Questioning intentions presentation

A TherapeuticQuestioning Workshop

Presented by Chris Lobsinger

Questioning Workshop Copyright 2000 Chris Lobsinger BSW MSW MAASW(07) 3201 2206 PO Box 445 Paddington Q 4064

Email: [email protected] Web Page: www.ozemail.com.au/~cnlob

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Theraputic Factors

IntentionsStage of Change



Contemplation

Techniques15%

Expectancy(placeboeffects)

15%

problemexplanation

questions

problem definitionquestions

behavioraleffect

questions

hypotheticalfuturequestions

INFLUENCINGINTENT

ORIENTINGINTENT

LINEALASSUMPTIONS

CIRCULARASSUMPTIONS

SN

OITS

EUQ EVIXELFER

SNOITSEUQ LAENIL

CIR

CU

LA

R QUEST IONS

confrontationquestions

leadingquestions

differencequestions

observerperspectivequestions

TherapeuticRelationship

30%

ExtratherapeuticChange

40%

Pre-Contemplation

PermanentExit

Maintenance

lRe

apse

Ac iton

t

Determina ion

STRATEGIC QUESTION

S



Techniques15%

Expectancy(placeboeffects)

15%

TherapeuticRelationship

30%

ExtratherapeuticChange

40%

Percentage of Improvement in Psychotherapy Patients as a Function of Therapeutic Factors.

Extra-therapeutic change: those factors that are a part of the client (e.g. ego strength and other homeostatic mechanisms) and part of the environment (e.g. fortuitous events and social support) that aid in recovery regardless of participation in therapy.

Expectancy (placebo effects): that portion of improvement that results from the clients’ knowledge that he or she is being treated and from the differential credibility of specific treatment techniques and rationale.

Techniques: those factors unique to specific therapies (e.g. biofeedback, hypnosis, or systematic desensitization).

Therapeutic relationship: includes a host of variables that are found in a variety of therapies regardless of the therapists’ theoretical orientation (e.g. empathy, warmth, acceptance and encouragement of risk taking). From the Handbook of Psychology Integration by M.J. Lambert, 1992, p.97. Copyright 1992 by Basic Books. Reprinted with permission.

Figure 2.1. Prochaska and DiClemente’s six stages of change

Motivational Interviewing 1991



Contemplation Pre-Contemplation

PermanentExit

M n enanai t

ce

Relpse

a

cn

Atio

mnat o

Deteri

i n



problemexplanation

questions

problem definitionquestions

behavioraleffect

questions

hypotheticalfuturequestions

INFLUENCINGINTENT

ORIENTINGINTENT

LINEALASSUMPTIONS

CIRCULARASSUMPTIONS

SN

OITS

EUQ EVIXELFER

SNOITSEUQ LAENIL

CIR

CU

LA

R QUEST IONS

confrontationquestions

leadingquestions

differencequestions

observerperspectivequestions

STRATEGIC QUESTION

S

Figure 1. A framework for distinguishing4 major groups of questions

Karl Tomms’Map

Intentions



INVESTIGATIVEINTENT

(Conservative effect on family)(Judgmental effect on therapist)

(Accepting effect on therapist)(Liberating effect on family_

(Constraining effect on family)(Oppositional effect on therapist)

(Creative effect on therapist)(Generative effect on family) S

NOIT

SEUQ EVIXELFER

SNOITSEUQ LAENIL

CIR

CU

LA

R QUEST IONS

CORRECTIVEINTENT

EXPLORATORYINTENT

FACILITATIVEINTENT

STRATEGIC QUESTION

S

Figure 2. Predominant intent andprobable effects of differing questions.

Fam. Proc., Vol. 27, March, 1988



Lineal QuestionsIntent: Investigative, reductive Therapist as scientistProblem explanation and definition questions

Strategic QuestionsIntent: instructive, correctiveTherapist as coachLeading questions and confrontation questions

Circular questionsIntent: exploration of connectionsTherapist as curious explorerBehavioural effects questions, difference questions

Reflexive QuestionsIntent: facilitativeTherapist as Geoffrey Robertson on HypotheticalHypothetical future questions, observer perspective questions

(Interventive interviewing: part III. Intending to ask Lineal, Circular, Strategic, or Reflexive Questions Karl Tomm, MD family process vol 27.number 1 March 1988)

Motivational InterviewingIntent: accommodate clients’ motivational stageTherapist as Hotel Manager(Motivational Interviewing W. Miller and S. Rollnick 1991 the Guildford press New York



! Lineal questions are investigative and reductionist! Therapist as scientist! Problem exploration and definition questions

PROS:Useful in gaining rapportUseful in discovering the clients views of problems and solutions Pulls apart problems and helps draw distinctionsUseful in pursuing clarity

CONS:Risky in term of highlighting blame.Risky in terms of harming the therapeutic alliance.

Effect on the client:

Conservative stabilising effect on the client may not lead to new possibilities for change.

Effects on the therapist:

Invites linear thinking and cause and effect judgements.



! Investigative reductionist intent

! Therapist as scientist

! Problem explanation and definition questions

What can I help you with?What can I do for you?What caused X to happen?What are your symptoms?What have you tried to remedy this?

Where did it happen?Where does it happen?

When did it first happen?When did is last happen?

Why did it happen?Why did you decide to come to counselling?How long have you been experiencing X?

Are you experiencing X?

Did something happen that started the problem?



! Exploring connections

! Circular questions are questions, which explore connections and are based on systemic assumptions

! Therapist as explorer

! Behavioural effect questions, difference questions

! Characterised by an absence of why questions

PROS:Useful in promoting a sense of curiosityUseful in opening up, different ways of viewing the problem.

CONS:If joining is not sufficient then circular question can make the client feel confused.

May not fit with cultural exceptions

Can be experienced as repetitious or overwhelming

Effect on the client:Opens up new possibilities

Effects on the therapist:Invites the therapist into an open accepting and generally non-judgmental mode



! Exploratory questions

! Therapist as explorer

! Behavioural effect, difference questions

Circular question explore in terms of:

1. Difference2. Agreement/disagreement3. Explanation and meaning

In terms of time across

1. Present2. Past3. Future /Hypothetical

Regarding different aspects

Problem definitionSequence of interactionComparison/ classificationInterventive questions

(Problem definition) What is the problem in the family now?Who agrees, who disagrees?How is this different than before?Who agrees, who disagrees?What does this mean?Who agrees, who disagrees?How will things be in the future if things continue as they are?How will this be different in the future if things change?Who agrees, who disagrees?



! Instructive and corrective intent

! Strategic questions are directive and corrective

! Leading and confrontation questions

PROS: Sometimes confrontation is required eg. in a setting of family violenceCan challenge the ideas that contribute to stuckness

CONS:High risk of alienating the therapeutic alliance.Can make the client feel guilty/ ashamed / Wrong

Effect on client:

Strategic questions have a constraining effect and act to block a particular response in favour of another

Effect on the therapist:

May invite the therapist into an oppositional stance against the problem or even more dangerously the person who is suffering with the problem.



! Corrective intent

! Therapist as coach

! Leading and confrontation questions

What will the effect on the problem be when you are ready to do your part in solving it?

What could you do now to acknowledge his/her feeling?

How do you think you can stop letting your anger push you around?

Have you always refused to except compliments gracefully?

Why don't you talk to your partner instead of your kids about the problem?

Is this habit of making excuses a new habit or and old one?



! Facilitative intent

! Hypothetical future questions, observer orientated questions

! Therapist as Geoffrey on Hypothetical

Pros:Enable re-evaluation and invite new possibilities

Cons: Can be difficult to convey for the therapist because of their facilitative intent.

May also lead not only to more possibilities, but more unhelpful confusion.

Effect on the client:

To help move them into a more imaginative space.

Effect on the therapist:

Invites the therapist into a very creative space as they wounder what kind of questions to ask and where they may lead.



! Facilitative intent

! Therapist as Geoffrey on Hypothetical

! Hypothetical future questions and observer oriented questions

FutureHow will things be different when x has happened?

ObserverWhat do you think he/she thinks when you do that?

Unexpected context changeWhat would it be like if you had the opportunity to do x instead of y?

Embedded solutionInstead of thinking that he/she is being wilful or stubborn, what if you thought that he /she was just confused how might you treat him/her then?

Normative comparison Do you think your family is more or less communicative than the average family?

Distinction clarifying questionsDo you think that his/her anger with you is about x, y, or maybe z?

Questions introducing hypothesisWhen you get angry and your partner withdraws what does your partner do?

Process interruption questions?When you feel as bad as you do right now, when you are at home, what do you do next?



! Motivational interviewing questions carry the intention to accommodate the clients’motivational stage.

! Based on the assumption of an underlying structure of change

! Therapist as hotel manager helping the client during their stay in whatever stage they are in and then “Helping them shift their bags when they would like to move to a new room”.

Table 2.1. Stages of Change and Therapist Tasks

Client Stage Therapist’s motivational tasks

Precontemplation Raise doubt - increase the clients’ perception of risks and problems with current behaviour.

Contemplation Tip the balance - evoke reasons to change, risks of not changing; stengthen the clients’ self-efficacy for change of current behaviour.

Determination Help the client to determine the best course of action to take in seeking change.

Action Help the client to take steps toward change.

Maintenance Help the client to identify and use strategies to prevent relapse.

Relapse Help the client to renew the processes of contemplation, determination, and action, without becoming stuck or demoralised because of relapse.



1. Problem RecognitionWhat things make you think this is a problem?What difficulties have you had in relation to your drug use?In what ways do you think you or other people have been harmed by your drinking?In what ways has this been a problem for you?How has your use of tranquilizers stopped you from doing what you want to do?

1. ConcernWhat is there about your drinking that you or other people might see as reasons for concern?What worries you about your drug use?What can you imagine happening to you?How do you feel about your gambling?How much does that concern you?In what ways does this concern you?What do you think will happen if you don’t make a change?

3. Intention to ChangeThe fact that you are here indicates that at least a part of you thinks it’s time to do something.What are the reasons you see for making a change?What makes you think that you may need to make a change.If you were 100% successful and things worked out exactly as you would like, what would be different?What things make you think that you should keep on drinking the way you have been?And what about the other side? What makes you think it’s time for a change?What are you thinking about your gambling at this point?What would be the advantages of making a change?I can see that you’re feeling stuck at the moment. What’s going to have to change?

4. OptimismWhat makes you think that if you did decide to make a change, you could do it?What encourages you that you can change if you want to?What do you think would work for you, if you decided to change?



Benefits Costs

Helps me relax Could lose my marriageI like getting high Bad example for my children

Damaging my healthSpending too much moneyDamaging my brainMight lose my jobWaisting my time/life

Benefits Costs

Happier marriage What to do about my friendsMore time for family Won’t have a way to relaxFeel betterHelps money problems

Continuing to drink as before

Making a change in my drinking



What stageis client in?

What type ofquestions might

be helpful?

What thereputicfactors areengaged?

What is myintention?



! Organises the structure and process of therapy

! Orientates and guides the interaction

! Influence the clients and counsellors responses

(S. Mayers, The Des Moins Institute Halidan Press, 2001)



Clients epistemology! Problem definition! What constitutes a solution! Time context for problem and solution! Cause and effect attributions! What kind of help/helper that would be ideal?

Cultural formulation as per (DSM IV TR)Appendix P.897-898Cultural identity of individualCultural explanations of the individuals illness.Cultural factors related to psychosocial environmental and levels of functioningCultural elements of the relationship individual and clinician.Overall curltural assessment and diagnosis and care.



Questioning Workshop Copyright 2000 Chris Lobsinger BSW MSW MAASW(07) 3201 2206, PO Box 445 Paddington Q 4064E-mail [email protected] Web page WWW.ozemail.com.au/~cnlobFeinberg P.H., Circular Questions: Establishing The Rational Context, Family Systems Medicine, 8:273-277,1990

Fleurdidas C., Nelson T. S., Rosenthal M., The Evolution Of Circular Questions Training Family Therapists. Journal of Martial and Family Therapy, 12: No 2, 113-127, and 1986

Miller W. R., Rollnick S., Motivational Interviewing, 1991, The Guildford Press, New York, London.

Miller S. D., Duncan B.L., Hubble M.A., Escape from Babel, Towards a Unifying Llanguage for Psychotherapy Practice, 1997 W.W. Norton and Company Newyork and London.

Miller S. D., Duncan B.L., Hubble M.A., The Heart and Soul of Change, What works in Therapy, 1999American Psychological Association, Washington D.C.

Penn P., Circular Questioning, Family Process Inc 21:267-287, 1982

Tomm K., Interventive Interviewing: Part I Strategising as a Fourth Guideline for the Therapist, Family Process 26:3-13, 1987

Tomm K. Interventive Interviewing Part II. Reflexive Questioning as a Means to Enable Self Healing. Family Process, Inc 26:167-183,1987

Tomm K. Interventive Interviewing Part III. Intending to Ask Lineal, Circular, Strategic, or Reflexive Questions?, 27:1-15,1988

! What did you like about the workshop?

! How could the workshop be improved?

! What would you like to have had more or less of?

! What other workshop topics would you like to see presented?

! Other Comments

Thank you for your feedback.



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Questioning intentions presentation