Questioning intentions presentation

A Therapeutic
Questioning Workshop
Presented by Chris Lobsinger
Questioning Workshop Copyright 2000 Chris Lobsinger BSW MSW MAASW
(07) 3201 2206 PO Box 445 Paddington Q 4064
Email: cnlob@ozemail.com.au Web Page: www.ozemail.com.au/~cnlob
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Theraputic Factors
Intentions
Stage of Change
Contemplation
Techniques
15%
Expectancy
(placebo
effects)
15%
problem
explanation
questions
problem definition
questions
behavioral
effect
questions
hypothetical
future
questions
INFLUENCING
INTENT
ORIENTING
INTENT
LINEAL
ASSUMPTIONS
CIRCULAR
ASSUMPTIONS
SNOITSEU
Q
EVIXELFER
SNOITSEUQ
LAENIL
CIRCULAR
QUESTIONS
confrontation
questions
leading
questions
difference
questions
observer
perspective
questions
Therapeutic
Relationship
30%
Extratherapeutic
Change
40%
Pre-
Contemplation
Permanent
Exit
Maintenance
lReapse
Aciton
t
Determinaion
STRATEGIC
QU
ESTIONS

Techniques
15%
Expectancy
(placebo
effects)
15%
Therapeutic
Relationship
30%
Extratherapeutic
Change
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
andsocialsupport)thataidinrecoveryregardlessofparticipationintherapy.
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
treatmenttechniquesandrationale.
Techniques: those factors unique to specific therapies (e.g. biofeedback, hypnosis, or
systematicdesensitization).
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,
acceptanceandencouragementofrisktaking).
From the Handbook of Psychology Integration by M.J. Lambert, 1992, p.97. Copyright 1992 by Basic Books.
Reprintedwithpermission.

Figure 2.1. Prochaska and
DiClemente’s six stages of change
Motivational Interviewing 1991
Contemplation Pre-
Contemplation
Permanent
Exit
M n enan
ai t
ce
Relpsea
c
n
A
tio
mnato
Deteri
in

problem
explanation
questions
problem definition
questions
behavioral
effect
questions
hypothetical
future
questions
INFLUENCING
INTENT
ORIENTING
INTENT
LINEAL
ASSUMPTIONS
CIRCULAR
ASSUMPTIONS
SNOITSEU
Q
EVIXELFER
SNOITSEUQ
LAENIL
CIRCULAR
QUESTIONS
confrontation
questions
leading
questions
difference
questions
observer
perspective
questions
STRATEGIC
QU
ESTIONS
Figure 1. A framework for
distinguishing4 major
groups of questions
Karl Tomms’
Map

Intentions
INVESTIGATIVE
INTENT
(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)
SNOITSEU
Q
EVIXELFER
SNOITSEUQ
LAENIL
CIRCULAR
QUESTIONS
CORRECTIVE
INTENT
EXPLORATORY
INTENT
FACILITATIVE
INTENT
STRATEGIC
QU
ESTIONS
Figure 2. Predominant intent and
probable effects of differing questions.
Fam. Proc., Vol. 27, March, 1988

Lineal Questions
Intent: Investigative, reductive
Therapist as scientist
Problem explanation and definition questions
Strategic Questions
Intent: instructive, corrective
Therapist as coach
Leading questions and confrontation questions
Circular questions
Intent: exploration of connections
Therapist as curious explorer
Behavioural effects questions, difference questions
Reflexive Questions
Intent: facilitative
Therapist as Geoffrey Robertson on Hypothetical
Hypothetical 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 Interviewing
Intent: accommodate clients’ motivational stage
Therapist 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 rapport
Useful in discovering the clients views of problems and solutions
Pulls apart problems and helps draw distinctions
Useful 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 curiosity
Useful 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
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. Difference
2. Agreement/disagreement
3. Explanation and meaning
In terms of time across
1. Present
2. Past
3. Future /Hypothetical
Regarding different aspects
Problem definition
Sequence of interaction
Comparison/ classification
Interventive questions
(Problem definition)
What is the problem in the family now?
Who agrees, who disagrees?
How is this different than before?
What does this mean?
How will things be in the future if things continue as they are?
How will this be different in the future if things change?

! 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 violence
Can 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.
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
Future
How will things be different when x has happened?
Observer
What do you think he/she thinks when you do that?
Unexpected context change
What would it be like if you had the opportunity to do x instead of y?
Embedded solution
Instead 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 questions
Do you think that his/her anger with you is about x, y, or maybe z?
Questions introducing hypothesis
When 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 Recognition
What 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. Concern
What 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 Change
The 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. Optimism
What 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 marriage
I like getting high Bad example for my children
Damaging my health
Spending too much money
Damaging my brain
Might lose my job
Waisting my time/life
Benefits Costs
Happier marriage What to do about my friends
More time for family Won’t have a way to relax
Feel better
Helps money problems
Continuing to drink as before
Making a change in my drinking

What stage
is client in?
What type of
questions might
be helpful?
What thereputic
factors are
engaged?
What is my
intention?

! 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.897-898
Cultural identity of individual
Cultural explanations of the individuals illness.
Cultural factors related to psychosocial environmental
and levels of functioning
Cultural elements of the relationship individual and
clinician.
Overall curltural assessment and diagnosis and care.

(07) 3201 2206, PO Box 445 Paddington Q 4064
E-mail cnlob@ozemail.com.au Web page WWW.ozemail.com.au/~cnlob
Feinberg 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, 1999
American 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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