changes that contributed to this huge shift.

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• Manny began to listen more to Ellen and think about the effects of his explosions on her. He felt his explosions were unfair and drew on cultural values of respect and family to develop fairer ways of relating to her. • Ellen drew on her stubbornness and spirituality to convey her concerns to Manny in ways that were less “stinging” and more compassionate. • The couple, drawing on their sense of humor and pride in family and culture, began to shift from being adversaries arguing about their children’s schools and future, to being allies who shared a common vision but different paths.

Status at Termination3 Therapy is ending because Manny has been laid off from his job and the couple has lost their health insurance. They are unable to pay a full fee and do not want to consider a sliding-scale fee. Manny and Ellen feel reasonably secure that they will be able to continue the changes they have made. We anticipated ways in which the couple could be pulled away from a relationship anchored in Loving Friendship. Ellen stated that she would notice herself beginning to hang onto resentments and not sharing them with Manny, which could lead to their growing and leaking out as “stinging criticisms.” Manny observed that when Ellen does share her concerns with him, cultural stereotypes about men being “king of the hill” and “in charge of their women” might encourage him to respond negatively to her criticisms and attempt to “assert his authority.” We also discussed Manny’s unemployment as a potential stressor on the relationship. Their plan to solidify progress and address these potential concerns include:

• A plan to talk with their respective mothers to validate and support these changes.

• Ellen will continue to talk with her best friend as a way to ensure that she is not holding onto resentments and to get other opinions about whether Manny’s explosions are becoming a concern. • Manny can tell by the “look on Ellen’s face” when she’s upset with him and has agreed to ask her how she’s doing at those times to help develop a better atmosphere for sharing her concerns. Manny does not have friends with whom he feels he could talk honestly about his explosions, but has agreed to call the therapist and check in if either he or Ellen become concerned about his explosions.

Follow-Up Recommendations At the conclusion of therapy, we discussed recommendations that Ellen and Manny would make to other couples struggling against the effects of Unfair

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Fighting. The couple offered the following recommendations for other couples and agreed that the suggestions would be very useful for themselves as well:

• It is important to remember the difference between intent and effects. Someone may not mean to hurt another’s feelings, but when that person does, it is important to acknowledge and apologize for the effects of their actions before trying to explain that he or she didn’t mean it. It is also important for the hurt person to assume that the other had good intentions despite the bad effects. • It is important for men, in particular, to put themselves in their wives’ shoes and think about what the relationship is like from their perspective. • It is important for couples to get away from the daily routine of children and life and find time to have fun. Having fun together reminds couples of why they got together in the first place and keeps the relationship alive. If Manny and Ellen decide to return to counseling, I would be very willing to meet with them.

COMMENTS ON THE TERMINATION/CONSOLIDATION SUMMARY I kept in touch with Manny and Ellen periodically for 6 months, and they continued to keep their relationship anchored in Loving Friendship. Although they still had periodic fights, they were overall pleased with the direction of their relationship. They reported that they found the termination/consolidation summary helpful and kept it in a drawer by their bed as a periodic reminder of “how far they had come.” There are several options here. One option is to transpose this summary into a therapeutic letter summarizing the work. A letter is more personal and offers possibilities to pose questions that further extend the conversation. In an age of computers, it is easy to write a termination/ consolidation summary and then cut and paste a letter that adds such questions. Another option is to send the report itself, which holds certain legitimacy as an official document. Choices can be determined by therapist and family preferences and what seems best suited for a particular situation. A termination/consolidation summary written in this fashion also holds certain advantages for clients in its effects on other helpers. The report humanizes clients and invites a consideration of them as more than just another case. Follow-up recommendations that reflect their wisdom and knowledge are potentially more applicable and immediately useful to clients in the future. Another helper reading the report

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coauthored with Manny and Ellen a year later could inquire about how the couple is doing with their distinction between intent and effects, or how Manny is doing with his suggestion that men should step into their partners’ shoes, or whether the two of them are finding time to remind each other of why they got together in the first place. These questions could quickly initiate an effective conversation that would be immediately relevant to the couple. Finally, a termination/consolidation summary written in this fashion represents a significant shift in how and for whom reports are written. Traditionally, termination reports document professional efforts with clients and are written to summarize our work for the benefit of another professional who might read it at some future date. This format documents clients’ efforts and is written to summarize their work for their benefit. Thus, the proposal for writing termination/consolidation summaries in this way reflects another example of an attempt to shift our work from professional turf to family turf.

SUMMARY This chapter has highlighted ways to use written documents to enhance the development of alternative stories between sessions and solidify our work with clients at the end of services. The use of therapeutic letters is a powerful clinical practice that can help clients hold onto what is important to them in sessions and provide a way to continue and extend therapeutic conversations. Letter-writing campaigns can become a literary equivalent of witnessing teams, in which therapist and client collect a series of letters from people in the client’s community that document their experiences of the client outside the influence of the problem and support the enactment of a new life. Finally, consolidation interviews provide a vehicle for helpers and clients to reflect on their work together and engage in a process that summarizes and acknowledges that work. Termination/consolidation summaries can become an important means of documenting the knowledge that emerges from these conversations. In this way, termination/consolidation summaries become professional reports that are co-developed with clients with the express purpose of summarizing their work for their benefit, while also meeting institutional requirements. This utilization of institutional requirements to enhance a collaborative clinical practice has been periodically explored throughout this book. The final chapter explores ways to develop institutional structures and organizational cultures that support more respectful and responsive ways of relating to clients.

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NOTES 1. Even though clients rarely object to a therapist’s taking notes, the process of asking their permission conveys respect and a willingness to make the therapist’s actions accountable to them. If a client were to express reservations, I would seek to understand those hesitations, offer a rationale for my request, offer to let the client keep the notes or a copy, and seek to find a way to work out an acceptable compromise. A number of clients have objected when I’ve asked their permission, but we have always been able to work out an acceptable compromise and they have thanked me for involving them in the decision. 2. It is important to note that Anya, in her role as a community support worker, had the flexibility and organizational support to “hang out” and spend a vast amount of time with Diana. This example highlights the importance of our availability to fit “services” to client needs rather than simply offering a menu of predetermined categorical services to which clients must fit. This again underscores the crucial importance of working on client turf rather than on professional turf. 3. Most licensing agencies require that termination summaries include a diagnosis and global assessment of functioning (GAF). Although I did not include that information in the copy of the report that I sent to Manny and Ellen, they were aware of it.

CHAPTER 10

Sustaining a Collaborative Practice in the “Real” World

In this book, I have emphasized the importance of how we approach clients and highlighted conceptual models and clinical practices that help clients and families envision and develop preferred lives. However, the full enactment of these ideas requires attention to the context of clinicians’ work. The organizational cultures in agencies shape workers’ interactions with clients. A relational stance of an appreciative ally is enhanced by institutional structures that support an appreciative organizational culture. Much of my more recent work has focused on helping community agencies develop institutional structures and organizational cultures that support collaborative clinical practice. In the process, I’ve encountered three interrelated challenges. First, collaborative approaches run counter to many dominant professional assumptions and practices. In that context, they can seem strange or unusual, and workers embracing these ideas can feel as though they are working “against the current” or somehow breaking unspoken rules or conventions. They may come to question themselves, become tentative in taking up these ideas, and slide back into old habits. It is difficult to support a shift in clinical ideology in isolation. Even when clinicians feel confident and solidly rooted in these ideas, there are pressures and demands that can pull them away from collaborative, strength-based practice. The documentation requirements of licensing agencies and current reimbursement structures direct workers’ attention toward problems and away from resourcefulness. Taken323

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for-granted professional ways of speaking privilege professional expertise and certainty over collaboration and curiosity. And managed care policies and the current push for evidence-based practice emphasize preestablished, replicable procedures over thoughtful and flexible clinical principles and can lead to a simplified conceptual process that erodes clinical imagination. These pressures force clinicians to become, in a sense, “bicultural,” pursuing preferred practices while responding to existing organizational demands.1 Finally, high workloads and dwindling resources lead to increased job stress and make it difficult to engage in reflective practice. Organizational responses to funding cutbacks (such as moving from salaried to fee-for-service positions, reducing supervision time, and cutting training budgets) exacerbate this situation by increasing professional isolation and reducing opportunities for learning and reflection. These effects show up in worker complaints such as “I don’t have time to think” and “I’m working too hard to work smart.” In the midst of organizational turmoil and competing demands, taking time to reflect on preferred practices may seem like an unattainable luxury. However, unless we periodically step back and reflect on the intentions, hopes, and preferences that bring us to this work, we run the risk of losing our mooring and becoming automatons. In this final chapter, I examine these interrelated challenges and offer beginning ideas to shape our efforts in addressing them.

MAINTAINING A REFLECTIVE PRACTICE The Introduction to this book began with the story of Kire, a relatively new family therapist who faced a challenging clinical dilemma and wondered, “What the heck do I do now?” The Introduction continued by emphasizing the importance of taking time to reflect on larger questions such as why are we meeting with families, what is our purpose in meeting with families, how are we relationally positioned in our conversations with families, how are we thinking about families and problems in those conversations, and, finally, what are we saying and doing (and not saying and not doing) in those conversations? The proposal that we take up these questions amid organizational frenzy may seem like an absurd suggestion. I contend that it is a basic necessity that actually saves time. I admit that this proposition can require a leap of faith, but teams that have taken that leap uniformly report that it is time well spent. One example is a team of child protective workers in an impoverished urban area who moved from crisis management to reflective practice. The team members committed to a

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weekly group supervision that focused on how they thought about families and emphasized the values that organized their work. They looked for successful interactions with families and traced out their small, daily practices in those interactions. The group members also recognized that their decisions with families had consequences and attempted to anticipate possible consequences and adjust their practice in advance. This led to a profound shift in which they came to encounter very few unpredicted crises and to have better relationships with families, with significantly fewer children in placement (which meant less collateral work and paperwork and more time for contact with families). Their motto became “Nothing is a crisis” (quite an accomplishment in child protective services), and they had a very low staff turnover rate over 5 years, which contributed to further stability and tremendous cost savings to the department. Reflection does not have to be time-consuming. It is possible to do it in brief stints. For example, my spouse and I have different approaches to housecleaning. I prefer to do it in large 3-hour stints, whereas she prefers to do it in small 2-minute stints (in between making toast or coffee). She is able to find significantly more 2-minute stints and accomplish much more cleaning. Similarly, in our work, we can develop brief daily practices of reflection (e.g., briefly noticing the sky or trees around us and taking a breath when we step outside, or taking a 1-minute pause before meetings to briefly consider “What is my purpose in being in this meeting, and what tendencies or ways of responding would I like to bring forward and hold back to help me accomplish that purpose?”). I invite readers to consider what small, daily practices could help to slow down your day or offer a momentary break from a frenzied pace. Beginning here helps us to develop a foundation for addressing these other challenges.

EXAMINING THE VALUES, ASSUMPTIONS, AND PRACTICES THAT SHAPE PROFESSIONAL LEGITIMACY Many clinicians committed to collaborative approaches have experienced their work at one time or another as being perceived by others (and perhaps by themselves) as somehow less “professional.” This undermining of the professional legitimacy of alternative practices occurs in a broader context of taken-for-granted professional values, assumptions, and practices. The concept of “discourse,” previously used to examine the influence of unspoken cultural values, assumptions, and practices on clients, can also be helpful in developing a better understanding of workers’ experience. Rachel Hare-Mustin (1994, p. 19)

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defines discourse as a “system of statements, practices, and institutional 2 structures that share common values.” Professional discourses include taken-for-granted assumptions (e.g., effective therapy begins with a thorough assessment of the problem, ethical therapy requires appropriate boundaries, etc.), unexamined professional habits (e.g., the use of DSM diagnoses, the use of professional jargon, the ways in which meetings are organized, etc.), and the professional institutions within which these assumptions and actions exist. These are all intertwined. Taken-forgranted professional assumptions shape how we act, and our actions maintain prevailing assumptions. The interaction between assumptions and practices occurs in the context of economic, political, and cultural institutions that both support and are supported by this process. In mental health and social services, these institutional forces include such things as (among others) paperwork requirements, insurance forms, course work requirements in graduate school, questions on licensing examinations, conference workshops, materials in professional and selfhelp books, pharmaceutical advertisements, and television shows about mental illness. All of these contribute to a collective sense of how things “should” be. Discourses function as a set of “truth claims” or invisible assertions that sit in the background of our work and are difficult to question. In our lives, we are subjected to multiple and often conflicting discourses (e.g., there is currently a push for both more strength-based, collaborative approaches and more medicalized approaches, each of which vie for legitimacy). However, over time, certain discourses become dominant and hold more sway in professional cultures. Dominant discourses both reflect prevailing social and political structures and tend to support them. For example, language such as “service providers and service recipients” both represents particular power relations between helpers and clients and perpetuates those dynamics. Professional discourses shape professional identity and how we, as clinicians, understand our work. Assumptions and practices that fit within dominant discourses make sense and are legitimized. Ideas and practices that fall outside dominant professional worldviews don’t “fit” and can be experienced as strange or weird. Often, this “lack of fit” is hard to put into words, but is experienced as a sense that something is just “not right.” In this way, discourses contribute to the construction of professional identity and constrain alternative possibilities. Clinicians seeking to embrace collaborative approaches in traditional settings often find themselves at the center of conflicting pulls growing out of a medical model and a more collaborative approach. This experience can have disorienting effects on their professional sense of self and their interactions with colleagues. In my own work,

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I’ve found it useful to place the challenges that arise here in a context of three sets of juxtaposed professional discourses (deficits and possibilities, professional expertise and collaboration, and protection and accountability). Although each juxtaposition could be seen as an oppositional dichotomy (either/or), I prefer to view them as differing pulls (both/and). The goal of these juxtapositions is to provide a framework for better understanding the challenges that practitioners can experience. Although the three are complexly intertwined, in the following discussion I separate them out and briefly examine each in turn.

Juxtaposing Discourses of Deficits and Possibilities The first juxtaposition is a discourse of deficits and a discourse of possibilities. An emphasis on deficits is reflected in the common assumption in mental health and social services that our job is to identify problems, discover their causes, and then intervene to cure or ameliorate those problems. This assumption is reflected in (and sustained by) the common practice of writing assessments with an emphasis on problem, precipitant, risk factors, and diagnosis. An example of this emphasis on deficits in action comes from the experience of a woman who recently started social work school. She describes a number of small classes that begin with unstructured check-ins and notes the following: “Most people talk in check-ins about things that are bothering them, and I often wonder if they find these things because they look for them. I think we can invent problems this way. Sometimes I wanted to tell the class about the wonderful morning I was having or how excited I was to be on this journey, and I found myself worrying that they’d think, ‘She’s out of touch with her emotions and what is really going on for her.’ ” This drift toward emphasizing problems over possibilities (e.g., “Here’s what I’m learning, here’s what I’m excited about, here’s who I’m becoming in this program,” etc.) reflects the operation of a discourse of deficits (the unexamined assumption that we “should” be talking about problems and the practices that accompany that assumption) as well as a subtle socialization of graduate students into that way of operating as professionals. An emphasis on possibilities is reflected in attempts to help families envision and live into nonproblematic, preferred lives. There is a focus on what is and could be rather than on simply what isn’t and should be. This assumption is reflected in (and sustained by) practices such as envisioning preferred directions in life and reauthoring conversations that

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develop broader stories. Although an emphasis on possibilities has many beneficial effects on clients (outlined in Chapter 1 under “Advantages of a Belief in Possibilities and Resourcefulness”), it can also be experienced as minimizing problems and may leave clients feeling unheard. It’s important to strike a balance between problems and possibilities and to make sure that we address both. It’s also important to acknowledge that an emphasis on deficits receives significantly more institutional support than an emphasis on possibilities. Although there is growing institutional support for strengths-based practice, a discourse of deficits receives considerable institutional support from managed care requirements (the need to show medical necessity for reimbursement), clinic licensing requirements (the requirement of diagnosing clients), and professional training (the prevalence of courses that emphasize psychopathology).

Juxtaposing Discourses of Professional Expertise and Collaboration A second juxtaposition is a discourse of professional expertise and a discourse of collaboration. Many traditional approaches are informed by a medical model that positions helpers as “experts” who assess clients, develop treatment plans, and implement interventions designed to bring clients more in line with “appropriate functioning.” There is a privileging of professional knowledge that can invite practitioners into professional certainty with attempts to assign professional meaning rather than elicit client meaning. The assumption of professional expertise is reflected in (and sustained by) the ways in which assessments are conducted (who asks the questions and writes the assessment) and “cases” are presented (the encouragement of objectivity, professional distance, and certainty in delivering formulations). An example of how the unquestioned acceptance of professional expertise has both seeped into and is supported by broader cultural assumptions comes from an encounter with an old neighbor from my own childhood whom I came across years later. When he learned that I was a psychologist, he remarked, “Oh, so when I say hello, you’re the person who knows what I really mean by that.” This assumption that there are experts who know more about a person’s experience and its meaning than the actual person can become quite problematic. It runs the risk of obscuring client knowledge, which limits our available collective wisdom. And it has potentially disempowering effects on clients as they are asked to “hand over” their expertise on their lives to professionals. This privileging of professional knowledge over client wisdom is supported by (and in turn supports) the social, political, and economic

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institutions that constitute the mental health industry. An example of this is heard in a radio ad for a for-profit psychiatric hospital for adolescents. The ad listed a number of problematic (yet not uncommon) adolescent behaviors and concludes with, “Are you afraid that you are losing your child? Call us for a free consultation and we’ll give your child back to you.” The free consultation was with a clerk from the hospital intake department. This corporate construction of a product need has become a profitable enterprise that both supports and is supported by this highlighting of professional expertise. An emphasis on collaboration honors the expertise of all involved parties. Clients are viewed as experts on their experience, with significant abilities, skills, and know-how, and clinicians are viewed as experts in hosting conversations that invite reflection, expand possibilities, and open space for the consideration of alternative experiences, views, and actions. This assumption is reflected in (and sustained by) practices like collaborative inquiry and a therapeutic stance of “not knowing” or cultural curiosity in which we approach each family as a unique culture and seek to understand its experience of the world. Although an emphasis on collaboration encourages client participation and involvement, it can also support a tendency to minimize the leadership role of clinicians in therapeutic relationships and obscure the power dynamics of those relationships. Again, it is important in our work to strike a balance between these differing pulls and simultaneously acknowledge that they respectively receive differing levels of institutional support. In our culture, certainty and expertise are often given more credence than curiosity and collaboration.

Juxtaposing Discourses of Protection and Accountability A final juxtaposition is a discourse of protection (professional responsibility for clients) and a discourse of accountability (professional responsibility to clients). A focus on protection is based on the assumption that clients are in a vulnerable position and that professionals have a responsibility to appreciate that vulnerability and ensure client safety. This assumption is reflected in (and sustained by) practices of confidentiality, involuntary hospitalizations, and the filing of neglect or abuse allegations when children are at risk. These practices are crucially important in our field and I am not in any way intending to demean them. A focus on protection can also be reflected in concerns about clients seeing their records (legal rights notwithstanding), disclosing diagnoses to clients, or having clients participate in clinical discussions. At times, this focus can have paternalistic effects as helpers take on increasing responsibility for making decisions about clients’ lives. The ways in which helpers

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respond to issues of client vulnerability and safety can be inadvertently disempowering of clients and undercut client welfare. While it is important to appreciate the positive intention behind a protective impulse, we can also critically reflect on possible paternalistic effects. Examples of such effects in a discourse of protection in action come from a therapist who encourages the parents of a developmentally delayed girl to lower their hopes for her in her life, or the head of a clinical review team who forbids a mother to attend a meeting because it might be too stressful for her. The purpose of these examples is to highlight the “voice of protection” operating in the background so that we can reflect on its effects and decide how we would like to relate to that voice. I am not suggesting we discard professional responsibilities, but that we carefully consider how we carry them out. A discourse of protection is supported by hierarchical professional relationships (“The doctor will see you now”), professional language (“cases” and “case managers”), and liability concerns (which have only grown as resources have diminished and more risky situations are being handled in the community). A focus on accountability assumes that clients are the best judges of the effects of professional actions on them and that our work benefits from taking client feedback into account. This assumption is reflected in (and sustained by) practices of transparency in which we share our organizing thoughts and assumptions in order to help clients become more aware of why we are asking what we are asking so as to help them participate on a more equal footing. It is also reflected in (and sustained by) practices that elicit client feedback in order to ensure that our efforts have empowering rather than inadvertently disempowering effects on clients. Although a discourse of accountability can have profoundly empowering effects on clients, it is also important to keep in mind client vulnerability and carefully consider factors that might constrain clients from speaking openly in giving their feedback. In responding to client feedback, it is also important to carefully consider our own thoughts and opinions, and to remember that working in partnership requires an appreciation of helpers’ voices as well as clients’ voices.

REFLECTING ON PROFESSIONAL DISCOURSES In reflecting on this juxtaposition of professional discourses, it is important not to view these descriptions as polarized dichotomies nor to misinterpret the discussion as simply a call to abandon “bad” discourses in order to step into “good” ones. We are all continually operating within a variety of discourses, and each may have both beneficial and negative effects on our work. The important point here is to acknowledge that

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our taken-for-granted assumptions and practices have effects and to encourage reflection on those effects. At the same time, a focus on deficits, professional expertise, and protection receive significantly more institutional support in our field than a focus on possibilities, collaboration, and accountability. Ways of thinking and practicing that fall outside dominant discourses are often seen as weird, illegitimate, or downright strange, and can easily be marginalized. Our work can be enriched when we examine the discourses that organize it and consider how those discourses fit with our preferred ways of relating to clients and families. Although professional identity has traditionally been rooted in client deficits, professional expertise, and professional responsibility for clients, it is interesting to ponder what a definition of professionalism might look like grounded in possibilities, collaboration, and professional responsibility to clients. The accusation of acting “unprofessional” has often been used to police professional actions. Imagine the effect if a definition of professionalism included accusations like: • It is unprofessional to inquire about difficulties without having first built a foundation of competence, connection, and hope. • It is unprofessional not to actively elicit client or family members’ wisdom that could contribute to resolving difficulties in their lives. • It is unprofessional to use objectifying language in any clinical discussion without considering how clients might experience it or how it might shape our thinking about clients. • It is unprofessional not to actively think about the ways in which our own assumptions about race, gender, class, and sexual orientation affect our interactions with all clients. • It is unprofessional not to routinely solicit clients’ feedback about their preferences for the direction of therapy and the effects of our actions on them. I invite you, as a reader, to consider other examples of “unprofessional” behavior within this new paradigm. The goal of this exercise is not to replace one set of professional specifications with another, but rather to expand our options in defining “professionalism” and increase our awareness of the discourses that operate on us all. The following questions provide an opportunity for further reflection about the discourses that shape our professional identities: • What are the taken-for-granted assumptions about what counts as “professional” behavior in your work context?

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• What might be some of the effects of these assumptions on your relationships with clients, other colleagues, and your professional self? • Which organizational assumptions and practices invite you to step into collaborative approaches, and which hold you back? • In what ways have you continued to embed your work in collaborative approaches in the face of organizational assumptions and practices that make it difficult? • How have you done that, and what has supported you in doing so? • How can you draw on and further embed your work in organizational assumptions and practices that support you in developing your preferred clinical practice? Finally, as has been highlighted repeatedly, the enactment of preferred directions in life and work is considerably enhanced by a community of support. The following reconnection questions can help clinicians develop allies for preferred ways of working: • What would be included in your definition of “professionalism” (a useful format for this might be “I am committed to grounding ”)? my work in a spirit of • How did that commitment come to be particularly important to you? What does it say about your hopes and dreams for your work? • As you think back across your life, who stands out as someone who would recognize and appreciate your efforts to keep your work grounded in this commitment? (Please feel free to search broadly in thinking about the answer. You might identify a current colleague; a person in your life outside work; a teacher, mentor, or fellow student in your professional training; someone who has passed on; an author or presenter whom you respect; a book or article you’ve read; a client you’ve worked with; etc.) • How is this person important to you in your life? What does he or she know about you or what has he or she witnessed that would tell this person that this commitment is important to you? How do you think the person’s witnessing of this commitment may have touched his or her life? If this person were somehow listening in on your responses, what do you think he or she might be thinking about them? • What’s it like for you to think about this person’s response and invoke his or her presence? What would help you hold onto this person’s presence (virtually or actually) in your work?

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The development of a community of support can provide clinicians with a strong foundation for pursuing preferred practices in the face of implicit pressures to “fit in.” It is important here for clinicians not to contribute to the development of an “us and them” mentality in which they develop a community of support in order to ignore and discount concerns raised by colleagues. Rather, the purpose of these questions is to help clinicians respond reflectively to others’ feedback without being undermined by that feedback. The questions above are an important start to help us, as clinicians, to shift our relationship to professional discourses that marginalize collaborative practice. However, we can go further and develop institutional structures that actively support collaborative practice.

BUILDING INSTITUTIONAL SUPPORTS FOR A CLINICAL PRACTICE OF POSSIBILITY, COLLABORATION, AND ACCOUNTABILITY Just as clients benefit from a supportive community standing behind them, the full development of a collaborative clinical practice requires organizational support. Community agencies committed to this approach can support it by developing organizational cultures that embed clinicians in an atmosphere of respect, connection, curiosity, and hope. To offer beginning steps toward this goal, the next sections examine ways to shift clinical discussion formats, clinical and administrative paperwork, and quality assurance practices to help institutionalize this atmosphere.

RETHINKING CLINICAL DISCUSSIONS As a result of a workshop about parent involvement, a protective worker insists that a mother attend a team meeting about her son’s future. At the meeting, six different team members in turn begin describing their respective observations about the mother’s difficulties in relating to her son. Their language is filled with acronyms and professional jargon. The conversation increasingly becomes a meeting of helpers talking about the family rather than a meeting with the family about services that might be helpful to them. The worker becomes concerned about the mother’s reaction to this intense scrutiny of her incompetence as a parent, but doesn’t quite know how to interrupt the process. She begins to wonder whether this idea of parents being present at professional meetings is a huge mistake.

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There has been an important increase in parent participation in professional meetings. However, we need to move beyond parents being present at meetings to parents being a presence in meetings. Ann Turnbull and Jean Summers (1987) have likened this shift to the Copernican revolution in the natural sciences. Copernicus suggested that the sun rather than the earth was the center of the universe and revolutionized science. The parallel revolution in mental health and social services would be to place the family at the center of the universe and view the service delivery system as one of many planets revolving around it. In this reorganization, we move from parents attending meetings to families being at the center of meetings and helpers moving into a primarily supportive and facilitative role (with space also being made for the sharing of professional wisdom as one of multiple knowledge sources). Some important first steps in this revolution would be to dramatically expand our efforts to include clients in meetings, to remember that ultimately the goal of such meetings is to help clients in their lives, and to organize our meetings in ways that increase client influence and participation. If clients can’t attend, we can outline what is likely to be discussed, ask how they would like their voices brought into the meeting, and jointly develop ways in which we can bring the conversation from the meeting back to them. Although these are crucial initial steps, the task of fully supporting parents in becoming a presence in meetings about their lives requires a shift in our meeting formats and the ways in which we speak about families, both in meetings they attend and in those they are unable to attend.

Clinical Meetings as Definitional Ceremonies Broadly speaking, we can identify two types of clinical meetings. One type may be generically classified as “determination meetings,” in which there are efforts to generate a particular direction in the work. Examples of these meetings are educational plan meetings, foster care review meetings and residential discharge meetings. Another type could be generically classified as “formulation meetings,” in which helpers, or helpers and a client, attempt to develop or clarify their thinking about the client’s situation. Examples of these meetings include intake meetings, case presentations, multidisciplinary teams meetings, and group supervision or consultation meetings. Based on the repeated assertion that every interaction with clients holds the potential to invite the enactment of particular life stories, we can view clinical meetings as definitional ceremonies or public rituals that shape client identities (Meyerhoff, 1978, 1982, 1986). With this in mind, it is important to consider the process as well as the outcome of

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these meetings. We can continually reflect on the life stories that clients are being invited to enact in our meetings with them and how that fits with the stories we would prefer to be inviting. This is not to suggest that we gloss over uncomfortable or hard topics, but rather that we have difficult conversations in ways that encourage experiences of competence, connection, and hope as much as possible. As there are many different types of determination meetings, it is difficult to outline structures that would apply across contexts. However, the following questions offer broad evaluative criteria that can help organize such meetings: • Where are we, as professionals, positioned in this conversation? Is this where we would prefer to be positioned? How can we talk about difficult subjects so that we are more likely to be experienced by clients as appreciative allies without sugarcoating the topic? • As clients participate in this meeting, are they more or less likely to experience themselves as being in a relationship with a problem rather than having or being a problem? How can we talk about problems in ways that support clients in viewing themselves as being in an ongoing and modifiable relationship with the difficulties in their lives? • Is this meeting organized around an agreed upon focus that represents a proactive shared vision? How can we begin meetings by developing agreements on preferred directions in life (or acknowledging and discussing differences when they exist)? • As clients participate, are they more or less likely to experience this meeting as a collaborative inquiry process? How can we organize our discussions in ways that amplify rather than constrain client influence and participation in this meeting? If we desire to deliberately constrain client influence and participation in this meeting, what is the rationale for that and how can we do that as respectfully as possible?

Reformatting Formulation Meetings Although this section primarily focuses on a format for formulation meetings, the overall format can also be adapted for determination meetings. Efforts to help families envision preferred directions in life, identify supports and constraints to preferred lives, and draw on their resourcefulness to address those challenges can be best supported by following a parallel process in clinical discussions. The following consultation ques3 tions support such a parallel process :

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• Who is in this family, and what are its members like outside the problem that brings them to you? Can you help us develop a three-dimensional picture of them and the context in which they live? What do you like about them, and what might they like about working with you? What do you feel proud of in your work with them (even if it is just a glimmer of pride)? • What safety concerns would be important for us to not lose sight of in this situation? What has helped the family acknowledge and address these safety concerns? • In 25 words or less, what would family say they’re working toward with you? • How would they say the work has been going (on a scale of 1– 10)? What would they say is contributing to things going well? What would they say is getting in the way of things going better? • How would you say it’s been going (on a scale of 1–10)? What would you say is contributing to things going well? What would you say is getting in the way of things going better? • What is it like for you working with this family? What do you like most about working with this family? What is the hardest thing about working with this family? What are you learning from working with this family? This format begins by eliciting a picture of the family and clinician outside the influence of the problem in order to obtain a fuller picture of the situation. Throughout the questioning process, supervisors, consultants, or team members can look for elements of competence, connection, safety, and hope. In this process, it is important to not lose sight of moments in which families and/or therapists may feel incompetent, disconnected, unsafe, or hopeless. It is crucial to have a thorough understanding of elements of risk. At the same time, threads of competence, connection, and hope are the foundation on which safety is built. The first two sets of questions attempt to construct such a foundation and set a tone for the remaining conversation. From here, we can ask questions about where therapy is headed from the family’s perspective. The question “In 25 words or less, what would family members say they’re working toward with you?” has three distinct elements. The phrase “In 25 words or less” asks for a concise summary, attempting to preclude a descent into a recitation of voluminous details. The phrase “family members” invites the therapist to step into the family’s perspective, supporting an attitude of cultural curiosity. And the phrase “working toward with you” implies both a future orientation and a collaborative partnership. Inviting therapists to step into client experience and consider a proactive focus for their work can in and

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of itself be quite useful. At the same time, when clinicians have difficulty with this question, it can direct attention to the need to develop an agreed-upon focus to guide collaborative work. The remaining questions assess both supports and constraints for therapeutic effectiveness. Throughout this process, we can look for both forward movement (as defined by the family and clinician) and constraining interactions and beliefs. As constraints begin to emerge, supervisors, consultants, or the team can help workers shift their relationship to those constraints. If we think about constraints as separate entities, we can draw on externalizing conversations to examine therapists’ relationships with those constraints. This process can then be thought of as a reauthoring interview to help therapists shift their relationship to those constraints. Conceptualizing this process as a reauthoring interview represents a different way of thinking about it. The focus is not on offering suggestions about what to do, but rather helping workers shift their relationship to constraints that hinder their effectiveness. Workers who have reordered clinical discussions in this way describe beneficial effects. For example, consider one worker’s response to such a format: “It felt great to build on what I was doing right rather than to have people tell me what I should be doing instead and then try to correct their misperceptions. I’m walking out of this meeting with much more energy and confidence, and I think I will carry that into my work with the family. It’s got a momentum of its own now.” At the same time, old habits die hard, and as professionals we have a lot of work to do in developing more respectful ways of speaking about clients. An important step in addressing these habits is to increase our sensitivity to the possible negative effects of taken-for-granted ways of talking about clients. The next section offers a way to help us in this endeavor.

Integrating a “Client Voice” in Clinical Discussions The idea of integrating a “client voice” in clinical discussions is based on the social constructionist assumption that identity is shaped in social interaction and our conversations with and about clients have subtle, but powerful effects on clients’ experience of self. With this in mind, it becomes important to carefully consider how we organize both the conversations we have with clients and our internal conversations about them. Our internal conversations about clients are often shaped by clinical discussions with other professionals. If clients cannot attend these

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meetings, we can structure such discussions in ways that include “client voices” by having someone on the team sit off to the side, listen to the discussion in the role of the client being discussed, and subsequently be interviewed by the team about his or her experience of the discussion (Madsen, 1996, 2004). This process can be facilitated in a number of ways. A typical format follows. After a discussion about the usefulness of therapeutic practices being accountable to the clients they are designed to help, participants are asked whether they would be interested in engaging in a process designed to increase their sensitivity to possible positive and negative effects of taken-for-granted ways of talking about clients. If they are willing, the process can proceed through the following steps: • A clinician is interviewed about a family or presents information about the family to the rest of the group, who listen and then ask questions of clarification. One member of the team is chosen to sit to the side in the role of a particular family member who represents the “client voice” and listens but does not participate in the discussion. • The group conducts a reflecting team discussion about the material presented. • The clinician reflects on the team discussion. • The group interviews the person who has listened in the role of the client voice about his or her experience of the discussion. • The group debriefs. Questions for the person listening in the role of the client voice often include examples such as: • What was this process like for you, and what reactions did you have to it? • What about the process felt respectful and empowering? What effects did that have on you? • Were there parts of our discussion that felt unhelpful, disrespectful, or disempowering? What effects did that have on you? • How could we have had the discussion in a way that addressed difficult issues and yet minimized those effects? Many participants have found the process very intriguing. In addition to participants receiving valuable direct feedback from the person in the role of the client voice, clinicians in the role of the client have found it to be a powerful experience, gaining firsthand knowledge of both positive and inadvertent negative effects of common professional practices.

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The power of this format grows over time. As more participants spend time in the role of the client, the voice becomes a stronger presence in the room. Although the primary purpose of utilizing the client voice is to provide participants with constructive feedback about taken-for-granted professional ways of speaking, many groups have found that the voice often provides an interesting and useful contribution to the clinical discussion as well. The process has also had interesting ripple effects. A student in a seminar that utilized a “client voice” process began raising questions at his practicum site about how clients would regard team clinical discussions. An outpatient therapist referred to the use of this process to open a conversation with her supervisor about how they could talk differently about clients in supervision. A mental health case manager who learned about this process in a workshop suggested it for a larger systems meeting that a mother could not attend. As the client voice becomes stronger in clinical discussions, participants become emboldened to respectfully advocate for clients in other settings.

Considerations in the Use of the “Client Voice” It is important that participants fully agree to participate and authorize use of the client voice to give them candid feedback. It’s also important that team members who are discussing a client have permission to be inadvertently offensive in their comments as long as they are willing to receive feedback about and address the effects of those comments. It helps when there is a foundation of trust in the group. At times, the person in the role of the client voice has spoken bluntly and passionately, and this process works better when it is done lovingly and in a way that honors clinicians’ best intentions. One danger of this format is that it can have silencing effects on clinicians, who may respond by saying only “nice, positive” things about clients. The intention in this process is not to sanitize clinicians’ conversations about clients, but to help them increase their sensitivity to the effects of unexamined professional ways of talking and to find respectful ways of having difficult conversations about clients. In fact, the format can be seen as an opportunity for practice, with the team members receiving feedback from the client voice that both acknowledges what they are doing well in the process and offers suggestions for continued improvement. The process flows more smoothly when team members are clear that critical feedback from the client voice is offered as a critique of taken-for-granted professional practices, rather than a critique of individuals, and such feedback is offered with a recognition that all are trying to develop more respectful ways of discussing hard topics.

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There are also times when using a client voice might be less useful; that is, when a clinician wants to examine difficult personal reactions to a client, and the conversation is focused more on the therapist than the client. This format is based on a belief that the person at the center of the conversation should have a say in who is to be involved in that conversation. If the conversation is primarily about a clinician rather than a client, it makes sense that the clinician determines who participates in it. At the same time, it is important to keep a clinician-centered discussion focused on the clinician and ensure that the conversation does not drift into a focus on the client. We can also reflect on whom to include as the client voice. Generally, teams have either picked a family member whose perspective would be useful to hear or have sought out the most marginalized voice in a clinical situation. Often this voice is not a family member. Some of the more interesting “voices” have been those of other helpers with whom a clinician has difficult working relationships. Although we have generally listened to one voice (in the interest of time), it is possible to enroll several voices. For example, Harlene Anderson (1997) has described a similar process using multiple voices, which she refers to as an “As If” exercise. This format has also been used constructively in management discussions about workers and academic discussions about students. This format can have a lasting impact on participants. One student reported that as a result of this process, she now carries two voices in her head when she does therapy. She experiences a “supervisory voice” reminding her to be a good diagnostician and conduct a thorough assessment, and a “client voice” reminding her to be an authentic human being and develop a strong relational connection. According to her report, the two voices usually complement each other. This is an intriguing comment. Although it is a fairly common experience to internalize a supervisory voice, the additional internalization of a client voice holds the potential to shift how we think, talk, and act with clients. Our efforts to shift clinical discussion formats and make those discussions more accountable to the people they are designed to serve offer ways to develop a more respectful clinical atmosphere. The next section examines ways to shift the context of writing about clients.

RETHINKING CLINICAL PAPERWORK A licensing auditor was examining records in an agency as part of a site review. As he reviewed the record of a teenage boy diagnosed with bipolar disorder, he noticed, much to his dismay, that one of the treatment goals was that the boy would raise his reading level

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(the boy was barely able to read). In a conversation with the program director, he criticized that goal, saying it had nothing to do with the boy’s bipolar disorder and hence was inappropriate for a mental health organization. He went on to give examples of appropriate goals: helping the boy become medication compliant, helping the family accept and understand the boy’s disorder, or helping the boy develop a better awareness of his disorder in order to manage it more effectively. The director replied that the goal was in the chart because the mother had requested it, believing the boy had to learn how to read in order to support himself in the future. As part of the program review, the auditor met with the mother. When he asked about how the program had been helpful to her family, she immediately responded, “They’ve helped us help him learn to read. That’s been the most important thing anyone has ever done for him.” If we want to support clinicians in making their work relevant and important to clients, we need to develop ways of documenting the work that supports this endeavor. These days, there is a lot of talk about involving consumers in treatment planning and utilizing treatment planning to “drive” the treatment. However, if the definition of what constitutes an acceptable goal remains unexamined, we may inadvertently drive treatment in a direction counter to our preferred values. Alternatively, we may simply go through the motions in completing paperwork and then do the “real” work outside that process, creating additional work and contributing to a lack of accountability in our work. Much of the paperwork we use in the field is based on a medical model and organizes our thinking in particular ways. It decontextualizes and medicalizes people’s lives. Carole Warshaw (1995, p. 75), a physician who was originally trained in internal medicine and later completed a residency in psychiatry, reflects on the effects of the medical model in examining problems in living: The medical model in fact is designed to extract information from the context of the patient’s life that gives it meaning to her or to him and transform it into medical events that have meaning for the clinician. It reduces information to categories that can be readily handled and controlled, transforms symptoms into disorders that can be treated or managed, and dismisses anything that does not fit the diagnosis or treatments that are known and available to that particular clinician or specialty. There is no room for the patient to say: “This is what is important to me.”

When paperwork requirements direct attention away from those issues that are important to families, we risk developing form-centered services rather than family-centered services. It is important that we

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develop paperwork that supports and enhances our work rather than simply documents it. The assessment process is a profound intervention. The questions we ask in assessments shape the stories clients tell us about their lives and their experience of self in the process. With this in mind, it’s important to structure assessment questions in ways that both highlight client resourcefulness and invite descriptions of difficulties in nonblaming and nonshaming ways. Although this challenge may seem difficult, given the licensing requirements that guide many clinics, it is not impossible. Chapters 2, 4, and 9 highlight generic outlines for assessments, collaborative therapy plans, and termination/consolidation summaries that fit licensing requirements and accomplish this. These outlines are summarized in Appendices A, C, D, and E. The process of assessment can also be reconsidered. There are several inherent risks when one party assesses another. Clients, as the objects of assessment, may feel objectified and disempowered. The process of assessment may also encourage distance and disconnection in the relationship between the assessor (clinician) and the assessed (client). One way to use the assessment process constructively is for therapists to shift from a role in which they, as professional experts, assess clients, to a role in which they and clients together draw on their mutual expertise to collaboratively assess problems that have come into clients’ lives. In this process, the concerns raised about an assessment process can be used to mutual advantage. As therapists and clients externalize and jointly assess problems, they increase the possibility that problems will become objectified and disempowered. A joint assessment of externalized problems may also encourage a distancing in the relationship between clients (the assessors) and problems (the assessed). This possibility is discussed in more detail in Chapter 2, and Appendix B contains a series of questions (clustered under assessment headings) that can be asked of clients to engage them in this type of assessment process. In this way, the institutional requirement of completing assessments can support preferred clinical practices and have empowering effects on clients. Next, we examine administrative paperwork.

RETHINKING ADMINISTRATIVE PAPERWORK Over the last few years, there has been a proliferation of forms in many agencies. We can distinguish between administrative forms (e.g., forms such as patient information forms, agreements to accept services, limits of confidentiality forms, explanations of clients’ rights and responsibilities, release of information forms, audiotape or videotape release forms) and clinical forms (e.g., assessment forms, therapy contracts, progress

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notes, quarterly updates, and termination summaries). Many of the administrative forms exist to register clients, maintain compliance with licensing standards, or initiate reimbursement mechanisms. These forms are often viewed as annoying but necessary evils. However, if we refer to the repeated assertion that everything we do with clients has the potential to invite the enactment of particular life stories and influence the therapeutic relationship, we are well served by attending to clients’ experience of completing forms. The process of filling out initial forms can be seen as an engagement ritual. Do we want clients’ initial contact with an agency to be channeled through a set of forms? How can we structure the process of completing forms so that it acknowledges, supports, and amplifies people’s participation and influence in their lives? How can we develop forms and organize the process in ways that help to humanize initial contact and encourage respectful connection? One way to attend to the process of completing forms lies in how we explain particular forms. For example, the process of completing release of information forms is often approached very matter-of-factly. We can come to assume that conversations with other professionals about clients are a right, rather than a privilege granted by clients, and can approach the requisite signing of a release form as a bureaucratic inconvenience. However, clients may experience the form as notice of our intention to engage in professional gossip and can feel objectified and disempowered or have any number of reactions. As one example of contextualizing administrative forms, consider the following introduction to a release of information form: I have found that I’m able to be most helpful to individuals, couples, and families when I can coordinate my efforts with other services they may be receiving or have received from other helpers. To do that, I’m requesting your permission to talk to other professionals in order to get their ideas about how I can be more helpful to you. I will be glad to share with you the ideas I receive, if you would like.

This introduction contextualizes the request to contact other helpers and opens more space for a conversation about the purpose of such communication and the conditions that clients may wish to attach to their permission. One way to encourage a different response to paperwork is to build such contextualizing introductions directly into our forms. Doing so institutionalizes the practice. However, when using more traditional forms, we can verbally contextualize them. The important point is to attend to clients’ experience of filling out forms and attempt to organize that process in ways that highlight rather than constrain clients’ influence and participation in their lives.

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RETHINKING QUALITY ASSURANCE A midlevel manager comes into an executive team meeting and sighs as she thinks about all the work that has gone into responding to documentation requirements for an upcoming audit. She looks to the team and says, “You know, I’ve been thinking, if our clinicians related to clients the way we’ve been relating to our clinicians, we’d fire them.” A close colleague responds, “You’re probably right, but if we don’t pass this audit, they won’t have jobs anyways.” If quality care rests on a foundation of relationships characterized by respect, connection, curiosity, and hope, how do we develop organizational cultures that institutionalize these qualities, both in how clinicians are encouraged to relate to clients and in how supervisors and administrators are encouraged to relate to clinicians? The following ideas represent some initial thoughts designed to stimulate thinking “outside the box” rather than to provide definitive answers. One organizing criterion for evaluating agency policies and procedures is to subject them to the following questions: • How does this policy or procedure encourage clinicians and supervisors, respectively, to attempt to better understand the phenomenological realities of families’ lives and workers’ work? • How does this policy or procedure promote attention to client and worker resourcefulness? • How does this policy or procedure support and enhance clients’ and workers’ influence and participation in the development of their lives and work? • How do we ensure that we are continually including client and worker voices in organizational reflection on the effects of policies and procedures on them? In posing these questions, I am not suggesting that managers abandon their organizational responsibilities to hold workers accountable for job-related performance, but rather recommending a reconsideration of how that is done. The ways in which managers fulfill an organizational responsibility to hold workers accountable shape the organizational cultures in which they both function. How do we develop institutional practices that are deliberately crafted to build organizational cultures grounded in a spirit of possibilities, collaboration, and accountability, rather than fall into organizational cultures that have developed as a byproduct of responding to institutional demands? As a beginning step to becoming more conscious about the cultures we create in everyday inter-

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actions, let’s examine alternatives for approaching outcome measures, utilization review and quality assurance procedures, and mechanisms to elicit consumer input.

Outcome Measures With an ever-present push for documenting effectiveness, the field is continually searching for valid and reliable measures through which to assess treatment outcomes. A practical “show me the results” orientation increasingly permeates our culture. This trend ranges from the growth of standardized testing at all grade levels in education to the rise of evidence-based practice in mental health and social services. In this era, programs that can demonstrate improved outcomes receive increased legitimacy among funders. It is crucial that we develop ways to ensure that our efforts are helpful to clients and constitute a wise investment for funders. At the same time, what we attempt to measure and how we attempt to measure it have effects on clients, workers, and therapeutic relationships. I’d like to raise several concerns about developing trends in outcome measurement and offer some questions that can constructively guide our efforts to bring outcome measurement in line with the values and principles that organize this book. The attempt to identify the essential factors of treatment protocols that contribute to positive outcomes for particular conditions, and then consistently apply them across situations to help clients, has a strong appeal in theory. However, there are translation difficulties when this approach is brought to real-world therapeutic interactions. Client experience is complex and nuanced and doesn’t fit neatly into predetermined categories. The attempt to isolate specific actions that contribute to change ignores the importance of the therapeutic relationship as a jointly developed process. And it is difficult to separate a particular clinical practice from the person practicing it and the social field in which it occurs. As highlighted in Chapter 1, 40 years of psychotherapy outcome studies have consistently emphasized the importance of client and relationship factors and suggested that particular therapeutic actions contribute a minimal amount to outcome. In addition, Pulleyblank Coffey et al. (2001) have identified a disturbing trend in community mental health toward an increasing emphasis on preestablished, replicable procedures over thoughtful and flexible clinical principles. They believe this trend results in simplified clinical thinking and eroded clinical imagination. At a time when services are becoming increasingly standardized and bureaucratized, the attempt to match specific therapeutic procedures to particular conditions encourages the development of approaches that can be easily encoded in a

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manual and replicated, and further contributes to an assembly-line ethos. It can lead to an atmosphere in which clients increasingly experience clinicians as acting on them rather than working with them. This instrumental focus is disempowering to clients. It may also encourage the development of “stuck treatment.” Clients who resent the experience of being “acted upon” may respond in ways that professionals interpret as “noncompliance” or “resistance.” Professionals, under increasing pressure to “show results,” may respond by pathologizing or countering client responses. The resulting behavioral sequence can lead to therapeutic stuckness (a rather ironic outcome of efforts originally designed to promote clinical effectiveness and cost-efficiency). As emphasized repeatedly, every interaction with clients is a clinical intervention. As such, what life stories do we want to be inviting in our attempts to ensure that we are being effective within a limited budget? Let me be very clear here. I am not suggesting that we discard concerns about clinical effectiveness or cost-efficiency, nor am I suggesting that we simply throw money at problems without evaluating the results of our investments. It is important that we ensure that our efforts are helpful to clients and constitute a wise investment for funders. The challenge is how to do that in ways that support a collaborative spirit. The following questions offer some guidelines in approaching this challenge: • How do we ensure that client voices are included in outcome measurement efforts to ensure continued accountability to the people we serve? • How do we develop nuanced measures that recognize that a particular clinical practice cannot be separated from the clinician practicing it and that therapeutic relationships are jointly developed? • How do we develop measures that recognize the uniqueness of human beings and encourage tailoring our efforts to particular clients rather than specific conditions? • How do we take into account the importance of client factors and relationship factors as the two biggest contributors to psychotherapy outcome as we attempt to develop outcome measures, and not focus only on isolated techniques (even though they may be easier to measure)? • Finally, how do we think carefully about our intentions, purposes, and values in this work to ensure that we are measuring what is valuable rather than simply valuing what is measurable? These are difficult and thought-provoking questions. As a beginning step in addressing them, I highlight two approaches to outcome measurement

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that support a collaborative spirit, encourage client participation, and promote accountability to those we serve. A qualitative approach to outcome measurement could draw on collaborative inquiry, as outlined in Chapter 5. At the beginning of joint work, we could ask members of a family, “How will we know that what we’re doing here is helpful?” At the end of services, we could go back and evaluate progress in light of those early comments (while also inquiring about ways in which the family’s initial impressions may have changed over time). The consolidation interview outlined in Chapter 9 offers a series of concrete questions to guide this process. In this approach, outcome measures are collaboratively developed with families, become immediately relevant to families, and directly support our clinical work as a co-research process. We could also examine themes that emerge across interviews to develop a grounded theory about contributions to positive outcome. An empirically based quantitative approach is exemplified in the efforts of Barry Duncan, Scott Miller, and Jacqueline Sparks (Duncan & Sparks, 2005; Duncan et al. 2003; Miller, Duncan, Brown, Sparks, & Claud, 2003) to move from evidence-based practice to what they call practice-based evidence. Practice-based evidence refers to a process of eliciting client perspectives about outcome (how clients are doing in their lives) and process (how therapy is going) in a way that provides immediate and ongoing feedback for clinicians. They have developed two simple, user-friendly scales that take about a minute each to complete and are completed at each session. The Outcome Rating Scale (ORS) offers a simple way for clients to evaluate how they’re doing in their lives in terms of personal, interpersonal, social, and overall well-being. The Session Rating Scale (SRS) offers a simple way for clients to evaluate how therapy is going in terms of factors known to be related to effective therapy (the degree to which clients felt heard, understood, and respected, the degree to which therapy focused on what clients deemed important, the degree to which clients felt the therapist’s approach was a good fit for them, and the degree to which the session felt right for clients). Through completing these scales, clients are invited to become active participants in the measurement process. The scales provide ongoing immediate feedback, as well as openings for therapeutic conversations about how things are going. This immediate feedback enhances clinical effectiveness and reduces the number of no-shows and cancellations. Duncan and Sparks (2005) document an elaborate outcome management system that integrates the use of these scales in a comprehensive fashion.4 Most research approaches strongly encourage the development of multiple measures, and a combination of qualitative and quantitative

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approaches have the potential to help us develop a rich appreciation for the information we are trying to obtain. These two examples are offered both as possible vehicles and as mechanisms to invite further reflection on the challenge of responding to the push for documenting effectiveness in a way that enhances clinical work, is consistent with family-centered values and principles, and organizationally conveys the importance of client participation and professional accountability in services.

Utilization Review and Quality Assurance Mechanisms Public sector agencies are under intense scrutiny by both funders and the public. Part of that scrutiny is reflected in agency utilization review/ quality assurance (UR/QA) teams that meet to review clinical records or charts. These reviews typically focus on whether paperwork is completed and meets certain regulatory requirements. Those regulatory requirements are traditionally based on a medical model and promote selective attention to certain aspects of records and inattention to others. UR/QA processes are a regulatory requirement that can also be used to support the ideas presented throughout this book. For example, in addition to the required questions on a UR/QA form, we could include the following questions: • Are individual, family, and broader contextual issues adequately considered? • Does this record promote sufficient attention to client resourcefulness? • Does this record convey a tone of respect for the client or family? Admittedly, the inclusion of these questions adds more work. However, excluding them runs the risk of ceding quality assurance to disconnected bureaucratic requirements rather than keeping it anchored in the foundation of respect, connection, curiosity, and hope that has consistently been shown to enhance therapeutic effectiveness. In addition to broadening the scope of UR/QA, we can shift the way in which the process is organized. I used to chair a UR/QA team in a mental health clinic. In that context, we were bound by licensing regulations and the combined tyranny of too many records and too little time. Despite our attempts to humanize the process, a common anticipatory response on many clinicians’ part was a fear of “flunking UR.” If clinicians’ interactions with families invite the enactment of particular stories about their lives, administrators’ interactions with clinicians can also invite the enactment of particular stories about their work. Based on this assumption, a number of questions can be raised about our adminis-

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trative practices. What would be the consequences of acknowledging and honoring what is present in clinicians’ work as well as searching for what is missing in the documentation of that work? How can UR/QA teams be developed as appreciative audiences for clinicians’ work while also meeting regulatory requirements? And how can administrators, supervisors, and clinicians find ways to openly discuss and share their dilemmas in embracing a family-centered philosophy while responding to licensing regulations that often operate from a very different set of assumptions? These questions support a spirit of possibilities, collaboration, and accountability. Weaving that spirit into the organizational culture may be the most important contributor to quality care. The ways in which organizations treat their employees will be directly reflected in how workers treat clients. If organizations want workers to work from a stance of an appreciative ally, they need to develop a culture that will support that stance. This can be a difficult endeavor for administrators, who also operate under significant organizational pressures. As an exadministrator who often was pulled into reacting to staff in ways that didn’t reflect my values, I realize this all too well. Again, I am not suggesting that managers abdicate organizational responsibilities, but that they reflect on how to approach those responsibilities in ways that are consonant with the values to which they aspire.

Eliciting Client Input One of the best ways to ensure quality is to elicit feedback from the clients we serve. They are the best judges of the effects of our efforts, and the process of seeking their feedback has therapeutic effects. Eliciting client input to improve services has beneficial effects both clinically and programmatically. We can seek client input in a variety of ways. At a very immediate level, we can continually check with clients to see how our work is going. For example, at the end of sessions, I routinely check with people to see what from the meeting they want to remember and carry away with them, and what will help them to do that. This provides a transition to then periodically ask some of the following questions: “I want to make sure that what we’re doing is working for you. How is this going for you? Are we moving in a direction that works for you?” “Are we talking about the right things? Are there things we should be talking about that we’re not?” “What direction do you hope we’ll move in over the next month?” “Are there factors outside our meetings that are affecting our work together?”

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“How will you know when therapy is coming to an end? What will have changed that will tell you that ending makes sense?” “Is there anything you need to know from me in order to make this conversation easier? At a broader level, many programs that receive public funding are required to conduct consumer satisfaction surveys. Such surveys provide a powerful way to elicit consumer feedback about our efforts to help them and yield a potential gold mine of valuable information to ensure quality of care. In consumer satisfaction surveys, we can ask scaling questions such as: “To what extent did you feel that we made an effort to understand the uniqueness of your life and family? How did we do that? How could we do that more?” “To what extent did you feel your abilities, skills, and wisdom were acknowledged and honored by us? How did we do that? How could we do that more?” “To what extent did you feel treated with respect and as an important partner in our work with you? How did we do that? How could we do that more?” “To what extent were you encouraged to be an active participant in our work with you? To what extent did we ask for your feedback throughout the process? How did we do that? How could we do that more?” Questions such as these convey a message about agency priorities and subtly organize our interactions with families. These questions also invite clients to reflect on their lives and can have beneficial clinical effects. In this way, they both support our clinical work and contribute to an appreciative organizational culture. We can also put more effort into the development of consumer advisory boards and develop ways to help them hold agencies truly accountable. We can make human rights committees more than a regulatory requirement and give clients a role in the governance of agencies. Finally, we can involve parents in developing proposals for funding (paying them as we would any important consultant) and, at a state level, in developing requests for proposals from agencies. Examples of such efforts include those by Peter Fraenkel (2006) in the collaborative development of programs for homeless families attempting to move from welfare to work, along with similar efforts by Marcia Sheinberg, Peter Fraenkel, and Fiona True in developing programs for sexually abused children and

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their families (Fraenkel, Sheinberg, & True, 1996; Sheinberg, True, & Fraenkel, 1994; Sheinberg & Fraenkel, 2001).

ADDRESSING THE LARGER CONTEXT OF ORGANIZATIONAL FRENZY Even when clinicians are thoroughly grounded in their commitment to a collaborative approach and have organizational structures that support them in that commitment, there is still the problem of extreme workloads and dwindling resources. For example, consider the following two stories: A clinician comes into a family therapy seminar in a community agency and breaks into tears. “I can’t stand it,” she says catching her breath, “I’m so frustrated and angry that I keep trying to do a job that just can’t be done. I’m cutting corners left and right in order to get done all that I’m responsible for, and I’m scared to death that I’m going to be caught and held responsible for what I’m not doing.” She concludes by apologizing for breaking down. A worker, contacted to assess training needs for his program, despairingly replies, “Unfortunately, the idea of getting any training right now feels self-abusive. If I focus on what my work could look like, I won’t be able to tolerate what it has to look like right now. There is no room to apply new ideas, and learning about them just feels like a setup to me. I’m hanging on by a thread here.” Clearly, when a person’s experience of work is similar to these stories, it becomes difficult to hold onto respect, connection, curiosity, and hope with clients. The workers in these two stories are experienced, competent helpers who are passionately dedicated to their work. Their stories, although distressing, are not unusual. In the process of providing training and consultation for community agencies and public sector workers, I encounter stories like these every day. The common themes are overwhelming frustration, severe emotional strain, exhaustion, and demoralization. These elements have often been collectively described as “burnout” and attributed to the difficult nature of the work and seen as an effect of prolonged exposure to clients’ suffering and misery. However, in an phenomenological study of child protective workers (one of the most likely groups to be candidates for burnout), Joyce White (1996) found that although all of the participants described their jobs as extremely difficult, frustrating, and overwhelming, they did not attribute

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their distress to clients, but rather to organizational problems such as high caseloads, inadequate resources, too much paperwork, and wasted time in transportation. One worker put it this way: I think that, although my clients often wear me down, I am somehow inspired by them. . . . I have no idea how they manage to live their lives. . . . [S]ome of my clients . . . have to manage with so little. So little money, so little support, that I’m stunned, really, at their strength and their creativity. I think that in this era of cutbacks it’s probably gotten a lot worse for them. . . . I find my clients funny, lovable, different, amusing. Sometimes I’ve had clients that I consider brilliant . . . I very rarely actually get depressed by my clients themselves. (in White, 1996, p. 133)

Their relationships with clients and colleagues actually buffered these workers from the disconnection and alienation that developed out of organizational difficulties. Many clinicians would agree that dealing with the organization of the work is much more difficult than direct client contact. Clinicians describe having too much to do with not enough time and too few resources, being overwhelmed with paperwork, and feeling exasperated with bureaucratic dilemmas and continually shifting mandates. As evidenced above, the relationships developed with clients have the potential to buffer workers against these organizational stresses. In this way, therapeutic relationships grounded in respect, connection, curiosity, and hope both anchor quality care and provide an effective bulwark against contextual forces that inadvertently undermine quality care. Legitimizing professional discourses of possibility, collaboration, and accountability, and building in institutional supports (alternative clinical discussion formats, revisions in clinical and administrative paperwork, different quality assurance mechanisms) can go a long way to alleviating the effects of organizational frenzy. At the same time, it is important to acknowledge and confront funding priorities that make the implementation of this work a near impossible task. It is important that supervisors and administrators acknowledge and bear witness to the heroic efforts of frontline workers and take forceful stands against the all-too-common demeaning of public sector workers. It is important to keep an acknowledgment of the dilemmas caused by underfunding on the table and part of an ongoing conversation in community agencies. It is important that workers, supervisors, and administrators all take steps to engage in self-care and collective care. And it is vital that we all raise questions about current funding priorities at local, state, and federal levels and advocate for funding that would truly allow us to build a system of care characterized by respect, connection, curiosity, and hope.

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NOTES 1. Ellen Pulleyblank Coffey and colleagues (Pulleyblank Coffey, 2004; Pulleyblank Coffey, Olson, & Sessions, 2001) have written two powerful articles documenting these trends in community mental health and offering additional ideas in addressing them. 2. Although the use of the term “discourse” can seem foreign and unwieldy, it best captures this interrelated combination of values, assumptions, practices, and institutional structures. 3. These questions are designed to be asked of the therapist. If a family were at this meeting, the same format could be used, with one person posing the questions to family members and the clinician. 4. For readers interested in learning more about these measures and their use, please consult www.talkingcure.com.

APPENDIX A

One Example of a Strength-Based Assessment Outline

Identifying Information • Demographic information Description of the Family • Brief appreciative description of client, family network, and community supports (attach genogram or eco-map) • Living environment and recent changes in household composition • Family hopes and preferred directions in life Presenting Concerns • Presenting concerns in the words of the referral source • Client/family response to referral • Client/family members definition of their concerns (in rank order) • Client/family vision of life when concerns are no longer a problem Context of Presenting Concerns • Situations in which problem(s) is most/least likely to occur • Ways in which client and others are affected by problem(s) • Client/family beliefs about the problem(s) • Family interactions around the problem(s) • Cultural supports for the problem(s) From Collaborative Therapy with Multi-Stressed Families, Second Edition, by William C. Madsen. Copyright 2007 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers of this book for personal use only (see copyright page for details).

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Family’s Experience with Helpers • Client’s/family’s current involvement with helpers • Client’s/family’s past experience with helpers • Impact of past experience on view of helpers Relevant History • Multigenerational history organized by theme that captures presenting concern, constraining interactions, beliefs and life stories, and experiences with helpers Medical Information • Status of physical health and relationship to the presenting concerns Mental Status • Effects of presenting concerns on concentration, attention, memory, etc. Risk Factors and Safety Factors • Suicide, violence, sexual abuse, neglect, substance misuse • Personal, familial, and community abilities, skills, and knowledge that protect from risk and promote safety • Individual and family preferences, intentions, and hopes that protect from risk and promote safety Diagnosis • DSM diagnosis if required (may also include client colloquial language) • Ways in which client’s experience is different from standard description of that diagnosis Formulation • Include information that addresses: 1. Client’s/family’s hopes and preferred direction in life 2. Existing supports and constraints at biological, individual, family, network, and sociocultural levels (as appropriate)

APPENDIX B

Questions to Assess Externalized Problems Rather Than Families

Description of the Family • Who are the important people in your lives? • Can you tell me about your life together outside the immediate problems that bring you here? • As I get to know you better, what do you think I might particularly appreciate about you? • Where would you like to be headed in your life together? Presenting Concern • What is the referral source’s biggest concern? • What is your reaction to that? • What concerns do you have? (in rank order) • How will your life look different when these concerns are no longer problems? Context of Presenting Concern • In what situations is the problem most/least likely to occur? • What is the effect of the problem on you and your relationships? • How does this problem interfere with your preferred life together? • How do you explain the problem? • How have you attempted to cope with the problem? • What broader cultural support does the problem receive? From Collaborative Therapy with Multi-Stressed Families, Second Edition, by William C. Madsen. Copyright 2007 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers of this book for personal use only (see copyright page for details).

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Family’s Experience with Helpers • What helpers are currently involved with you? • What has been your past experience with helpers (good and bad)? • What impact does that have on your view of helpers? • How might that affect our work together? Relevant History • What is the history of the relationship between the problem and you? • When has the problem been stronger/weaker in the history of that relationship? • When have you been stronger/weaker throughout the history of that relationship? • What has supported the problem’s influence on you (family-of-origin level, family–helper level, broader sociocultural level)? • What has supported your influence on the problem (family-of-origin level, family–helper level, broader sociocultural level)? Medical Information and Risk Factors • What effects has the problem had on your physical health? Has it exacerbated existing medical concerns for you or others? • What, if any, interactions has the problem had with suicidal ideation, violence, substance misuse, sexual abuse, or neglect in your lives? Formulation • Where would you like to be headed in your life together? • What constraints stand in the way of your getting there? • What abilities, skills, and wisdom might you draw on to address those constraints?

APPENDIX C

Considerations in Collaborative Therapy Contracts Agreed-Upon Focus of Therapy (Long-Term Goals) If we think about therapy as support for a journey toward preferred directions in life, the agreed-upon focus of therapy can be thought of as a brief, anticipatory summary of that journey. Long-term goals that are proactive and collaboratively developed set a direction for joint work. This long-term focus provides direction and a context for short-term goals. It helps to make our work relevant to clients and organizes therapy in a way that becomes focused on the development of life outside the problem rather than on the “correction of dysfunction.” In this way, therapy fits to the context of clients’ lives, rather than attempting to fit clients to the context of therapy.

Short-Term Goals Short-term goals refer to the immediate goals to be addressed in therapy that provide a foundation for the pursuit of preferred long-term directions in life. Short-term goals need to fit in the context of the agreed-upon focus of therapy and to be developed collaboratively. The language in which goals are framed is important. Goals need to strike a balance between capturing clients’ imaginations and remaining concrete, specific, and achievable. Framing goals in specific terms helps to keep clients more clearly focused on their preferred directions. It is also important to develop goals that are achievable. A future focus invites hope and a sense of movement. Goals that are too ambitious or difficult can quickly sabotage that movement. Finally, it is useful to help clients define goals that represent the beginning of new behaviors rather than the end of undesirable From Collaborative Therapy with Multi-Stressed Families, Second Edition, by William C. Madsen. Copyright 2007 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers of this book for personal use only (see copyright page for details).

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ones. Proactive goals lead to more efficient therapy. Whereas a goal of ending undesirable behaviors keeps us embedded in the problem, proactive goals invite us outside the realm of problems and open more possibilities.

Plan for Therapy Goals have two components: what we are aiming for, and how and what we are going to do to achieve it. The plan for therapy highlights the latter by spelling out in concrete detail who will do what, with whom, for how long in order to accomplish the short-term goals. This gives us a template against which to evaluate our work together. It allows us periodically to review what we’ve agreed to do and examine the degree to which that work fits with original intentions. In situations in which there is a discrepancy, it allows us to evaluate together our reactions to that discrepancy. Although therapy plans typically specify only the activities that will be undertaken by family members, it is important to include the efforts of various helpers as well. Therapy plans have the potential to hold workers as well as family members accountable for the actions each agrees to take.

Ways That Improvement Might First Be Noticed This section orients therapists and clients to change. By inviting reflection on how changes might first appear, it promotes attention to the direction of change rather than the magnitude of change and reinforces a proactive focus and sense of movement. The examination of ways that improvement might first be noticed is interventive and increases the probability of noticing forward momentum. Framing it as ways that improvement might first be noticed alleviates discouragement that could arise in the event that changes are not noticed and opens up space for an investigation of other ways in which improvement might first be noticed. This section also helps to break down goal attainment into concrete, measurable goals.

Indications That Goals Have Been Achieved This section helps to clarify a stopping point and make therapy more accountable to both clients and funders. It institutionalizes the question “What needs to happen for us to stop meeting like this?” It is particularly useful for clients who have had chronic involvement with multiple providers. Often, services go on and on with no end in sight. A clearly demarcated stopping point gives some structure to the work and provides us with clear, distinguishing features against which to determine the necessity for continuing services. It also helps to make services more accountable to clients. We can measure events in clients’ lives against the material in this section and use that comparison to make ongoing evaluations about whether to continue or end services. It is important in this process that these indications be mutually defined and mutually evaluated.

APPENDIX D

An Interview Outline to Consolidate Alternative Stories

Traditionally, the process of termination has been organized around a metaphor of loss. Although there are often elements of loss in termination, the process can also be viewed as a rite of passage, somewhat similar to a graduation ceremony. The following questions provide a framework for consolidation interviews. They are useful to review and amplify the changes family members have made, to develop contingency plans with families for the possible reemergence of problems, and to document client’s wisdom and solidify changes they’ve made.

Useful Questions for a Consolidation Interview Reviewing-the-Journey Questions • What were you most concerned about at the beginning of our work together? • What problems were you struggling with? • How strong were those problems (on a scale of 1–10)? • How strong would you say those problems are now (on a scale of 1–10)? • When you compare the problems’ influence at the beginning of our work with their influence now, what do you notice? Reauthoring Questions • What steps did you take to bring about that change in the problems’ influence? • How did you do that? • What does it mean that you’ve taken these steps? These ideas are based on the concepts of Epston and White (1995). From Collaborative Therapy with Multi-Stressed Families, Second Edition, by William C. Madsen. Copyright 2007 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers of this book for personal use only (see copyright page for details).

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• What does it tell you about each other and about your relationship? • What does it say about what you care about and value in your life together? • With these new achievements as a foundation, what changes might follow next? Circulation Questions • Now that you’ve accomplished these changes, who else should know about them? • What difference do you think it would make in their attitude toward you if they had this news? • Would it be better to go along with people’s old ideas about you or catch them up on these new developments? • What would be the impact of those people hearing about these developments? • What would be the best way of letting them know about these accomplishments? Problem Resurgence Questions • If this problem were to attempt a comeback, how would you first notice it? • What might give you an indication that this problem was coming back? • What might be the first sign of that indication? (continue to trace back) • What have you learned about managing this problem in the past? • What of that knowledge could you bring to addressing its attempted comeback? Client Wisdom Questions • I periodically meet with other families struggling with the same kind of problem you described. From what you now know, what bits of wisdom would you have to offer them? • If they were to ask you about what you’ve learned in dealing with this problem, what would you say to them? • Much of what I’ve learned about helping families comes from my work with families. Based on what you’ve learned in your accomplishments, what thoughts would you have for professionals trying to help other families with similar issues?

APPENDIX E

Coauthoring Termination/Consolidation Summaries with Clients

Traditional Termination Summary Licensing agencies traditionally require that termination summaries contain the following information: • • • • •

Presenting Problem and Diagnosis Treatment Goal and Plan Client Condition and Level of Functioning at Termination Reasons for Termination Follow-Up Recommendations

Based on the consolidation interview outline in Appendix D, we could coauthor termination/consolidation summaries with clients that are organized in the following fashion:

Termination/Consolidation Summary Initial Concerns • What were the family members most concerned about? • How concerned (1–10) were they? • Effects of problems on family members From Collaborative Therapy with Multi-Stressed Families, Second Edition, by William C. Madsen. Copyright 2007 by The Guilford Press. Permission to photocopy this appendix is granted to purchasers of this book for personal use only (see copyright page for details).

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Therapy Goals and Plan • What was the agreed-upon focus of therapy? • Who did what to address that focus? Course of Treatment • Current level of concern (1–10) • Family’s contribution to changes Status at Termination • Rationale for termination • Family’s plan to solidify progress • Early warning signs of possible problem resurgence • Family’s plan to address possible problem resurgence Follow-Up Recommendations • Family/therapist recommendations for family • Family recommendations for other families and therapists working on similar problems.

References

Adams-Westcott, J., & Isenbart, D. (1995). A journey of change through connection. In S. Friedman (Ed.), The Reflecting Team in Action: Collaborative Practice in Family Therapy (pp. 331–352). New York: Guilford Press. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: Author. Amundson, J., Stewart, K., & Valentine, L. (1993). Temptations of power and certainty. Journal of Marital and Family Therapy, 19(2), 111–123. Andersen, T. (1987). The reflecting team: Dialogue and meta-dialogue in clinical work. Family Process, 26(4), 415–428. Andersen, T. (Ed.). (1991). The Reflecting Team: Dialogues and Dialogues about the Dialogues. New York: Norton. Andersen, T. (1999). The reversal of light and sound. Gecko: A Journal of Deconstruction and Narrative Ideas in Therapeutic Practice, 2, 5–9. Anderson, C. M., & Stewart, S. (1983). Mastering Resistance: A Practical Guide to Family Therapy. New York: Guilford Press. Anderson, H. (1995). Collaborative language systems: Towards a postmodern therapy. In R. Mikesell, D. D. Lusterman, & S. McDaniel (Eds.), Integrating Family Therapy: Family Psychology and Systems Theory (pp. 27– 44). Washington, DC: American Psychological Association. Anderson, H. (1997). Conversation, Language, And Possibilities. New York: Basic Books. Anderson, H. (2005). Myths about “not-knowing.” Family Process, 44(4), 497– 504. Anderson, H., & Goolishian, H. (1988). Human systems as linguistic systems: Evolving ideas about the implications for theory and practice. Family Process, 29, 371–393. 364

References

365

Anderson, H., & Goolishian, H. (1992). The client is the expert: A not-knowing approach to therapy. In S. McNamee & K. J. Gergen (Eds.), Therapy as Social Construction (pp. 25–39). Newbury Park, CA: Sage. Anderson, H., Goolishian, H., & Winderman, L. (1986). Problem determined systems: Towards transformation in family therapy. Journal of Strategic and Systemic Therapies, 5, 1–13. Aponte, H. (1992). Training the person of the therapist in structural family therapy. Journal of Marital and Family Therapy, 18(3), 269–281. Aptheker, B. (1989). Tapestries of Life: Women’s Work, Women’s Consciousness, and the Meaning of Daily Experience. Amherst: University of Massachusetts Press. Asay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The Heart and Soul of Change: What Works in Therapy (pp. 33–56). Washington, DC: American Psychological Association. Bachelor, A. (1991). Comparison and relationship to outcome of diverse dimensions of the helping alliance as seen by client and therapist. Psychotherapy, 28, 534–549. Bateson, G. (1979). Mind and Nature: A Necessary Unity. New York: Dutton. Becker, C. (2005). From Chronic Conflict to Dialogue in Couple Therapy: Creating Conditions and Resources for Constructive Conversations. Course at the Family Institute of Cambridge, Watertown, MA. Belkin Martinez, D. (2005). Therapy for liberation: The Paulo Freire methodology. Retrieved April 20, 2006, from www.liberationhealth.org. Bepko, C., & Krestan, J. (1990). Too Good for Her Own Good: Breaking Free from the Burden of Female Responsibility. New York: Harper & Row. Berg, I. K. (1991). Of visitors, complainants, and customers: Is there really such a thing as resistance? Family Therapy Networker, 13, 21. Berg, I. K. (1994). Family Based Services: A Solution-Focused Approach. New York: Norton. Berg, I. K., & Kelly, S. (2000). Building Solutions in Child Protective Services. New York: Norton. Berg, I. K., & Miller, S. D. (1992). Working with the Problem Drinker: A Solution-Focused Approach. New York: Norton. Berry, M. (1992). An evaluation of family preservation services: Fitting agency services to family needs. Social Work, 37(4), 314–321. Bird, J. (2000). The Heart’s Narrative: Therapy and Navigating Life’s Contradictions. Auckland, NZ: Edge Press. Bird, J. (2004). Therapy That Sings: Therapy in a New Linguistic Key. Auckland, NZ: Edge Press. Blount, A. (1987). Systemic Approaches to Management in Clinical Settings. Conference presentation at the American Association for Marriage and Family Therapy Annual Conference, Chicago, IL. Blount, A. (1991). The Two Worlds of Mental Health Services. Conference Presentation at the American Association for Marriage and Family Therapy Annual Conference, Dallas, TX. Blow, A. J., & Sprenkle, D. H. (2001). Common factors across theories of mar-

366

References

riage and family therapy: A modified delphi study. Journal of Marital and Family Therapy, 27(3), 385–402. Bruner, J. (1986). Actual Minds, Possible Worlds. Cambridge, MA: Harvard University Press. Bruner, J. (1990). Acts of Meaning. Cambridge, MA: Harvard University Press. Burish, T. G., & Bradley, L. A. (1983). Coping with chronic disease: Definitions and issues. In T. G. Burish & L. A. Bradley (Eds.), Coping with Chronic Disease: Research and Application (pp. 3–12). New York: Academic Press. Burr, V. (1995). An Introduction to Social Constructionism. London: Routledge. Cade, B., & O’Hanlon, W. H. (1993) A Brief Guide to Brief Therapy. New York: Norton. Cecchin, G. (1987). Hypothesizing, circularity, and neutrality revisited: An invitation to curiosity. Family Process, 26, 405–413. Cecchin, G., Lane, G., & Ray, W. A. (1994). Influence, effect, and emerging systems. Journal of Systemic Therapies, 13(4), 13–21. Chasin, R., Herzig, M., Roth, S., Chasin, L., Becker, C., & Stains, R. (1996). From diatribe to dialogue on divisive public issues: Approaches drawn from family therapy. Mediation Quarterly, 13(4), 323–344. Chasin, R., Roth, S., & Bograd, M. (1989). Dramatizing ideal futures and reformed pasts: Action methods in a systemic frame. Family Process, 28, 121–136. Colorado, A., Montgomery, P., & Tovar, J. (1998). Creating respectful relationships in the name of the Latino family: A community approach to domestic violence. Dulwich Centre Newsletter, 1, 2–33. Combs, G., & Freedman, J. (1994). Narrative intentions. In M. Hoyt (Ed.), Constructive Therapies (Vol. 1, pp. 67–91). New York: Guilford Press. Connor-Greene, P. A. (1993). The therapeutic context: Preconditions for change in psychotherapy. Psychotherapy, 30(3), 375–382. Cooperrider, D. L (2000). Positive image, positive action: The affirmative basis of organizing. In D. L. Cooperrider, P. F. Sorensen, D. Whitney, & T. F. Yaeger (Eds.), Appreciative Inquiry: Rethinking Human Organization Toward a Positive Theory of Change (pp. 29–54). Champaign, IL: Stipes. Cooperrider, D. L., Sorensen, P. F., Whitney, D., & Yaeger, T. F. (Eds.). (2000). Appreciative Inquiry: Rethinking Human Organization Toward a Positive Theory of Change. Champaign, IL: Stipes. Crowe, T. (2006). Some Externalising Questions in Relation to Addictive Thinking (Self). Retrieved April 30, 2006, from www.dulwichcentre. com.au. Denton, W. H. (1989). DSM-III-R and the family therapist: Ethical considerations. Journal of Marital and Family Therapy, 15(4), 367–377. Denton, W. H. (1990). A family systems analysis of DSM-III-R. Journal of Marital and Family Therapy, 16(2), 113–126. de Shazer, S. (1985). Keys to Solution in Brief Therapy. New York: Norton. de Shazer, S. (1988). Clues: Investigating Solutions in Brief Therapy. New York: Norton. de Shazer, S. (1991). Putting Differences to Work. New York: Norton. Dickerson, V. C. (2004a). Who Cares What You’re Supposed to Do? Breaking

References

367

the Rules to Get What You Want in Love, Life, and Work. New York: Perigee Books. Dickerson, V. C. (2004b). Allies against self-doubt. Journal of Brief Therapy, 3(2), 83–95. Dickerson, V. C., & Zimmerman, J. L. (1992). Families with adolescents: Escaping problem lifestyles. Family Process, 31, 341–353. Dickerson, V. C., & Zimmerman, J. L. (1995). A constructionist exercise in antipathologizing. Journal of Systemic Therapies, 14(1), 33–45. Dore, M. M., & Alexander, L. B. (1996). Preserving families at risk of child abuse and neglect: The role of the helping alliance. Child Abuse and Neglect, 20(4), 349–361. Duncan, B., Miller, S., Sparks, J., Claud, D., Reynolds, L., Brown, J., et al. (2003). The Session Rating Scale: Preliminary psychometric properties of a working alliance measure. Journal of Brief Therapy, 3, 3–12. Duncan, B. L., Miller, S. D., & Sparks, J. (2004). The Heroic Client: A Revolutionary Way to Improve Effectiveness through Client-Directed, OutcomeInformed Therapy (rev. ed.). San Francisco: Jossey-Bass. Duncan, B. L., & Sparks, J. (2005). Heroic Clients, Heroic Agencies: Partners for Change. Ft. Lauderdale, FL: Institute for the Study of Therapeutic Change. Durrant, M. (1993). Residential Treatment: A Cooperative, Competency-Based Approach to Therapy and Program Design. New York: Norton. Ehrenreich, B. (1989). Fear of Falling: The Inner Life of the Middle Class. New York: HarperCollins. Ehrenreich, B., & Ehrenreich, J. (1979). The professional–managerial class. In P. Walker (Ed.), Between Labor and Capital: The Professional Managerial Class (pp. 5–45). Boston: South End Press. Elliot, H. (1998). En-gendering distinctions. In S. Madigan & I. Law (Eds.), Praxis: Situating Discourse, Feminism and Politics in Narrative Therapies (pp. 35–64). Vancouver, BC: Yaletown Family Therapy. Elms, R. (1990). Hostility, apathy, silence and denial: Inviting abusive adolescents to argue for change. In M. Durrant & C. White (Eds.), Ideas for Therapy with Sexual Abuse. Adelaide, Australia: Dulwich Centre Publications. Epston, D. (1994). Extending the conversation. Family Therapy Networker, 18(6), 31–37, 62–63. Epston, D. (1996, November). Questions for a Narrative Practice. Presentation at Family Institute of Cambridge, Watertown, MA. Epston, D., & White, M. (1995). Termination as a rite of passage: Questioning strategies for a therapy of inclusion. In R. A. Neimeyer & M. J. Mahoney (Eds.), Constructivism in Psychotherapy (pp. 339–354). Washington, DC: American Psychological Association. Epston, D. E. (1999). Co-research: The making of an alternative knowledge. In Narrative Therapy and Community Work: A Conference Collection (pp. 137–157). Adelaide, Australia: Dulwich Centre Publications. Eron, J. B., & Lund, T. W. (1996). Narrative Solutions in Brief Therapy. New York: Guilford Press. Fenichel, O. (1954). Psychoanalysis of character. In The Collected Papers of Otto Fenichel (Vol. 2). New York: Norton.

368

References

Fraenkel, P. (2006). Engaging families as experts: Collaborative family program development. Family Process, 45, 237–257. Fraenkel, P., Sheinberg, M., & True, F. (1996). Making Families Safe for Children: Handbook for a Family-Centered Approach to Intrafamilial Child Sexual Abuse. New York: Ackerman Institute for the Family. (Republished as a CD-ROM, 2004) Frank, J. D. (1982). Therapeutic components shared by all psychotherapies. In J. H. Harvey & M. M. Parks (Eds.), Psychotherapy Research and Behavior Change. The Master Lecture Series (Vol. 1, pp. 9–37). Washington, DC: American Psychological Association. Free, N. K., Green, B. L., Grace, M. C., Chernus, L. A., & Whitman, R. M. (1985). Empathy and outcome in brief focal dynamic therapy. American Journal of Psychiatry, 142(8), 917–921. Freedman, J., & Combs, G. (1993). Invitations to new stories: Using questions to explore alternative possibilities. In S. Gilligan & R. Price (Eds.), Therapeutic Conversations (pp. 291–308). New York: Norton. Freedman, J., & Combs, G. (1996a). Narrative Therapy: The Social Construction of Preferred Realities. New York: Norton. Freedman, J., & Combs, G. (1996b). Gender stories. Journal of Systemic Therapies, 15 (1), 31–46. Freedman, J., & Combs, G. (2002). Narrative Therapy with Couples . . . and a Whole Lot More! A Collection of Papers, Essays and Exercises. Adelaide, Australia: Dulwich Centre Publications. Freeman, J. C., Epston, D., & Lobovits, D. H. (1997). Playful Approaches to Serious Problems: Narrative Therapy with Children and Their Families. New York: Norton. Freeman, J. C., & Lobovits, D. H. (1993). The turtle with wings. In S. Friedman (Ed.), The New Language of Change: Constructive Collaboration in Psychotherapy (pp. 188–225). New York: Guilford Press. Freire, P. (1971). Pedagogy of the Oppressed. New York: Herder and Herder. Freire, P. (1994). Pedagogy of Hope. New York: Continuum. Freud, S. (1949). An Outline of Psycho-Analysis. New York: Norton. Geertz, C. (1973). The Interpretation of Cultures. New York: Basic Books. Gergen, K. (1985). The social constructionist movement in modern psychology. American Psychologist, 40, 266–275. Gergen, K. (1990), Therapeutic professions and the diffusion of deficit. Journal of Mind and Behavior, 11 (3/4), 353–367. Glaser, B. G., & Strauss, A. L. (1967). The Discovery of Grounded Theory. Chicago: Aldine. Goldner, V. (1992). Making room for both/and. Family Therapy Networker, 16(2), 55–61. Goldner, V. (1998). The treatment of violence and victimization in intimate relationships. Family Process, 37(3), 263–286. Goldner, V., Penn, P., Sheinberg, M., & Walker, G. (1990). Love and violence: Gender paradoxes in volatile attachments. Family Process, 29(4), 343–364. Griffith, J. L., & Griffith, M. E. (1992). Owning one’s epistemological stance in therapy. Dulwich Centre Newsletter, 1, 5–11.

References

369

Griffith, J. L., & Griffith, M. E. (1994). The Body Speaks: Therapeutic Dialogues for Mind–Body Problems. New York: Basic Books. Hall, R. (1996). Partnership accountability. In C. McLean, M. Carey, & C. White (Eds.), Men’s Ways of Being (pp. 211–238). Boulder, CO: Westview Press. Hamkins, S. (2005). Introducing narrative psychiatry: Narrative approaches to initial psychiatric consultations. International Journal of Narrative Therapy and Community Work, 1, 5–18. Hammond, S. A. (1996). The Thin Book of Appreciative Inquiry. Plano, TX: CSS. Hammond, S. A., & Royal, C. (2001). Lessons from the Field: Applying Appreciative Inquiry (rev. ed.). Plano, TX: Practical Press. Hardin, M., Cole, E., Mickens, J., & Lancour, R. (1996). Family Group Conferences in Child Abuse and Neglect Cases. Washington, DC: ABA Center on Children and the Law. Hare-Mustin, R. (1994). Discourses in the mirrored room: A postmodern analysis of therapy. Family Process, 17, 181–194. Harkaway, J. E., & Madsen, W. C. (1989). A systemic approach to medical noncompliance: The case of chronic obesity. Family Systems Medicine, 7(1), 42–53. Hartley, D. (1985). Research on the therapeutic alliance in psychotherapy. American Psychiatric Association Annual Review, 4, 532–549. Herzig, M. (2001, July). Moving from polarized polemic to constructive conversation—A Report from the Public Conversations Project. Interact: The Journal of Public Participation, pp. 1–11. Herzig, M., & Chasin, L. (2006). Fostering Dialogue Across Divides: A Nuts and Bolts Guide from the Public Conversations Project. Watertown, MA: Public Conversations Project. Hester, R., & Miller, W. (1989). Handbook of Alcoholism Treatment Approaches: Effective Alternatives. New York: Pergamon Press. Hoffman, L. (1985). Beyond power and control: Toward a “second order” family systems therapy. Family Systems Medicine, 3, 381–396. Hoffman, L. (1992). A reflexive stance for family therapy. In S. McNamee & K. J. Gergen (Eds.), Therapy as Social Construction (pp. 7–24). London: Sage. Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139–149. Hubble, M. A., Duncan, B. L., & Miller, S. D. (Eds.). (1999). The Heart and Soul of Change: What Works in Therapy. Washington, DC: American Psychological Association. Imber-Black, E. (1986). Toward a resource model in systemic family therapy. In M. Karpel (Ed.), Family Resources: The Hidden Partner in Family Therapy (pp. 148–174). New York: Guilford Press. Imber-Black, E. (1988). Families and Larger Systems: A Family Therapist’s Guide through the Labyrinth. New York: Guilford Press. Imber-Black, E. (1991). The family–larger system perspective. Family Systems Medicine, 9(4), 371–396. Jackson, D. D. (1957). The question of family homeostasis. Psychiatric Quarterly Supplement, 31, 79–90.

370

References

Jenkins, A. (1990). Invitations to Responsibility: The Therapeutic Engagement of Men Who Are Violent and Abusive. Adelaide, Australia: Dulwich Centre Publications. Jenkins, A. (1996). Moving towards respect: A quest for balance. In C. McLean, M. Carey, & C. White (Eds.), Men’s Ways of Being (pp. 117–134). New York: Westview Press. Johnson, J. (1973). Foucault Live: Collected Interviews, 1961–1984. New York: Semiotext(e). Kaplan, L., & Girard, J. L. (1994). Strengthening High-Risk Families: A Handbook for Practitioners. New York: Lexington Books. Karpel, M. (Ed.). (1986). Family Resources: The Hidden Partner in Family Therapy. New York: Guilford Press. Kegan, R., & Laskow Lahey, L. (2000). How the Way We Talk Can Change the Way We Work : Seven Languages for Transformation. San Francisco: Jossey-Bass. Kinney, J., Haapala, D., & Booth, C. (1991). Keeping Families Together: The Homebuilders Model. New York: Aldine de Gruyter. Kliman, J., & Madsen, W. C. (2004). Social class and the family life cycle. In B. Carter & M. McGoldrick (Eds.), The Expanded Family Life Cycle: Individual, Family, and Social Perspectives (classic ed.). Boston: Allyn & Bacon. Kliman, J., & Trimble, D. (1983). Network therapy. In B. Wolman & G. Stricker (Eds.), Handbook of Family and Marital Therapy (pp. 277–314). New York: Plenum Press. Kuehl, B. P., Newfield, N. A., & Joanning, H. (1990). A client-based description of family therapy. Journal of Family Psychology, 3(3), 310–321. Lambert, M. J. (1992). Implications of outcome research for psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of Psychotherapy Integration (pp. 94–129). New York: Basic Books. Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of Psychotherapy and Behavior Change (4th ed., pp. 143–190). New York: Wiley. Lax, W. D. (1995). Offering reflections: Some theoretical and practical considerations. In S. Friedman (Ed.), The Reflecting Team in Action: Collaborative Practice in Family Therapy (pp. 145–166). New York: Guilford Press. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic Inquiry. Newbury Park, CA: Sage. Lund, T. W., & Eron, J. B. (2005). When clients seem “unheroic.” In B. Duncan & J. Sparks (Eds.), Heroic Clients, Heroic Agencies: Partners for Change (pp. 38–45). Ft. Lauderdale, FL: Institute for the Study of Therapeutic Change. Madigan, S. (1993). Questions about questions: Situating the therapist’s curiosity in front of the family. In S. Gilligan & R. Price (Eds.), Therapeutic Conversations (pp. 219–236). New York: Norton. Madigan, S. (1997). Re-considering Memory: Re-remembering lost identities back toward re-membered selves. In C. Smith & D. Nylund (Eds.), Narrative Therapies with Children and Adolescents (pp. 338–355) New York: Guilford Press.

References

371

Madigan, S., & Epston, D. (1995). From “spy-chiatric gaze” to communities of concern: From professional monologue to dialogue. In S. Friedman (Ed.), The Reflecting Team in Action (pp. 257–276). New York: Guilford Press. Madsen, W. C. (1992). Problematic treatment: Interaction of patient, spouse and physician beliefs in medical noncompliance. Family Systems Medicine, 10(4), 365–383. Madsen, W. C. (1996). Integrating a “client voice” in clinical training. American Family Therapy Academy Newsletter, 64, 24–26. Madsen, W. C. (1998). Attitude as intervention. In T. Nelson & T. Trepper (Eds.), 101 More Interventions in Family Therapy (pp. 27–32). New York: Haworth Press. Madsen, W. C. (1999a). Inviting new stories: Narrative ideas in family-centered services. Journal of Systemic Therapies, 18(3), 1–22. Madsen, W. C. (1999b). Collaborative Therapy with Multi-Stressed Families: From Old Problems to New Futures. New York: Guilford Press. Madsen, W. C. (2004). Sustaining a collaborative clinical practice in the “real” world. In S. Madigan (Ed.), Therapeutic Conversations 5: Therapy from the Outside In (pp. 133–146). Vancouver, BC: Yaletown Family Therapy. Maisel, R., Epston, D., & Borden, A. (2004). Biting the Hand That Starves You: Inspiring Resistance to Anorexia/Bulimia. New York: Norton. Man-kwong, H. (2004). Overcoming craving: The use of narrative practices in breaking drug habits. International Journal of Narrative Therapy and Community Work, 1, 17–24. Markus, H., & Nurius, P. (1986). Possible selves. American Psychologist, 41, 954–969. Martin-Baro, I. (1994). Writings for a Liberation Psychology. Cambridge, MA: Harvard University Press. Meyerhoff, B. (1978). Number Our Days. New York: Simon & Schuster. Meyerhoff, B. (1982). Life history among the elderly: Performance, visibility and remembering. In J. Ruby (Ed.), A Crack in the Mirror: Reflexive Perspectives in Anthropology (pp. 99–117). Philadelphia: University of Pennsylvania Press. Meyerhoff, B. (1986). Life not death in Venice: Its second life. In V. W. Turner & E. M. Bruner (Eds.), The Anthropology of Experience (pp. 261–286). Chicago: University of Illinois Press. Miller, J. B. (1976). Toward a New Psychology of Women. Boston: Beacon Press. Miller, S., Duncan, B., Brown, J., Sparks, J., & Claud, D. (2003). The Outcome Rating Scale: A preliminary study of reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2, 91–100. Miller, W. (1985). Motivation for treatment: A review with special emphasis on alcoholism. Psychological Bulletin, 98(1), 84–107. Minuchin, S., & Fishman, C. (1981). Family Therapy Techniques. Cambridge, MA: Harvard University Press. Mirsky, L. (2003a, February 20). Family group conferencing worldwide: Part one in a series. Retrieved April 30, 2006, from www.restorativepractices.org. Mirsky, L. (2003b, April 3). Family group conferencing worldwide: Part two in a series. Retrieved April 30, 2006, from www.restorativepractices. org.

372

References

Mirsky, L. (2003c, May 7). Family group conferencing worldwide: Part three in a series. Retrieved April 30, 2006, from www.restorativepractices. org. Monk, G. (1997). How narrative therapy works. In G. Monk, J. Winslade, K. Crocket, & D. Epston (Eds.), Narrative Therapy in Practice: The Archaeology of Hope (pp. 3–31). San Francisco: Jossey-Bass. Monk, G., Winslade, J., Crocket, K., & Epston, D. (Eds.). (1997). Narrative Therapy in Practice: The Archaeology of Hope. San Francisco: Jossey-Bass. Morgan, A. (2000). What Is Narrative Therapy?: An Easy-to-Read Introduction. Adelaide, Australia: Dulwich Centre Publications. Nichols, M. P. (1984). Family Therapy: Concepts and Methods. Boston: Allyn & Bacon. Nichols, M. P. (1987). The Self in the System: Expanding the Limits of Family Therapy. New York: Brunner/Mazel. Nichols, M. P. (1995). The Lost Art of Listening: How Learning to Listen Can Improve Relationships. New York: Guilford Press. Nichols, T., & Jacques, C. (1995). Family reunions: Communities celebrate new possibilities. In S. Friedman (Ed.), The Reflecting Team in Action: Collaborative Practice in Family Therapy (pp. 314–330). New York: Guilford Press. Nylund, D., & Corsiglia, V. (1994). Becoming solution-focused forced in brief therapy: Remembering something important we already knew. Journal of Systemic Therapies, 13(1), 5–12. Nylund, D., & Thomas, J. (1994). The economics of narrative. Family Therapy Networker, 18, 38–39. Nylund, D., & Thomas, J. (1997). Situating therapist’s questions in the presence of the family: A qualitative inquiry. Journal of Systemic Therapies, 16(3), 211–228. O’Hanlon, B. (2003). A Guide to Inclusive Therapy. New York: Norton. O’Hanlon, B., & Beadle, S. (1994). A Field Guide to Possibility Land: Possibility Therapy Methods. Omaha, NB: The Center Press. O’Hanlon, W. H., & Weiner-Davis, M. (1989). In Search of Solutions: A New Direction in Psychotherapy. New York: Norton. O’Neill, M., & Stockell, G. (1991). Worthy of discussion: Collaborative group therapy. Australian and New Zealand Journal of Family Therapy, 12(4), 201–206. Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome in psychotherapy—noch einmal. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of Psychotherapy and Behavior Change (4th ed., pp. 270–378). New York: Wiley. Palazzoli, M. S., Boscolo, L., Cecchin, G., & Prata, G. (1981). Paradox and Counterparadox: A New Model in the Therapy of the Family in Schizophrenic Transaction. New York: Aronson. Pare, D. A. (1995). Of families and other cultures: The shifting paradigm of family therapy. Family Process, 34(1), 1–19. Pare, D. A. (1996). Culture and meaning: Expanding the metaphorical repertoire of family therapy. Family Process, 35(1), 21–42. Parry, A., & Doan, R. E. (1994). Story Re-visions: Narrative Therapy in the Postmodern World. New York: Guilford Press.

References

373

Patterson, C. H. (1984). Empathy, warmth, and genuineness in psychotherapy: A review of reviews. Psychotherapy, 21, 431–438. Payne, M. (2000). Narrative Therapy: An Introduction for Counselors. Newbury Park, CA: Sage. Pulleyblank Coffey, E. (2004). The heart of the matter 2: Integration of ecosystemic family therapy practices with systems of care mental health services for children and families. Family Process, 43(2), 161–174. Pulleyblank Coffey, E., Olson, M., & Sessions, P. (2001). The heart of the matter: An essay about the effects of managed care on family therapy with children. Family Process, 40(4), 385–399. Ransom, D. C. (1982). Resistance: Family- or therapist-generated? In A. S. Gurman (Ed.), Questions and Answers in the Practice of Family Therapy. New York: Brunner/Mazel. Ravella, N. F. (1994). Guest editor’s introduction. Journal of Systemic Therapies, 13(4), 1–9. Rogers, C. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. Rogers, C. (1961). On Becoming a Person. Boston: Houghton Mifflin. Roth, S. (1999). Speaking What Is Difficult to Speak: An Exercise in Open Speaking. Unpublished training exercise. Roth, S. (2006a). Speaking What Is Difficult to Speak: An Exercise in Open Speaking. Unpublished manuscript. Roth, S. (2006b). From the theory to the practice of inquiring collaboratively: An exercise in and clinical example of an interviewee-guided interview. In H. Anderson & D. Gehart (Eds.), Collaborative Therapy: Relationships and Conversations that Make a Difference. New York: Routledge. Roth, S., & Chasin, R. (1994). Entering one another’s worlds of meaning and imagination: Dramatic enactment and narrative couple therapy. In M. Hoyt (Ed.), Constructive Therapies (Vol. 1, pp. 189–216) New York: Guilford Press. Roth, S., & Epston, D. (1996). Consulting the problem about the problematic relationship: An exercise for experiencing a relationship with an externalized problem. In M. Hoyt (Ed.), Constructive Therapies (Vol. 2, pp. 148–162). New York: Guilford Press. Russell, S., & Carey, M. (2004). Narrative Therapy: Responding to Your Questions. Adelaide, Australia: Dulwich Centre Publications. Ryan, D., & Carr, A. (2001). A study of the differential effects of Tomm’s questioning styles on therapeutic alliance. Family Process, 40(1), 67–78. Sandau-Beckler, P. A., Salcido, R., & Ronneau, J. (1993). Culturally competent family preservation services: An approach for first-generation Hispanic families in an international border community. Family Journal: Counseling and Therapy for Couples and Families, 1(4), 312–323. Sanders, C. (1997). Re-authoring problem identities: Small victories with young persons captured by substance misuse. In C. Smith & D. Nylund (Eds.), Narrative Therapies with Children and Adolescents (pp. 400–422). New York: Guilford Press. Sennett, R., & Cobb, J. (1972). The Hidden Injuries of Class. New York: Random House.

374

References

Sheinberg, M. (1992). Navigating treatment impasses at the disclosure of incest: Combining ideas from feminism and social constructionism. Family Process, 31(3), 201–217. Sheinberg, M., & Fraenkel, P. (2001). The Relational Trauma of Incest: A Family-Based Approach to Treatment. New York: Guilford Press. Sheinberg, M., True, F., & Fraenkel, P. (1994). Treating the sexually abused child: A recursive multimodal program. Family Process, 33, 263–276. Simblett, G. J. (1997). Narrative approaches to psychiatry. In G. Monk, J. Winslade, K. Crocket, & D. Epston (Eds.), Narrative Therapy in Practice: The Archaeology of Hope (pp. 121–157). San Francisco: Jossey-Bass. Smith, L., & Winslade, J. (1997). Consultations with young men migrating from alcohol’s regime. Dulwich Centre Newsletter, 2/3, 16–34. Stacey, K. (1997). Alternative metaphors for externalizing conversations. Gecko, 1, 29–51. Stiles, W. B., Shapiro, D. A., & Elliot, R. (1986). Are all psychotherapies equivalent? American Psychologist, 41, 165–180. Sullivan, H. S. (1953). The Interpersonal Theory of Psychiatry. New York: Norton. Swartz, R. (2004). Narrative work in public social services through wraparound planning. Journal of Systemic Therapies, 23(2), 51–67. Thomas, L. (2002). Poststructuralism and therapy—What’s it all about? International Journal of Narrative Therapy and Community Work, 2, 85–89. Tomm, K. (1984a) One perspective on the Milan systemic approach: Part I. Overview of development, theory and practice. Journal for Marital and Family Therapy, 10, 113–125. Tomm, K. (1984b) One perspective on the Milan systemic approach: Part II. Description of session format, interviewing style and interventions. Journal for Marital and Family Therapy, 10(3), 253–271. Tomm, K. (1989). Externalizing the problem and internalizing personal agency. Journal of Strategic and Systemic Therapies, 8(1), 54–59. Tomm, K. (1990). A critique of the DSM. Dulwich Centre Newsletter, 3, 5–8. Tomm, K. (1991). Beginnings of a “HIPs and PIPs” approach to psychiatric assessment. Calgary Participator, 21–24. Tomm, K. (with Karl, Cynthia, Andrew, & Vanessa). (1992). Therapeutic distinctions in an on-going therapy. In S. McNamee & K. J. Gergen (Eds.), Therapy as Social Construction (pp. 116–135). London: Sage. Tomm, K. (1995). Co-Constructing Therapeutic Practices. Presentation at the National Association for Family-Based Services Conference, Chicago, IL. Tomm, K. Suzuki, K., & Suzuki, K. (1990). The Ka-No-Mushi: An inner externalization that enables compromise? Australian and New Zealand Journal of Family Therapy, 11(2), 104–107. Turnbull, A. P., & Summers, J. A. (1987). From parent involvement to family support: Evolution to revolution. In S. M. Pueschel, C. Tingey, J. W. Rynders, A. C. Crocker, & D. M. Crutcher (Eds.), New Perspectives on Down Syndrome: Proceedings on the State-of-the-Art Conference (pp. 289–306). Baltimore: Brookes. Turnell, A. (2004). Relationship-grounded, safety-organized child protection

References

375

practice: Dream-time or real-time option for child welfare? Protecting Children, 19(2), 14–25. Turnell, A., & Edwards, S. (1999). Signs of Safety: A Solution and Safety Oriented Approach to Child Protection Casework. New York: Norton. Turner, V. (1969). The Ritual Process. New York: Cornell University Press. VanDenBerg, J., & Grealish, M. (1996). Individualized services and supports through the wraparound process: Philosophy and procedures. Journal of Child and Family Studies, 5, 7–21. van Gennep, A. (1960). The Rites of Passage. London: Routledge & Kegan Paul. Waldegrave, C., Tamasese, K., Tuhaka, F., & Campbell, W. (2003). Just Therapy—A Journey. Adelaide, South Australia: Dulwich Centre Publications. Walsh, F. (1996). The concept of family resilience: Crisis and challenge. Family Process, 35(3), 261–282. Walsh, F. (2006). Strengthening Family Resilience (2nd ed.). New York: Guilford Press. Warshaw, C. (1995). Violence and women’s health: Old models, new challenges. In Dare to Vision: Shaping the National Agenda for Women, Abuse, and Mental Health Services (Proceedings of a Conference held July 14–16, 1994, in Arlington, VA, co-sponsored by the Center for Mental Health Services and Human Resource Association of the Northeast). Holyoke, MA: Human Resource Association. Waters, D. B., & Lawrence, E. C. (1993). Competence, Courage and Change: An Approach to Family Therapy. New York: Norton. Watzlawick, P., Bavelas, J. B., & Jackson, D. D. (1967). Pragmatics of Human Communication: A Study of Interactional Patterns, Pathologies and Paradoxes. New York: Norton. Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of Problem Formation and Problem Resolution. New York: Norton. Weedon, C. (1987). Feminist Practice and Poststructuralist Theory. New York: Blackwell. Weingarten, K. (1995). Radical listening: Challenging cultural beliefs for and about mothers. In K. Weingarten (Ed.), Cultural Resistance: Challenging Beliefs about Men, Women, and Therapy (pp. 2–22). Binghamton, NY: Haworth Press. Weingarten, K. (1997). The Mother’s Voice: Strengthening Intimacy in Families. New York: Guilford Press. Weingarten, K. (1998). The small and the ordinary: The daily practice of a postmodern narrative therapy. Family Process, 37(1), 3–16. Weingarten, K. (2003). Common Shock: Witnessing Violence Everyday: How We Are Harmed, How We Can Heal. New York: Dutton. West, W. (2003). Conversations with persons dealing with problems of substance use. International Journal of Narrative Therapy and Community Work, 1, 29–42. White, J. (1996). A Phenomenological Study of the Experiences of Child Protective Social Workers: Don’t Shoot the Messenger. Unpublished dissertation, Massachusetts School of Professional Psychology.

376

References

White, M. (1993). Deconstruction and therapy. In S. Gilligan & R. Price (Eds.), Therapeutic Conversations (pp. 22–80). New York: Norton. White, M. (1995). Re-Authoring Lives: Interviews and Essays. Adelaide, Australia: Dulwich Centre Publications. White, M. (1997). Narratives of Therapists’ Lives. Adelaide, Australia: Dulwich Centre Publications. White, M. (2000). Reflections on Narrative Practice: Essays and Interviews. Adelaide, Australia: Dulwich Centre Publications. White, M. (2001). Folk psychology and narrative practice. International Journal of Narrative Therapy and Community Work, 2, 3–37. White, M. (2004). Narrative Practice and Exotic Lives: Resurrecting Diversity in Everyday Life. Adelaide, Australia: Dulwich Centre Publications. White, M. (2005, September 21). Definitional ceremony and outsider-witness responses. Workshop Notes, www.dulwichcentre.com.au. White, M., & Epston, D. (1990). Narrative Means to Therapeutic Ends. New York: Norton. Winslade, J., Crocket, K., & Monk, G. (1997). The Therapeutic Relationship. In G. Monk, J. Winslade, K. Crocket, & D. Epston (Eds.), Narrative Therapy in Practice: The Archaeology of Hope (pp. 53–81). San Francisco: JosseyBass. Winslade, J., & Monk, G. (1999). Narrative Counseling in Schools: Powerful and Brief. Thousand Oaks, CA: Corwin Press. Wright, L. M. (1990). Research as a family therapy intervention technique. Contemporary Family Therapy, 12(6), 477–484. Wright, L. M., & Levac, A. M. (1992). The non-existence of non-compliant families: The influence of Humberto Maturana. Journal of Advanced Nursing, 17, 913–917. Wynne, L. C., Shields, C. G., & Sirkin, M. (1992). Illness, family theory and family therapy: Conceptual issues. Family Process, 31(1), 3–18. Yalom, I. D. (2002). The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients. New York: HarperCollins. Zimmerman, J. L., & Dickerson, V. C. (1993). Bringing forth the restraining influence of pattern in couples therapy. In S. Gilligan & R. Price (Eds.), Therapeutic Conversations (pp. 197–218). New York: Norton. Zimmerman, J. L., & Dickerson, V. C. (1994). Using a narrative metaphor: Implications for theory and clinical practice. Family Process, 33, 233–246. Zimmerman, J. L., & Dickerson, V. C. (1996). If Problems Talked: Narrative Therapy in Action. New York: Guilford Press.

Index

Abusive relationships/behavior bond between partners in, 212 externalizing conversations, 200–202 questions for, 202 and professional values, 164–165 therapist’s reactions, 106–107 Accountability structures and client empowerment, 42–43, 329– 330 in externalizing conversations, 199 goal-setting function, 138–139 partnership aspects, 42–43 and transparency, 43 Action-oriented methods, 246–247 Administrative paperwork, 342–343, 348–349 Agency in alternative story development, 240– 241 in cultural narrative, 7 development of, 118–120 in goal setting, 142 in heroic counter story, 232 in learning about the problem’s tactics, 226–227 Aggressive metaphors, 208–210 Agreed-upon focus of therapy, 139–140, 358

Alcohol abuse, 202–204 externalizing conversations, 202–204 inviting responsibility for, 203–204 moderation versus abstinence question, 204 shift in relationship to, 203–204 Allies in clinician support, 332–333 effective use of, 282 identification of, 254–257 reciprocal contributions, 258 recruitment of, 281–282 re-membering conversations with, 253– 257 support function, 255–257 in therapeutic letters, 289, 292 Alternative stories action and meaning in, 239–240 in consolidation interview, 311–312 development of, 238–246 questions for, 240–242 dominant story relationship, 216, 241 enactment of, 246–247 externalizing conversations in, 216– 217 intentional states in, 243 meaning questions, 242–246 and note-taking, 287

377

378

Index

Alternative stories (continued) opening space for, 235–238 outsider witnessing group function, 267 reauthoring questions function, 216, 228–235 supportive community nurturing of, 249 therapeutic letters enhancement of, 284 Anthropological approach. See also Collaborative inquiry family macro-culture understanding, 26–28 and “intervening” with families, 160– 162 thin- and thick-descriptions in, 26–27, 73 “Appreciative ally” stance, 22–24. See also Allies description of, 22–24 guidelines, 23 implementation in practice, 22–24 social constructionism in, 22 therapist’s stance with clients, 9–10 Appreciative Inquiry, 133, 135 Assessment, 46–86 alternative outline, 83–85 clinical assumptions effect on, 47–52 conceptual framework effect, 48–52 of constraints, 52–57 demographic information, 76 diagnosis in, 80–81 disempowering effects, 82 of family beliefs, 63–68 family description, 76–77 of family’s experience with helpers, 78 format, 74–75 formulation process, 81–82 history taking, 79 inherent risks in, 82–83, 342 interactional patterns, 57–63 intervention aspect of, 72 medical information, 797, 84 medical model in, 73–74 mental status, 79 modernist approach, 49 outline of, 74, 83–85, 354–355 presenting concerns in, 77–78, 83 rethinking of, 342 reexamination of, 72–74, 342 risk and safety factors, 79–80 social constructivist approach, 49–52, 85

strength-based outline, 354–355 as therapist-patient joint process, 342 thick versus thin descriptions, 73 traditional organization of, 72–73 Attitudes, 19–22. See also Client attitudes/beliefs B Behavioral treatment goals contemporary emphasis on, 152 drawbacks, 152–153 Beliefs assessment, 63–68 constraining aspects, 63–68 externalizing conversations effect on, 192 resistance factor, 97 Biological constraints, assessment, 53, 55– 56 Blame. See Self-blame Bureaucracies. See Institutional structures ”Burnout,” 351–352 C Change process belief in, 28–32 in collaborative therapy contract, 143– 144, 359 journey metaphor, 126 outcome measures, 345–348 proactive focus, 111–113, 121–123 treatment protocol approach, drawbacks, 345 Chart review, 348–349 Child abuse, therapist’s responsibilities, 164 Client attitudes/beliefs, 63–68 assessment, 63–68 constraining aspects, 63–68 externalizing conversations effect on, 192 resistance factor, 97 in stuck treatment, 346 toward family roles, 67–68 toward problems, 64–66 toward treatment, 66–67 “Client voice” format and accountability, 43 beneficial effects, 338–340 in clinical discussions, 337–340

Index feedback considerations, 339 internalization of, 340 process, 338 ripple effects, 339 Clinical meetings, 333–340 client participation, 333–340 “client voice” in, 337–340 as definitional ceremonies, 334–335 reformatting formulations, 335–337 rethinking of, 333–334 Clinical paperwork, 340–342, 348–349 Collaborative inquiry, 171–185 constraining and sustaining elements, 174–180 containing environment for, 166–170 conversational structures in, 167–169 empowering effects, 163 envisionary stage, 173–174 organizational framework, 171–185 professional values in, 163–166 purpose of, 162–163 Collaborative partnership advantages, 37–38 definition, 13n2, 34 in home-based therapy, 35–37 power differential minimization, 34–35 resistant clients, 112 and treatment outcome, 34 Common factors, psychotherapy outcome, 20 Communication agreements, 169 Community agencies building collaboration practices in, 333–352 competing demands, 323–324 professional discourse in, 325–330 quality assurance, 344–351 “Community of concern,” 250–251 Community of support, 249–283, 332–333 alternative story nurturing, 249 for clinicians, 332–333 development of, 281 effective use of, 282 as expectations buffer, 227 and externalizing conversations, 188– 189 function, 180–184 internalization of, 252 reconnection to, 250–251 recruitment of, 281–282 re-membering conversations function, 255–257

379

Competence, professional, 17 Confidentiality professional focus on, 329 therapy context, 251 in witnessing groups, 274 Confrontation approach, 104–106 Consolidation interview, 307–316 adaptations of, 315–316 circulation questions, 312–313, 361 client wisdom questions, 314–315 organization, 308 problem resurgence questions, 313– 314 reauthoring questions, 311–312 reviewing-the-journey questions, 310– 311 Constraints, 52–68 in abusive and violent clients, 200–202 assessment, 52–57 beliefs role, 63–68 in clinical meeting formulations, 337 in collaborative inquiry, 174–180 conceptual model advantages, 57 cultural influences, 70–71 helping clients with, 176–180 and interactional patterns, 57–63 levels of, 52–54 in life stories, 68–70 Consumer advisory boards, 350 Containing environment, 166–170 Contracting, 137–151, 358–359 accountability structures function, 138– 139 agreed upon focus of therapy, 139–140, 358 behavioral outcome measures drawbacks, 152–153 change indicators, 143–144, 359 client investment in, 139 continual crises effect, 149–151 development of, 137–151 funding sources negotiation, 151–153 improvement measures, 143–144 language in, 142 long-term goals, 139–140, 358 mandated clients, 144–149 plan for therapy section, 143, 359 possible negative effects, 137–138 proactive approach, 141–142 short-term goals, 140–142, 358–359 Control beliefs, 65. See also No-control stance

380

Index

Conversational structures, 167–170, 186n2 case example, 167–169 in collaborative inquiry, 167–169 communication agreements in, 169 in containing environment, 170 planful responsiveness in, 168 Coping questions, 194, 196–197, 237 Coping strategies present problems focus of, 130–132 reauthoring emphasis, 216 “Co-research,” 161–163, 186 Counterplot, and reauthoring questions, 216 Crises and goal setting, 149–151 proactive vision role in, 150 stepping up and stepping back metaphor in, 151 Criticize/defend pattern, 115 Cross-cultural negotiation case example, 24–25 in family “micro-cultures,” 26–27 and professional values, 164–165 and resistance, 96–98 therapeutic process usefulness, 25 Cultural anthropology, 160–162 Cultural constraints/influences and alcohol use, 203 in deconstructing questions, 223–224 discourse in understanding of, 54–55, 70–71 and expectations, 198, 223–226 in externalizing conversations, 188– 189, 197–198 family micro-culture understanding, 26–28 internalization, 70–71 and intervening with families, 160–162 in life stories, 6–7, 70–71 relational stance commitment, 24–28 and social constructivism, 51 therapeutic letters influence on, 292–295 thin versus thin descriptions, 26–27 “Cultural curiosity,” 157–158 “Customer relationship” stance, 101, 111 D Debriefing in reflecting teams, 266 in witnessing groups, 279

Deconstructive questioning, 218–228 cultural constraints in, 223–226 exceptions to dominant story in, 229 externalizing conversations map, 216– 218 function of, 215 organization of, 218 and preferences, 222–223 Defensiveness, externalization effect, 189 Deficit model versus envisioning possibilities, 134– 136, 327–328 in mental health tradition, 28–31 professional assumptions in, 31 in professional discourse, 327–328 versus resource model, 29–30, 327–328 support for, 30–31 “Denial.” See also Resistance and no-problem stance, 101–113 and resistance, 102 therapeutic dilemma, 104–105 Depression, and therapeutic letters, 285– 301 Diagnosis, 80–81 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 80– 81, 86n3 Dichotomous thinking, 207–208 Discourse and cultural assumptions, 54–55, 70– 71 definition, 326, 353n2 function of, 326 internalization of, 55, 70–71 prescriptive nature of, 55 and professional conflicts, 326–330 Disempowering processes, 39–41 in assessment process, 82 definition, 39 medical model role in, 40–41, 328 professional expertise role in, 328–329 standardized treatments effect, 346 Dominant story, 68–70 alternative story relationship, 216, 228–235, 241 case example, 69–70 challenges to, 70–72 constraining effects, 68–70 deconstructive questions, 215 eliciting exceptions to, 229 case example, 230–235 “exceptions” in, 220, 229–235

Index in externalizing conversations map, 216–217 history of, 219–220 and note-taking, 287 reauthoring questions, 228–235 recursiveness, 71–72 E Effect questions. See also Deconstructing questioning connectedness support function, 221–222 dimensions, 220 examples of, 195 in externalization of problem, 194–195, 221 mapping of, 220–221 preference questions link, 222–223 and therapeutic relationship, 222 Emotional postures, 166–167 Empathy effect questions support of, 222 and externalizing assumptions, 189 Empowering processes accountability structures in, 42–43 collaborative inquiry effect, 163 in consolidation interview, 314–315 definition, 39 engaging in, 39–41 life stories function, 7–9 resistance factor, 90 Ethnocentrism, 27 Evidence-based practices competing demands, 324 disempowering effect of, 41 instrumental focus of, 21 outcome focus of, 345 versus practice-based evidence, 347 translation difficulties, 345 Evaluation problem, 206–207, 211 Exceptions, to dominant story, 220, 229– 238 Expectations cultural influences, 198, 223–226 deconstruction of, 227 supportive community influence on, 227 Experiencing the problem, 194–195 Expert knowledge, 33 Externalizing conversations, 187–213 abusive clients, 200–202 accountability language in, 199

381

alcohol abusers, 202–204 in assessment process, 342 avoidance of responsibility concern, 198–200 beginning phase of, 190–193 in changing constraining beliefs, 192 in clinical thinking, 56 comfort level in, 193 community of support in, 188–189 cultural assumptions/prescriptions in, 188–189, 197–198 difficulties, 210–212 effect questions support of, 221 exercise for understanding of, 210, 214n7 experience questions in, 194–195 in framing problems, 10, 56 graphic of, 188 in identity formation, 51 versus internalizing assumptions, 56 language in, 191 map of, 216–217 outline, 193–197 overview, 188 strengths-based approach, 204–206 therapeutic letter function, 295–299 violent clients, 200–202 Externalizing Conversations Map, 216– 218 F Family-centered services collaborative approach in, 35–37 definition, 35 radical reorientation as result of, 36 Family-group conferencing, 35 Family “micro-cultures,” 25–28 Family roles, beliefs, 67–68 Family systems, 3, 90–91 Family turf metaphor, 35–37 Feedback, in accountability structures, 42–43 Follow-up recommendations, 319–320, 363 Framing, in goal setting, 141–142 Functionalist metaphor overextention of, 93 versus relationship metaphor, 207 symptoms explanation, 92–93, 207 Funding sources, 151–153 Future locus. See Proactive vision

382

Index

G Goal setting, 137 accountability structure function, 138– 139 behavioral outcome measures in, 152– 153 client investment in, 139 collaborative development of,137–151 framing of, 141–142 function of, 137 indicators of achievement in, 144 language in, 142 mandated clients, 144–149 medical model influence, 138 possible negative effects, 137–138 proactive approach, 141–142 scaling questions in, 141 in therapy contracts, 140–142, 358– 359 Guilt, witnessing groups, 273–279 H Home-based therapy, 35–37 Homeless families, collaboration, 350 Homeostasis metaphor, 90–91 Hope connecting with, resistant clients, 107– 110 development of, 118–120 and envisioning possibilities, 133–136 in no-control stance, 117–120 and psychotherapy outcome, 20 Hopelessness, in service providers, 18 I “Identified patient” approach, 61 Identity change, in therapy as journey, 126 Inner externalizations, 209 Institutional structures building collaborative practices in, 333–352 burnout in, 351–352 competing demands, 323–324 professional discourse role in, 325–330 quality assurance in, 344–351 “Instruction interaction,” 156, 185 Intentions in alternative stories, 243

in identity change, 205 in no-control complaints, 116–118 questions for, 243–244 Interactional patterns assessment, 57–63 case examples, 59–63 constraints, 57–63 diagnosis of, 59 interventions, 62–63 minimize/maximize pattern, 60–61, 115, 272 no-control stance clients, 114–116 overresponsible/underresponsible pattern, 59–60, 104–107, 200, 295–297 power differences in, 58 pursue/withdraw pattern, 61 and resistance, 96–98 Internal conversations, 51 Internalization and dominant life story, 68–70 of external conversations, 50–51 in identity formation, 51 of prescriptive discourse, 55, 70 of sociocultural assumptions, 70–71 Internalizing metaphors, 207 Intervention, 155–186 anthropological approach, 155–186 family therapy emphasis on, 155–156 instrumental approach drawbacks, 156 meaning of, 155–158 Invitational interaction, 158–160, 185–186 Involuntary hospitalization, 329 J Journal metaphor, proactive vision, 126 L Labeling, diagnostic, 81 Language in externalizing conversations, 191 in goal setting, 142 Letter-writing campaigns, 303–307 in developing community, 303–307 mechanics of, 303 “re-remembering” function, 303 sample letter, 306–307 Letters. See Therapeutic letters Liability concerns, client protection link, 330

Index Licensing requirements/regulation assessment influence, 73, 342 deficit model support, 328 utilization review/quality assurance, 348–349 Life stories. See also Dominant story constraints, 68–70 cultural shaping of, 6–7 empowering effect, 7–9 enactment, 71–72 recursiveness, 71–72 and resource versus deficit model, 29–31 in shaping of experience, 5–6 social constructivist approach, 51 Local knowledge, 33 M Managed care competing demands, 324 deficit model support, 328 goal setting constraint, 138 measurable outcomes emphasis, 152 and therapy contract negotiation, 151– 153 Mandated clients goal setting, 144–147 no-control stance in, 113 relational stance with, 145–146 resistance, 101–102 therapeutic dilemma, 105 therapeutic relationship approach, 145 “this is not a problem stance,” 101–105 Manualized treatment, drawbacks, 345– 346 Matching treatments, 345–346 Meaning questions in alternative stories, 242–246 story development integration, 244–246 transformative effect, 242–243 Medical model assessment influence, 73–74 clinical paperwork basis, 341 deficit model origin, 31 disempowering effects of, 40–41, 328 goal-setting approach, 138 no-control stance support, 114 in professional discourse, 326–327 professional expertise link, 328–329 social functioning application, 31–32 Medication resistance, 66–67 Meetings. See Clinical meetings

383

Mental status, assessment, 79 Militaristic metaphors, 208 Minimize/maximize interactions, 60–61, 115, 272 Miracle question, 129, 237 Modernist approach, 49–50, 73 Morphogenesis, 90, 95 Morphostasis, 90, 95 Motherhood constraints, 176–180 sociocultural “shoulds,” 71, 176 “Multiproblem families,” 10, 13n3 N Narrative perspective constraining aspects, 68–70 cultural influences, 6–7 dominant form of, 68–70 interactional pattern in, 63 recursiveness, 71–72 in shaping of experience, 5–6 No-control stance, 102–103, 113–123 No-problem stance, 101–113 Noncompliance and evidence-based practice, 21 and modernist approach, 49 standardized treatments role, 346 Nonproblematic future, focus on, 125 “Not-knowing” stance, 157 Note taking permission for, 287, 322n1 process of, 287–288 and therapeutic letters, 287–288 O Oppositional thinking, 207–209 Organizational cultures building collaborative practices in, 333–352 burnout in, 351–352 competing demands, 323–324 professional discourse in, 325–330 quality assurance in, 344–351 Outcome. See Psychotherapy outcome Outcome Rating Scale, 347, 353n4 Outer externalizations, 209 Outsider witnessing groups, 266–267. See also Witnessing groups Overresponsible/underresponsible pattern, 59–60, 104–107, 200, 295–297

384

Index

P Paperwork. See Clinical paperwork; Administrative paperwork Parenting, professional knowledge, 165– 166 Parenting as a Calling, 173–175, 185 Parents Helping Parents, 37 Paternalism, 329–330 Pathologizing interactional patterns (PIP), 57, 59, 63 Personal responsibility. See Responsibility Personality, social constructionist approach, 50 Plan for therapy, 143, 359 Plot. See Dominant story Possibilities belief in, 32–33 deficit model juxtaposition, 327–328 institutional support for, 333–340 Postmodernism, 73, 264 See also Social constructionism Power differential assessment process problem, 82 in collaborative approach, 34–36 in home-based therapy, 36 and interactional patterns, 58 professional–working class relationships, 99 resistance factor, 98, 99 in therapeutic relationship, 294 Practice-based evidence, 347 Preference questions effect questions link, 222–223 examples of, 196 in externalizing conversations, 194, 196 function of, 177, 222–223 in narrative literature, 213n2 in reauthoring process, 238 in subverting the dominant story, 218– 219 values and intentions clarification in, 177 Primary relationships, 41 Proactive vision advantages, 128–130 and continual crises, 150 development of, 11, 33, 125–154 envisioning possibilities in, 133–136 flexibility, 131–132 function of, 126 no-control stance clients, 121–123

questions in development of, 132–133 resistant clients, 111–113 in therapeutic letters, 288 therapy as journal focus, 126 “Problem-determined system,” 76 Problem-focused approach and assessment, 76 and externalizing assumptions, 189–190 possibilities approach juxtaposition, 327–328 in professional discourse, 327–328 versus solution-focused approach, 189– 190 Professional discourses, 326–333 Professional meetings. See Clinical meetings Professional responsibility, 329–331 Professional training problem-focused approach in, 328 witnessing group benefits, 280 Professionalism, definition, 331–332 Progress notes, 302 Protest metaphors, 209 Psychoanalytic theory, of resistance, 89 Psychotherapy outcome, 345–348 common factors literature, 20 measurement, 345–348 qualitative assessment, 347 quantitative assessment, 347–348 therapeutic alliance factor, 20, 345 therapeutic letters contribution, 302 Public Conversations Project, 167, 186n2 Pursue/withdraw pattern, 61 Q Qualitative approach, outcome assessment, 347 Quality assurance, 344–351 client input, 349–351 collaborative approach , 346–347 outcome measures in, 345–348 rethinking of, 344–351 and utilization review, mechanisms, 348–349 R “Radical listening,” 158 Reauthoring questions, 228–235 alternative story generation, 216, 228 in clinical meeting formulations, 337

Index externalizing conversations map, 216– 217 function, 216 organization of, 229 preference questions in, 238 and termination, 360–361 Reconnection interviews. See Re-membering conversations Reflecting teams in community organizations, benefits, 279–280 “democratic” therapeutic relationship effect, 264 history, 262–263 versus one-way mirror method, 263 organization, 264–266 postmodern perspective, 264 shared debriefing in, 266 utilization, 262–264 in witnessing, 268 Reflective listening in reflecting teams, 265 relational factors, 280 witnessing group responses, 269 Reframing, deep commitment contrast, 119 Regrounding, therapeutic letter function, 292 Regulatory requirements assessment influence of, 73, 342 medical model, 348 utilization review/quality assurance, 348–349 Reimbursement regulations, and assessment, 73 Relational responsibility and abusive patients, 107 in males, cultural factors, 106 resistant clients, 109–110 Relational stance, 15–45 of “appreciative ally,” 22–28 conceptual model, 44 cultural curiosity in, 24–28 definition, 9 importance of, 9–10, 15–45 mandated clients, 145–146 modernist approach, 49 psychotherapy outcome studies, 20 social constructionism in, 22 witnessing group benefits, 280 Relationship metaphor, 207, 209 Re-membering conversations finding an ally in, 254–257 linking to the present, 255–257

385

organization of, 253 origin of metaphor, 252 principles, 252–253 spirituality in, 257 in witnessing groups, 274 Residential programs, 132 Resistance, 87–124 and beliefs about problem, 66 and beliefs about treatment, 66–67 challenges to, 90–91 as construction, 87, 123n1 cross-cultural negotiation of, 96–98 and disempowerment, 90 dissolving metaphor, 95–96 to evidence-based practice, 21 feminist literature relevance, 209 functionalist metaphor, 92–93 generic guidelines, 123 helper’s contribution, 94 homeostasis metaphor for, 90–91 interactional process, 94 interpretation, 89–90 in mandated clients, 101–102 metaphors, 88–96 and modernist approach, 49 no-control stance, 102–103, 113–123 therapeutic suggestions, 113–123 no-problem stance, 102–103, 113– 123 confrontation approach, 104–106 therapeutic suggestions, 103–113 oppositional metaphor, 208–209 and overresponsible/underresponsible pattern, 104–107 social class context, 98–100 standardized treatments effect, 346 understanding metaphor, 93–94 “Resistant helpers,” 98 Resource model advantages of belief in, 32–33 versus deficit model, 29–30 Responsibility. See also Professional responsibility and blame, 198–199 in cultural narrative, 7 externalizing conversations effect on, 198–200 Risk assessment, 79–80 Rite of passage metaphor phases, 126 termination framing, 308 Role beliefs, families, 67–68

386

Index

S Safety factors, assessment, 79–80 Scaling questions children, 219 and client feedback, 350 in goal setting, 141 resistant clients, 112 Secondary gain, and symptoms, 93 Secondary relationships, 41 Self, social constructionist conception, 50– 51, 107 Self-blame cultural influences, 224 externalization of, 189, 199 and responsibility, 198–199 witnessing groups, 273–279 Sense of self, and externalization, 189 Session Rating Scale, 347, 353n4 Sexual abuse, therapist’s reactions, 106– 107 Shame, externalization of, 189, 198–199 Shared debriefing, reflecting teams, 266 Short-term goals, 140–142 framing of, 140–141 proactive approach, 141–142 scaling questions approach, 142 in therapy contract, 140–142, 358– 359 “Shoulds” in life stories, 70–71 sociocultural context, 70–71 Signs of safety approach, 80, 86n4 Social class differences in professional-family interactions, 98– 99 resistance factor, 98–100 and therapeutic relationship, 98 Social constructionism and assessment, 49–52, 73, 85 concept of self in, 50–51 conceptual aspects, 49–52 cultural conception, 51 focus of, 50 in life stories formulation, 51 in relational stance, 22 Social networks constraining aspect, 53–54, 56 disconnection from, 250 in reconnection process, 250–251 in witnessing groups, 272–279 Sociopolitical constraints, 54

Solution-focused perspective and goal setting, 142 interactional pattern intervention, 63 versus problem-focused approach, 189– 190 and externalizing assumption, 189– 190 “resistance” stances, 101–103, 111 Spirituality, in re-membering conversations, 257 Spouse abuse. See Abusive relationships Standardized treatments, drawbacks, 345– 346 Stigmatization, and DSM-IV diagnoses, 81 Story metaphor. See Life stories Strategic family therapy interactional pattern intervention, 62– 63 resistance interventions, 92 Strengths-based approach assessment example, 354–355 versus deficit model, 29, 327–328 externalization approach, 204–206 loss of balance in, 18 professional discourse conflicts, 326–328 Structural family therapy homeostasis disruption in, 91 interaction pattern intervention, 62 Structural metaphors, 207 “Stuck treatment,” 346 Substance abuse, 202–206 externalizing conversations, 202–204 inviting responsibility for, 203–204 Support system. See Community of support Symptoms, functionalist metaphor, 92–93 T Team meetings. See Clinical meetings “Techniquism,” 92, 123n2 Termination, 307–321, 360–361. See also Consolidation interview circulation questions, 312–313, 361 client wisdom questions, 314–315, 361 consolidation interview, 307–316 follow-up recommendations in, 319– 320, 363 licensing agency requirements, 316–317 metaphor of loss in, 307–308 problem resurgence questions, 313– 314, 361

Index reauthoring questions, 311–312, 360– 361 reviewing-the-journey questions, 310– 311, 360 rite of passage metaphor, 308 status at termination, 319, 363 termination/consolidation summary, 316–321 Therapeucentrism, 27–28 “Therapeutic agent,” 13n1 Therapeutic alliance. See Therapeutic relationship Therapeutic letters, 284–302 adjunct to clinical meetings, 172 in alternative story enhancement, 284 client writing of, 299–300 closing of, 288 cultural constraints examination, 292– 295 economics of, 302 effects on client, 300–301 enduring support function, 181–184 examples of, 285–299 externalization function, 295, 297– 299 framing sentences in, 288 guiding principles, 284–285 progress notes link, 302 re-grounding function, 292 and termination/consolidation summary, 320 therapy outcome factor, 302 use of, 301–302 Therapeutic relationship effect questions support of, 222 importance of, 20 mandated clients, 145 negotiation stance in, 294 power discrepancy, 294 psychotherapy outcome predictor, 20, 345 and reflecting teams, 264 social class issues, 98 termination effects, 308 Therapists accountability structures, 42–43 attitudes importance, 19–22 contribution to resistance, 94 professional discourses, 326–333 power differential, 294 social class issues, 98–100 Therapy contracts. See Contracting

387

Thick descriptions anthropological stance, 26–27 in family assessment, 73 Thin descriptions anthropological stance, 26–27 in family assessment, 73 Training. See Professional training Transference, and resistance, 89 “Transparency” and accountability, 43 and professional values, 165 Treatment contracts. See Contracting Treatment outcome. See Psychotherapy outcome Treatment protocols, 345 U Unconscious, and resistance, 89 “Unprofessional” behavior, 331 Utilization review/quality assurance, 348– 349 V Values, professional and child abuse, 164 in collaborative inquiry, 163–166 discourse in shaping of, 325–330 transparency, 165 Victimization. See No-control stance Violence and externalizing conversations, 200–202 externalizing responsibility contracts, 201–202 questions for, 202 “Visitor relationship,” 102 W Western culture confrontational metaphors in, 209 and social constructivism, 51 Witnessing groups, 262–283 client ratings of, 279 in community organizations, benefits, 279–280 confidentiality, 274 debriefing, 279 development of, 266–267 framework for questions, 268–271 friendship network in, 272–279

388

Index

Witnessing groups (continued) in life story acknowledgment, 267–272, 279–280 versus applause, 272 preparation for, 273–276 reflecting team comments, 268 relational factors, 280 “resonance” metaphor in, 268 support function, 180–181 and therapeutic letters, 299

therapist’s responsibility, 276 training benefits, 280 The Wizard of Oz, 5–9 Women cultural prescriptions effect on, 198 sociocultural “shoulds,” 71 Working on family turf metaphor, 35 Wraparound services, 35 Written documentation. See Therapeutic letters