Careful construction of questions has been at the heart of family therapy development. It began with the earliest pioneers of family therapy, working in Palo Alto to unpack family communication binds. It was then taken on by psychoanalytically-trained family therapists in Milan who sought means of posing relational questions without imposing any hierarchical assumptions; known as ‘circular questions’, these were nevertheless testing hypotheses previously developed, based on referral information. Thereafter post-modernism supervened, guiding therapists to act without any underlying assumptions at all, simply to skilfully facilitate the emergence of family stories.
The bridge into the post-modern era was provided Cecchin, one of the founders of the Milan group, together with Karl Tomm in Calgary. The language of therapy was privileged; ‘who behaved how’ during sessions became relegated to the periphery on consultations. Instead, family stories entered systemic work, and the ‘coordinated management of meaning’ that follows. All these approaches have enriched a contemporary understanding of questions in systemic work, but in every instance their main purpose was to facilitate a change in family relating, not to assess how family members relate to one-another. So the contribution of each to assessment is limited.
Not least because, from our standpoint, behaviour or feelings constitute important additional phenomena that can significantly add to the understanding of a family. The skills set out below address observed behaviour and feelings, as well as responding to what was spoken, or what had followed prompting a family member to contribute their opinion and thoughts. Their purpose is to expand and clarify communication within the family, without which a full understanding of what brought the family to the clinic would be much more difficult.
Finally, as illustrated elsewhere (e.g. Dana’s family), such skills are a means to an end and should never be considered out of context. Practicing any of the skills drawn from those described below is always best done in response to a perceived need. For example, as might become evident during role-play or observing a videotape, using the ‘pause’ button to reflect on what had just been observed and the alternative responses a therapist could make. We end with a case-example where very poor family communication is present, providing an opportunity to think of how such skills might be used, and be useful.
Embodied skills: structure and spontaneity in family therapy
Post-modernism had introduced far greater self-consciousness about therapist positioning. During the 1970’s and 80’s Salvador Minuchin had been regarded as a masterly family therapist, bringing colour and spontaneity into sessions with families, admired for his warmth and wit, and remembered as much for when he was standing up or getting family members to change places as for his incisive comments when seated. All were prompted by the structural perspective he brought to meeting families, which guided his active use of himself.
That was followed by a similarly admired but very different therapy style introduced by the Milan group, working against the grain of the ‘Mediterranean style’ social behaviour and expressed emotion of their own country (and that which Minuchin unashamedly portrayed and justified). Their restrained way of working, where structure rather than spontaneity was prized (including team reflections and hypothesising outside the consultation room i.e. very different to Minuchin thinking out loud in sessions) became a new trade-mark style for family therapists.
Each of these developments had required a new use of self on the part of the therapist, from well-practiced spontaneity (e.g. Minuchin) through restraint (Milan) to active facilitation of new stories (e.g. Michael White), including team reflections on these (e.g. Tom Andersen). By now emphasising the importance of assessment, and of a developed formulation that makes sense of the difficulties which brought a family to the clinic, the systemic approach to family work we describe returns the therapist to a more active style of working (albeit with a far more explicit emphasis on self-reflection than was customary thirty years ago).
Lived experience and told stories: responding to criticism that his work was insufficiently reflective, and reductionist, Minuchin published a paper in 1998 entitled, Where is the family in narrative family therapy? It prompted a published debate that was concluded by a further paper by Minuchin, describing his concern about what he evidently felt was the false “dichotomy (being presented) between discourse and people-in-dialogue” (1999). Instead of a deep interest in a therapist’s lived experience of a family, privileging their spoken language had, in his view, come to almost represent a moral position in systemic work.
His response was understandable, as he was the first major figure in family therapy to describe how an individual’s therapist spontaneity was dependent upon a well-learnt structure. In his books (including that on structural family therapy techniques, which Fishman co-authored), he compared such learning with that of a Samurai warrior (though he could have equally used Aikaido as an example). Through a long period of apprenticeship learning, an individual acquires a vast body of knowledge that includes mindfulness (although Minuchin didn’t use the term), and a deep understanding of self in relation to others, under the pressure of family circumstances and social adversity (which he did describe, in Families of the Slums).
He proposed that skills should be acquired ‘in order to be forgotten’. In different language, techniques learnt to be embodied, not just within the concepts brought to the consultation, but also in terms of the therapist’s natural style (just as a practiced musician, water-colourist or tennis player would hope to find – effortlessly ‘comfortable in their own skin’). Equally, the systemic model we describe, to undertake an assessment, and collaboratively develop a formulation, requires considerable organisation on the part of the therapist, guiding the encounter but not intruding into it.
The organisation underpinning the therapist’s engagement with the family provides a natural flow for the therapeutic encounter, where informality is present, neither formal nor rigid. Examples of this are illustrated elsewhere, for example in ‘therapeutic engagement’. Any departure from a customary way of working should always be of interest, and usually become a focus for self-reflection.
Questions concerning communication
The 1st edition of Integrated Family Therapy introduced these as ‘micro-executive’ skills (to contrast them with the ‘macro’ skills required to structure overall therapeutic contact). Karl Tomm’s account of these acknowledged the strong influence of the Milan group’s work on circular questioning, but in fact both he and our 1st edition owed much to Cleghorn and Levin’s earlier work, on stimulating, clarifying and expanding communication. Their categorisation of these is still useful and provides the basis of the summary below. Karl Tomm remains influential in this edition of Integrated Family Therapy, recognising questions and conversation as intervention in their own right.
Such skills to use questions and conversation as intervention are one of a set of four categories of skill that Cleghorn and Levin described. The others categories are:
- skills ‘to establish and maintain a focus in the session’ i.e. how to manage the session as problems are described and clarified
- ‘stimulating transactions’ i.e. getting family members to relate to one-another in the here-and-now
- ‘labelling and interpreting transactions’ i.e. ensuring an open shared understanding of what is happening in the here-and-now
It will be evident that #2 and #3 (defined forty years ago) are not very postmodern! Although intended to facilitate an assessment rather than family transactional change, these are not very different to Minuchin’s way of working in a session. They reflect the importance then attached to a therapist’s lived experience of a family. Since the integrated approach also values the contribution to assessment of the lived experience of a family communication, the paramodern, a fuller description of these is provided in the Appendix.
Stimulating, clarifying and expanding communication
- clarifying communication between any family member and themselves
Example: can I just check that out? did you mean …, or did I hear that wrong?
Tell me more about that. When did things start?
- clarifying communication that takes between family members
Example: I’m not sure what you were meaning there – when you were telling Dana … did you mean …? or did I hear that wrong?
- gets a family member to clarify the communication that took between family members
Example: how did you hear that Tony? I wasn’t sure … can you check out with Dana what she meant when she said that …
Mum, how do you think Dana’s Dad heard that? can you check with him if that’s right?
Dana, what are your thoughts about what he said? and about how long this has gone on?
- picks up on the indirect, contradictory, latent, or unsaid or aspect of a family member’s communication
Example: did you hear that Tony? I thought Dana was perhaps meaning something else. What do you think?
Dana, what you said seems unexpected; do you think your Dad knew what you meant?
Mum, I’m looking at Dana and guessing she thinks you’ve got her wrong
(looking at parents). I’m confused, I thought Dana was asking for something, not complaining…
Mum, I’m listening to what you say but I’m feeling something else is going on Tony, I’m feeling that what Dana said somehow upset both your Mum and your Dad; they felt she was just complaining – how does that get so misunderstood? is that something we can talk about?
It will be clear that the construction of the questions became increasingly relational, not very different to the circular questions described by the Milan group. It’s likely that a therapist’s earliest questions in a consultation will be drawn from #1 and #2, and as the problems become more fully described understanding the relational aspects of each deepened by #3 and #4.
Not only does even the most linear question gain a potential for circularity by being raised within a family context, it will be apparent from the examples that few questions or statements were purely drawn from just one category. Establishing and maintaining a clear focus (whether of enquiry or described as a ‘conversation’) is a universally important skill. As the curiosity-based questions become more circular, transactions between family members are inevitably stimulated, and commenting on these in a tentative way is an important means of sustaining the focus, including eliciting the support necessary to allow this to happen.
An example of longstanding unhelpful communication
As the basis for a set of exercises on communication, we return to the thirty-seven year old inpatient re-admitted under a Short Term Detention Certificate to an acute psychiatric ward, with renewed suicidal threats and life-threatening parasuicidal behaviour, which usually quickly subsided after admission. From her longstanding contact with healthcare providers (for treatment of recurrent depressive episodes), ward staff knew of her past history of childhood sexual abuse, and that her husband, a storeman the Community MH team had never met, had problems with alcohol.
The following conversation between them took place during a visit on the ward the evening before a ward-round when a decision was to be made about whether to discharge her or apply for a CTO (Compulsory Treatment Order). It is presented twice, once as spoken, and then again including the unsaid.
Husband: so, what do you think, will they apply for an Order?
Patient: don’t know, we’ll have to wait and see
Husband: are you feeling any better then?
Patient: not sure – maybe. I don’t know. We’ll just have to wait and see what they say
Husband: do you want me to bring in more clothes?
Patient: I don’t know. I might not be staying. No, you better had. But not that black lacy thing you brought me in last time! Drawing him back (he had turned away, so had missed her wry smile to him) she asks, Are you going to your brother’s at the weekend?
Husband: don’t know, probably. Depends upon what the bairns want – Sean’s got his football, don’t know about Heather
Patient: she’ll be staying at her boyfriend’s again?
Husband: I suppose so (looks towards the corridor leading out of the ward)
Patient: can I have a smoke? (he passes her a cigarette; she watches him digging in his pocket for a light, looks toward the smoking room but then sits back and puts the cigarette it in her pocket, and looks down at her lap)
Husband (after a silence): who’s that woman across the way – the one who’s looking at us; do you know her? (Looking up, she shakes her head) what’s she in for? (pursing her lips, she shakes her head again). A long silence follows – finally broken by the arrival of the tea trolley.
Before reading it again with the additional annotations: it would be useful to first re-read the transcript to think what was going on between the couple, and the possible effects of past experience and anticipated consequences. Then to review which of the communication skills presented above might be useful.
Thickening the description of any formulation is critically dependent upon communication skills. After reading the annotations about the unspoken thoughts of each, and their non-verbal behaviour, consider again which skills would now seem most helpful or appropriate.
Husband (she’s still not said that she won’t do it again): so, what do you think, will they apply for an Order?
Patient: (he can’t talk to me) don’t know, we’ll have to wait and see (how do I know how I’ll be feeling?! no point waiting for him to help me! Anyway, they’ll just make their own minds up anyhow)
Husband: are you feeling any better then? (Risky question…shouldn’t have asked, she’ll trip me up: no = F***** hell, danger now, yes=danger ahead)
Patient: not sure – maybe. I don’t know. We’ll just have to wait and see what they say (what am I supposed to say? He’s like one of the children!)
Husband (a practiced question): do you want me to bring in more clothes? (Maybe she’ll say how she’s feeling?)
Patient: I don’t know (do I want to stay, or go?) I might not be staying. (both: F**** hell, danger ahead) No, you better had (he’s not ready for me to leave; does he want me home? does he want a divorce? but we’re still a couple, aren’t we?) But not that black lacy thing you brought me in last time! (maybe I still look good to him in it?). Drawing him back (he had turned away, so had missed her wry smile to him) she asks (he looks miserable, better show I still care for him), Are you going to your brother’s at the weekend?
Husband (what the f***’s that question about? Does she care at all what happens to us? To where we go when she’s in here?!) don’t know, probably. (rising anger’s no good) Depends upon what the bairns want – Sean’s got his football, don’t know about Heather (nor do you!)
Patient (I do): she’ll be staying at her boyfriend’s again?
Husband (she never wants to be at home now, can’t blame her): I suppose so (nor me be here, and these people … never again … even if I can never again have her at home with me) looks towards the corridor leading out of the ward
Patient (I make him want to leave – he can’t refuse me asking this): can I have a smoke? He passes her a cigarette; she watches him digging in his pocket for a light (he doesn’t have to do that), looks toward the smoking room (no, I’ll stay here with him) so sits back and puts the cigarette instead in her pocket, looks down at her lap (why can’t you just do something more for me like that?)
Husband, after a silence (she just sits, sits, cries, sits then BAM! How am I supposed to know why? know what’s coming and when?! what I’m supposed to do? Are they all like that here?): who’s that woman across the way – the one who’s looking at us; do you know her? (she looks up, shakes her head) what’s she in for? She purses her lips (never asks me that question! he doesn’t know me at all) and shakes her head again. A long silence follows (an image comes to her of a three-legged marriage stool – the hospital as one leg, she and her husband the other two). Her thoughts are finally broken by the arrival of the tea trolley.
After re-reading the transcript, think about you might have picked up of what had not been spoken, what you would have tracked, which of your own thoughts you’d have privileged, and now – based something like this conversation taking place in a consultation room – at what points might you have come in to say something, that might have facilitated some expansion of what was spoken, without which no further exploration is likely of the situation underlying the patient’s predicament and of those involved with her.
Appendix: micro-executive skills
These are described as relevant to the task of an initial family meeting, highlighting only those that are most frequently used to aid an early understanding of the referred problems and thus contribute to the formulation:
- stimulating, clarifying and expanding communication skills to establish and maintain a focus in the session: how to manage the session as problems are described and clarified
- attempts to keep a family focused on an issue of possible systemic importance
- refocusing the discussion when distractions occur
- knowing when to label the defocus (because of its possible systemic significance) rather than simply ploughing on and ignoring it
- stimulating transactions: getting family members to relate to one-another in the here-and-now
- directs family member to become involved with /talk to /look at another
- re-establishing that if one or other directs their response to the therapist
- introducing themselves into the transactions to ensure it continues
- asking another family member to get involved to achieve the same
- occasionally proposing a different way of responding, to better understand
- labelling and interpreting transactions: ensuring an open shared understanding of what is happening in the here-and-now
- an unacknowledged but obvious affect of a family member
- a transaction that took place between one family member and another
- briefly stopping a transaction to label it
- asking a family member/s to do similarly
- commenting on an unvoiced or apparently avoided affect
- referring to how the therapist is themselves feeling