Principles of Motivational InterviewingGeared to Stages of C.docx

Principles of Motivational Interviewing
Geared to Stages of Change:
A Pedagogical Challenge
Katherine van Wormer
ABSTRACT. This article discusses the significance of
motivational in-
terviewing as a framework with wide application across the
spectrum of
social work practice. This article discusses the basic
assumptions of the
motivational approach and argues that social workers can regard
this as a
bridge between treatment agencies organized around competing
philos-
ophies. Suggestions are made for incorporating content across
diverse
curriculum areas. doi:10.1300/J067v27n01_02 [Article copies
available for a
fee from The Haworth Document Delivery Service: 1-800-
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dress: <[email protected]> Website: <http://www.HaworthPress.
com> © 2007 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Motivational interviewing, harm reduction,
addiction,
substance abuse, stages of change
INTRODUCTION

Social work educators strive to present class content that
parallels the
treatment needs of agencies while at the same time preparing
students to
assume leadership positions regarding the introduction of
treatment in-
novations, especially of those that are evidence based. One area
that is
often overlooked, perhaps because of its affiliation with
substance abuse
Katherine van Wormer, MSSW, PhD, is Professor of Social
Work, University of
Northern Iowa, 36 Sabin Hall, Cedar Falls, IA 50614 (E-mail:
[email protected]).
Journal of Teaching in Social Work, Vol. 27(1/2) 2007
Available online at http://jtsw.haworthpress.com
© 2007 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J067v27n01_02 21
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counseling, is the change-inducing strategy generally known as
motiva-
tional interviewing (MI). An Internet search (as of November,
2004) of
“Social Work Abstracts” revealed a mere 11 listings for articles
on the
subject of MI and 14 on the related subject of harm reduction,

compared
with 278 listings for MI and 507 for harm reduction on
PsycInfo. Evi-
dently psychologists have given this treatment modality which
is aimed
at enhancing client motivation much more emphasis than have
social
workers. And yet, as most readers of this paper will realize,
social work-
ers have long practiced many of the precepts that now are
incorporated
in the MI formulation. In any case, because of its wide
applicability of
such an approach, especially in situations of short-term
treatment for
clients in situations that are self-destructive (for example, drug
misuse,
exposure to family violence), MI is of special relevance to the
social work
profession.
This article makes the case that interventions directed toward
client lev-
els of motivation are highly consistent with social work’s
predominant
strengths perspective formulation (see Rapp, 1998; Saleebey,
2002). Sug-
gestions are made for incorporating motivational content into
courses
across the social work curriculum including human behavior in
the so-
cial environment (HBSE), generalist practice, correctional
treatment and
counseling.
WHAT IS MOTIVATIONAL INTERVIEWING?

MI is a non-confrontational model based on the fundamental
truth
from social psychology that decisions to move toward change
are more
powerful if they come from within. MI is defined by Miller and
Rollnick
(2002) as “a client-centered, directive method for enhancing
intrinsic
motivation to change by exploring and resolving ambivalence”
(p. 25).
This approach is client-centered in the sense that most of the
state-
ments concerning the toll the drinking, gambling and so on are
taking is
elicited from the client. There is also a focus, however, on the
client’s
cognitions to help him or her move in the direction of health-
seeking be-
haviors (Substance Abuse and Mental Health Services
Administration,
[SAMHSA]1999, TIP 35).
MI is the pragmatic approach most closely associated with the
harm
reduction or public policy model. The focus is on providing
empathic
counseling and reinforcing the client’s sense of self efficacy or
ability to
exert some control over his or her life. From this treatment
modality, the
therapist assesses the level of the client’s motivation for
change. Careful
22 JOURNAL OF TEACHING IN SOCIAL WORK

to avoid fighting with the client, the motivational worker rolls
with the
resistance and in so doing, hopes to dispel it. Motivational
techniques
are geared to help people find their own path to change;
feedback is of-
fered to the client about what he or she seems to be saying
about the
need to reduce or eliminate self-destructive behaviors.
MI has been a favored treatment modality in substance abuse
treat-
ment; it also has wide applicability to any area of social work
that is cen-
tered on the need for behavioral change. The development of MI
is
credited to the persistent questioning by young Norwegian
psycholo-
gists and interns of psychologist William Miller as he
demonstrated his
techniques for enhancing clients’ receptiveness to substance
abuse treat-
ment and promote their willingness to change (Miller, 1996).
Miller’s
protégés wanted to know how this was done and what the theory
behind
it was. The result was a beginning conceptual model that was
followed
by years of testing and refinements which culminated in the
writing of
the groundbreaking text, “Motivational Interviewing: Preparing
People
to Change Addictive Behavior” (Miller & Rollnick, 1991).

My first encounter with the principles of motivational work
came
through an exchange between my university and social work
faculty at
a large urban university in northeast Britain. “Of what
importance is
motivation?” I asked myself at the time, my experience having
been solely
with involuntary clients. “Who comes to treatment voluntarily,
anyway?”
I wondered. That’s just the point, of course. When treatment
methods (total
abstinence, urinalysis tests, confrontational presentation of
assessment re-
sults) are designed to tear down resistance rather than establish
rapport,
few people sign up for the experience of their own accord. The
expense
of U.S. mental health care is an additional inhibiting factor. In
the
United Kingdom, nationalized health care (The National Health
Service)
and the availability of neighborhood drop-in clinics are
conducive to harm
reduction strategies–meeting the client where the client is and
helping
the clients modify their harmful practices at their own pace.
Although the contrasts between European pragmatism and U.S.
pu-
nitiveness persist, especially regarding chemical dependency,
many of
the aspects of an individually tailored approach to helping are
beginning
to gain acceptance (Mueser, Noordsky et al., 2003). For social
work prac-

titioners, this development can only enhance their success in
fields such
as correctional and addictions work.
In its basic formulation and precepts, MI closely parallels the
strengths
perspective of social work practice (van Wormer and Davis,
2003). The
strengths approach, as Saleebey (2002) suggests, is “a versatile
practice
approach, relying heavily on ingenuity and creativity, the
courage and
Katherine van Wormer 23
common sense of both clients and their social workers. It is a
collaborative
process” (p. 1). According to this positive, feedback-oriented
framework
which builds on clients’ strengths and resources, client
resistance and
denial are often viewed as healthy, intelligent responses to a
situation
that might involve unwelcome court mandates and other
intrusive prac-
tices (Rapp, 1998).
As in the strengths formulation, the focuses of MI is on
collaboration
of counselor and client, as well as on personal choice (see
Saleebey, 2002).
When the focus on the professional relationship is on promoting
healthy
lifestyles and on reducing the problems that the client defines as

impor-
tant rather than on the substance use per se, many clients can be
reached
who would otherwise stay away (Denning, 2000; Graham, Brett,
& Baron,
1994). Central to this approach is the building of a relationship
between
therapist and client. In working with youth, this relationship is
crucial in
terms of promoting self-esteem and the confidence to try on new
roles.
In the MI orientation, the strategy is to help develop and
support the client’s
belief that he or she can change; this is the principle of self-
efficacy men-
tioned earlier (SAMHSA, 1999).
The motivational, like the strengths approach, meets the client
where
he or she is at that point in time. The harm reduction
practitioner as-
sesses the level of the client’s motivation for change, and
instead of
engaging in a tug of war with the client, “rolls with resistance.”
MI tech-
niques are geared to help people find their own path to change.
The thera-
pist provides feedback through additive paraphrasing, a
technique that
involves selectively disseminating to the client what he or she
seems to
be saying about the need to reduce or eliminate self-destructive
behav-
iors (van Wormer and Davis, 2003).
Table 1 presents the critical components of MI in a nutshell.

These
six elements of current motivational approaches have been
identified
and presented in brief clinical trials (SAMHSA, 1999). They are
sum-
marized by the acronym FRAMES.
WHAT IS THE SCIENTIFIC EVIDENCE
FOR THIS APPROACH?
In the Substance Abuse Field
Most studies to date have been conducted in the treatment of
substance
abuse disorders (Miller & Rollnick, 2002). A review of the
evidence-based
literature reveals that motivational techniques are particularly
useful as
a prelude to other services such as in employee assistance
programs
where treatment encounters are brief. The most widely cited and
ex-
haustive study in the literature pertaining to MI is the eight-
year-long
comparison study directed by the National Institute on Alcohol
Abuse
and Alcoholism, Project MATCH (1997). Project MATCH
involved al-
most 2,000 patients in the largest trial of psychotherapies ever
under-
taken. The goal of this $28 million project was not to measure

treatment
effectiveness, but, rather, to study which types of treatments
worked for
which types of people.
The three treatment designs chosen for this extensive study
were
based on the principles of the three most popular treatment
designs–
conventional Twelve-Step-based treatment, cognitive strategies,
and
motivational enhancement therapy. All therapy provided was
individu-
ally rather than group based for more rigorous control of the
process. In-
dividuals were assigned randomly to the three varieties of
treatment.
Among the treated subjects, less successful outcomes were
associ-
ated with male gender, psychiatric problems, and peer group
support for
drinking. Because there was no control group deprived of
treatment,
generalizations concerning the efficacy of treatment cannot be
made, a
fact that has brought this massive project in for considerable
criticism
(Bower, 1997). What this extensive and long-term study does
show,
however, is that all three individually delivered treatment
approaches are
TABLE 1. FRAMES: Critical Elements of Effective

Motivational Intervention
• Feedback regarding personal risk or impairment is given to the
client following assess-
ment of substance abuse patterns (or other risk-taking
behaviors) and associated
problems.
• Responsibility for change is placed squarely and explicitly on
the client (with respect for
the client’s right to make choices for himself or herself).
• Advice about changing–reducing or stopping–harmful
behavior is clearly given to the
client by the clinician in a nonjudgmental manner.
• Menus of self-directed change options and treatment
alternatives are offered to the client.
• Empathic counseling–showing warmth, respect, and
understanding–emphasized.
• Self-efficacy or optimistic empowerment is engendered in the
client to encourage
change.
Note: This table is based on information in SAMHSA (1999)
TIP 35 published by the U.S. Department of
Health and Human Services and inspired by the work of Miller
and Rollnick.
relatively comparable in their results, that treatment that is not
abstinence
based (motivational enhancement) is as helpful in getting

clients to re-
duce their alcohol consumption as the more intensive treatment
designs.
That abstinence could be a long-term but not immediate
outcome of this
treatment protocol was another significant finding of this mass
experiment.
The format was this: Treatments were provided over 8- and 9-
week
periods, with motivational therapy being offered only four times
and the
other two designs offering 12 sessions. All of the participants
showed
significant and sustained improvements in the increased
percentage of
days they remained abstinent and the decreased number of
drinks per
drinking day. However, treatment researchers noted that
outpatients
who received the Twelve-Step facilitation program were more
likely to
remain completely abstinent in the year following treatment
than were
outpatients who received the other treatments. Individuals high
on reli-
giosity and those who indicated they were seeking meaning in
life gen-
erally did better with the Twelve-Step, disease model focus,
while clients
with high levels of psychopathology did not. Clients low in
motivation
did best ultimately with the design geared for their level of
motivation.
An interesting outcome of this study is that insurance

companies
have come to endorse MI treatments, undoubtedly due to its
brevity and
therefore cost effectiveness (van Wormer & Davis, 2003). Their
en-
dorsement, in turn, has bolstered their client-centered approach
for use
in substance abuse counseling. I believe it has an applicability
that goes
far beyond the substance abuse field. If the techniques work
well with
alcoholics reluctant as they are to give up the use of mood
altering sub-
stances, how much more amenable such techniques might be in
other
treatment areas–in standard health care and mental health
counseling,
for example.
Empirical Research in Other Areas
While the literature is still emerging in areas apart from
substance
abuse counseling, available evidence suggests that motivational
strate-
gies hold great promise for promoting healthy behavior change.
In their
review of the health care literature, Resnicow, DiIorio et al.
(2002)
found that for nonaddictive behavior, less time may be needed
to re-
solve client ambivalence; and compliance measures are less
tangible for
some health-promoting behaviors than, for example, cigarette
use. Brief
adaptations of MI are often used for such situations of limited

contact.
One difficulty in the medical field concerns the training of
personnel
used to giving orders to adopt a new style of relating to
patients. Besides,
physicians and nurses are often too busy to put the adequate
time into
training and role plays. Experiments using counselors,
psychologists, and
social workers, however, have achieved significantly better
results
compared with standard intervention groups in obtaining diet
changes
in overweight diabetics, overweight children, and patients at
risk of cor-
onary heart disease (Resnicow, DiIorno et al., 2002) Promising
results
have been found in work with schizophrenic patients as well.
Participants
who attended several motivational sessions showed much
improvement
in attitudes toward drug treatment and greater insight into their
illness than
did participants in a support counseling group (Kemp, Kirov et
al., 1998).
More rigorous studies are needed, however, before we can
definitely
state that MI outshines other means of ensuring medical patient
compli-
ance. Mueser et al. (2003) conducted a review of systematically
con-

trolled research into treatments for dually diagnosed patients.
What these
researchers found was that the programs with the best results
were inte-
grated (to treat both the substance abuse and the mental
disorder), were
long term, and were motivation-based.
An even greater challenge in terms of employee training and
non-
compliant participants is found in the criminal justice field.
Ginsburg,
Mann et al. (2002) pursue the investigation of motivational
work in this
highly authoritarian milieu. Referring to Project MATCH, these
authors
indicate that given the success of motivational strategies with
alcoholics
many of whom were offenders, further research would likely
show that MI
has application with offender populations in general. Further
credence
is provided to this supposition in the finding that MI strategies
achieved
a high level of success in working with clients who initially
were angry.
Ginsburg, Mann et al. (2002) cite several preliminary studies
showing
that harsh confrontational techniques have less effect in
promoting change
in offenders than do motivational interventions. Their
recommendation
for MI with sexual offenders is based on case studies from the
United
Kingdom which documented that sexual offenders responded
well to this

approach. It seems self evident that any strategy designed to
foster inter-
nally motivated behavior change should have more success in
offender
rehabilitation as opposed to more externally imposed controls.
A key ad-
vantage of MI is its ability to tailor particular intervention
strategies to
the individual client’s position on the stages-of-change
continuum. Let
us consider these strategies in some detail.
THE STAGES-OF-CHANGE MODEL
People are ultimately capable of making an informed choice in
their
own best interest. The choices they make depend on their
readiness to
change, i.e., what stage of change they are in at a certain point
in time
(van Wormer & Davis, 2003). The stages-of-change model,
sometimes
referred to as the Transtheoretical Model because it relies on
several
theories of social psychology, was first proposed by Prochaska
and
DiClemente (1986) for use in helping smokers break their
nicotine habit.
The model has since been applied and adopted in many
addiction treat-
ment and other helping settings around the world. DiClemente
and

Velasquez (2002) describe the series-of-change model as
follows:
In this model change is viewed as a progression from an initial
precontemplation stage, where the person is not currently
consid-
ering change; to contemplation, where the individual undertakes
a
serious evaluation of considerations for or against change; and
then to preparation, where planning and commitment are
secured.
(p. 201)
Once the initial stage tasks are accomplished, as DiClemente
and
Velasquez (2002) further inform us, clients can be expected to
take ac-
tion toward change; such action steps, in turn, lead to the final
and fifth
stage of change, maintenance, in which the person works to
maintain
long-term change. If the individual falters, however, a sixth
stage–
relapse or recurrence of the behavior–may occur. Such
backtracking is
considered a normal part of the behavior change process.
The stages-of-change model is a natural fit with MI and harm
reduc-
tion practices because of the primary focus on client choice and
the em-
phasis on helping people progress through the stages at their
own pace.
Instead of a dualistic, one-size-fits-all framework where there is
either
complete recovery or total failure, this approach offers the

possibility of
small steps punctuated by expected set-backs on the road to a
resolution
of one’s problems.
The starting point for the therapist is to determine where the
client is,
at what level of change. As Boyle (2000) indicates, it is not
unusual for
involuntary clients to enter treatment at the precontemplative
stage. For
the purposes of illustration, let us assume the client is a hard-
drinking
teenager brought to treatment through a court order. Typical
teenage
comments at each level of the stages of progression are
contained in
Table 2.
During the initial precontemplation stage of work with the
typical
teen drug user, the goals for the therapist are to establish
rapport, to ask
rather than to tell, and to build trust. Eliciting the teen’s
definition of the
situation, the counselor can reinforce discrepancies between the
client’s
and others’ perceptions of the problem. During the
contemplation stage,
while helping to tip the decision toward reduced drug/alcohol
use, the
counselor emphasizes the client’s freedom of choice. “No one

can make
this decision for you” is a typical way to phrase this sentiment.
Informa-
tion is presented in a neutral, “take-it-or-leave-it” manner.
Typical ques-
tions are, “What do you get out of drinking?” “What is the down
side?”
And to elicit strengths, “What makes your family member
believe in
your ability to do this?” At the preparation for change and
action stages
questions like, “What do you think will work for you?” help
guide the
youth forward without pushing him or her too far too fast.
Patricia Dunn (2000) finds that the stages of change model is
appro-
priate for social work because it is compatible with the mission
and con-
cepts of the profession, is an integrative model, and is grounded
in
empirical research. Through building a close therapeutic
relationship,
the counselor can help the client develop a commitment to
change. The
way motivational theory goes as this: If the therapist can get the
client to
do something, anything, to get better, this client will have a
chance at suc-
cess. This is a basic principle of social psychology. Examples of
tasks that
William Miller (1998) pinpoints as predictors of recovery are
going to
AA meetings, coming to sessions, completing homework
assignments
and taking medication (even if a placebo pill). The question,

according to
Miller, then becomes, “How can I help my clients do something
to take
TABLE 2. An Ambivalent Teen Progresses Through the Stages
Stage of Change Adolescent Comments
Precontemplation My parents can’t tell me what to do; I still
use, so what if I get
high now and then?
Contemplation I’m on top of the world when I’m high, but then
when I come
down, life is a drag. It was better before I got started on these
things.
Preparation I’m feeling good about setting a date to quit, but
who knows?
Action Staying clean may be healthy, but it sure makes for a
dull life.
Maybe I’ll check out one of these groups.
Maintenance It’s been a few months; I’m not there yet but I’m
hanging out
with some new friends.
action on their own behalf?” A related principle of social
psychology
is that in defending a position aloud, as in a debate, we become
commit-

ted to it. One would predict, from motivational enhancement
perspec-
tive, that if the therapist elicits defensive statements in the
client, the
client will become more committed to the status quo and less
willing to
change. For this reason, explains Miller, confrontational
approaches
have a poor track record. Research has shown that people are
more
likely to grow and change in a positive direction on their own
than if
they get caught up in a battle of wills.
In their seven-part professional training videotape series, Miller
and
Rollnick (1998) provide guidance in the art and science of
motivational
enhancement. In this series the don’ts are as revealing as the
do’s. Ac-
cording to this therapy team, the don’ts, or traps for therapists
to avoid,
are as follows:
• A premature focus, such as on one’s addictive behavior
• The confrontational/denial round between therapist and client
• The labeling trap–forcing the individual to accept a label such
as
alcoholic or addict
• The blaming trap, a fallacy that is especially pronounced in
cou-
ples counseling
To learn more about the specifics of this technique, students can

visit
the CSAT (Center for Substance Abuse Treatment) Website at
www.csat. samhsa.gov. TIP 35, “Enhancing Motivation for
Change” can
be ordered from this site. Also consult
www.motivationalinterview.org
for further information.
GOODNESS OF FIT
WITH THE SOCIAL WORK CURRICULA
Clearly, students in substance abuse courses must learn the
skills of
motivational interviewing, as this is the method increasingly
endorsed
by insurance companies and substance abuse treatment agencies
(van
Wormer & Davis, 2003). But social workers in other areas,
whether
child welfare (parental substance abuse is often a factor),
corrections
(where the need for decision making in the direction of law
abiding
behavior is paramount), or mental health agencies (where
medical
compliance may be a key to good health), will also find a
grounding in
http://www.csat
http://www.motivationalinterview.org
motivational techniques highly useful. The relevance of
motivational

training to four other areas of social work education, the core
areas of
social work, namely, (1) practice, (2) human behavior, (3)
research, and
(4) policy, are described as follows.
Practice
Social work practice courses tend to focus on treatment after the
fact
of personal crisis often involving self destructive behavior
rather than
on prevention; such courses also tend to focus on individual
rather than
public health. Yet there is a well established body of literature
on effec-
tive prevention of behaviors such as teen pregnancy, and
reduction of
disease risk that should be included in advanced practice
courses fo-
cused on working with families, children, and adolescents
(Williams,
Rounds, & Copeland, 2002). Skills development in risk-
reducing behav-
ior along the lines of learning how to elicit motivation inducing
state-
ments in clients is invaluable in this regard.
Human Behavior in the Social Environment (HBSE)
Why people do the things they do and which life events or
interven-
tions can be turning points in people’s lives are themes of
undergraduate
and graduate courses in human behavior. An in-depth study of
motiva-

tion to change is an important aspect of the psychology of
human behav-
ior, one that is often overlooked in HBSE courses. Yet the
connection to
human development issues that traditionally comprise the
knowledge
base of the HBSE curriculum of human motivation is obvious.
Research
Motivational theory has been an outgrowth of social psychology
re-
search into decision making. Students, in their critical analysis
of evi-
dence-based treatment interventions can benefit by exploring
the
burgeoning research on strategies to elicit motivation.
Advanced re-
search students can be made aware of the wealth of grant funded
oppor-
tunities in experimental research in this area. This fact of this
demand
can be borne out by an Internet search with the substance abuse
search
engine, www.jointogether.org. This resource provides
announcements
of funded research opportunities related to substance abuse
treatment
interventions.
http://www.jointogether.org
Policy

How to provide client-based treatment against the backdrop of
an
under-funded and punitive social welfare system–students of
policy will
have to tackle that problem. Policy courses should include
content on the
need for government policies conducive to prevention of disease
and to a
treatment climate conducive to motivational strategies. Students
can be
referred to www.statepolicy.org, the Influencing Social Policy
Web site,
and the Harm Reduction Coalition at
<www.harmreduction.org>.
CAUTIONARY NOTE
There is some risk that the authorities (government officials,
insur-
ance companies) will co-opt motivational interviewing
techniques and
that, in so doing, they will miss the spirit of this client-centered
effort.
Accordingly, the effort will not be client-centered at all but, in
fact, might
be construed as a ruse to elicit information from a trusting
client.
Consider Iowa as a case in point. My observations are drawn
from in-
formal interviews with authorities at the Iowa Board of
Substance Abuse
Certification and through conversations with individual
counselors. The
board of certification requires proficiency in motivational

techniques; MI
trainings are offered throughout the state for all counselors. The
impetus
for this apparent paradigm shift, in all probability is related to
insurance
company reimbursement incentives. Following Project MATCH
results
that show motivational counseling achieves effectiveness in
fewer sessions
than does the Twelve-Step or cognitive approach, third party
payers logi-
cally promote MI strategies as more cost effective.
The paradigm shift that I refer to earlier is more apparent than
real
given the authoritarian structure within much counseling
activity that
takes place. Treatment compliance is apt to be mandated, often
under
the threat of imprisonment or loss of driving privileges. Harm
reduction
philosophy, the guiding model for substance abuse treatment in
many
European countries, is congruent with a voluntary system in
which the
clients come and go as they choose and total abstinence is not
required.
Most treatment in the Untied States, in contrast, is geared
toward the
court-ordered client. So MI-trained counselors for all their high-
powered
listening skills and experience in eliciting insightful responses
in the cli-
ent, are often in the position of wearing two hats, one as a
counselor
meeting the client where the client is, the other as an employee

of the
state, county or even correctional establishment. As one
counselor put
http://www.statepolicy.org
http://www.harmreduction.org
it, “The client opens up and tells you everything and you’re
having a
great session. The last five minutes you suddenly change your
tactics
and say, ‘You have a serious problem and will be required to
attend so
many treatment sessions and you must be drug free the whole
time’ and
the client gets furious and feels deceived and says something
like ‘but
you said I didn’t seem to have much of a problem’” (personal
interview
of April 8, 2004).
DiClemente and Velasquez (2002) address this issue indirectly,
they
caution that to elicit a list of the “cons” in using an addictive
substance
and then later to use these statements as ammunition against the
client
defeats the purpose of the exercise (the listing the pros and cons
of drug
use). They advise that the clinician should trust clients to reach
their
own conclusions. Until the structure, at least in the substance
abuse and

correctional areas, is less authoritarian and punitive,
motivational strat-
egies can only go so far. Such an approach is ideal, however, at
mental
health centers and private counseling clinics where clients come
more
or less of their own accord. I have used such strategies with
adults in
treatment for mental disorders and with teenagers brought into
treatment
by their parents to good effect.
CONCLUSION
Social workers in whatever field of practice are change agents,
or
hope to be. In their individual, group, and family work, the aim
is to help
people help themselves. Students of social work, therefore, need
training
in the most psychologically effective methods known to modern
science.
Motivational enhancement strategies have been shown to be
effective in
curbing risk taking behaviors, especially related to health and
mental
health. Motivational techniques are highly effective in helping
clients
move from a precontemplative stage to an action stage of
behavior change.
Social work educators can help their students shape appropriate
interven-
tions to reflect client stages of motivation. HBSE instructors
can focus
on the human behavior components in MI theory and learn how
and why

MI works better than harsh confrontation. Courses on health and
mental
health can focus on the prevention attributes of motivational
concepts.
Finally, policy courses can consider the structural impediments
to insti-
tuting client centered programming. In substance abuse and
offender
situations, however, the American social structure is not always
conducive
to a treatment regimen centered on the principles of stages-of-
change
which proceed at the client’s, not the treatment center’s, pace.
MI has a tremendous potential in areas in which clients are
subjecting
themselves or are being subjected by others to harm. I am
thinking of
the victims of domestic violence or family members of persons
with ad-
dictions problems or mental illness in need of help to prevent
the situa-
tion from growing desperate. Because of its versatility, MI
techniques
can be taught to practitioners at various agencies. This
commonality of
treatment approach should help bridge the gap between agencies
(for
example, women’s shelter and substance abuse treatment
centers) whose
philosophy in the past has clashed due to professional bias and
incon-

gruities in focus. A main advantage of such a common approach
is that
services for treatment of clients with dual and multiple
diagnoses could
be readily integrated to meet client needs and to provide more
consis-
tency in approach.
REFERENCES
Bower, B. (1997). Alcoholics anonymous. Science News, 151,
62-63.
Boyle, C. (2000). Engagement: An ongoing process. In A.
Abbott (Ed.), Alcohol,
tobacco, and other drugs (pp. 144-158). Washington, DC:
NASW Press.
Denning, P. (2000). Practicing harm reduction psychotherapy:
An alternative ap-
proach to addictions. New York, NY: Guilford Press.
DiClemente, C. & Velasquez, M. (2002). Motivational
interviewing and the stages of
change. In W. R. Miller & S. Rollnick (Eds.), Motivational
interviewing: Preparing
people for change (2nd ed., pp. 201-216). New York, NY:
Guilford.
Dunn, P. (2000). Dynamics of drug use and abuse. In A. Abbott
(Ed.), Alcohol, tobacco
and other drugs: Challenging myths, assessing theories,
individualizing interven-
tions (pp. 74-110). Washington, DC: NASW Press.
Ginsburg, J., Mann, R., Rotgers, F., & Weekes, J. (2002).

Motivational interviewing
with criminal justice populations. In W.R. Miller & S. Rollnick
(Eds.), Motivational
interviewing: Preparing people for change (2nd ed., pp. 333-
346). New York, NY:
Guilford.
Graham, K., Brett, P., & Bacon, J. (1994, March 7-10). A harm
reduction approach to
treating older adults: The clients speak. Paper presented at the
5th International
Conference on the Reduction of Drug-Related Harm, Toronto,
Ontario, Canada.
Kemp, R., Kirov, G., Everitt, B., Hayward, P., & David, A.
(1998). Randomised con-
trolled trial of compliance therapy: 18-month follow up. British
Journal of Psychia-
try, 172, 413-419.
Miller, W. (1996). Motivational interviewing: Research,
practice, and puzzles. Addic-
tive Behaviors, 21(6), 835-842.
Miller, W. (1998). Toward a motivational definition and
understanding of addic-
tion. Motivational Interviewing Newsletter for Trainers, 5(3), 2-
6. Website: www.
motivationalinterview.org/clinical/motmodel.html
http://www.motivationalinterview.org/clinical/motmodel.html
http://www.motivationalinterview.org/clinical/motmodel.html

Miller, W.R. & Rollnick, S. (1991). Motivational interviewing:
Preparing people to
change addictive behaviors. New York, NY: Guilford Press.
Miller, W.R. & Rollnick, S. (1998). Motivational interviewing:
Professional train-
ing videotape series. Directed by Theresa Moyers, University of
New Mexico:
Albuquerque.
Mueser, K., Noordsky, D., Drake, R., & Fox, L. (2003).
Integrated treatment for dual
disorders. New York, NY: Guilford.
Prochaska, J. & DiClemente, C. (1986). The transtheoretical
approach. In J.C.
Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 163-
200). New York, NY:
Brunner/Mazel.
Project MATCH Research Group (1997, January). Matching
alcoholism treatment
to client heterogeneity: Project MATCH post-treatment
outcomes. Journal of Stud-
ies on Alcohol, 58, 7-28.
Rapp, C.A. (1998). The strengths model: Case management with
people suffering
from severe and persistent mental illness. New York, NY:
Oxford University Press.
Resnicow, K., DiIorio, C., Soet, J., Borrelli, B., Ernst, D.,
Hecht, J., & Thevos, A. (2002).
In W. Miller & S. Rollnick, Motivational interviewing:
Preparing people for
change (2nd ed., pp. 201-216). New York, NY: Guilford.

Saleebey, D. (2002). Introduction: Power to the people. In D.
Saleebey (Ed.), The
strengths perspective in social work practice (3rd ed., pp. 1-22).
Boston, MA:
Allyn & Bacon.
Substance Abuse and Mental Health Services Administration
(SAMHSA) (1999).
Enhancing motivation for change in substance abuse treatment.
TIP 35. Rockville,
MD: SAMHSA.
van Wormer, K. & Davis, D.R. (2003). Addiction treatment: A
strengths perspective.
Belmont, CA: Wadsworth.
doi:10.1300/J067v27n01_02
BUSI 414
BUSI 411
Discussion Board Forum 2 Instructions
Thread:
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Option A:
Utilizing one of the internet search engines, find an
organization that has recently been forced to increase or
decrease capacity dramatically to align with customer demand.

Discuss specifically the key drivers for the change in demand
along with the steps that were taken and the expected impact.
Be sure to provide any URLs you used as a reference source for
your answer. The selected article must provide well-rounded
information and address the topic. You must post the annotation
in the reference section.
· All references must be annotated.
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work that is engaging and substantive. Simply meeting the
minimum requirements earns one only the minimum grade.
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results of plagiarizing a post or parts of a post will be a zero on
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course, etc.) for this course’s assignments will result in a very
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Page 2 of 2
Page 1 of 1
CIRCULAR QUESTIONING AND
NEUTRALITY; AN INVESTIGATION OF
THE PROCESS RELATIONSHIP
Michael J. Scheel

Collie W. Conoley
ABSTRACT: This study investigated the possibility that
interventive
circular questions violate the principle of neutrality advanced
by the
Milan school as essential to the practice of systemic family
therapy. A
method for categorizing circular questions as interventive or
descrip-
tive was developed to explore neutrality violations. Neutrality
was
operationalized as client perceptions of therapist side-taking
and feel-
ings of discomfort. Immediately after family therapy, individual
fam-
ily members viewed videotape replays of moments when
circular
questions were posed and rated their perceptions of therapist
side-
taking and feelings of discomfort for each selected moment.
Findings
indicated a greater tendency for non-neutrality with interventive
questions. Neutrality was also represented as multidimensional
through the lack of correlation between side-taking and
discomfort
ratings.
KEY WORDS: circular questions; Milan family therapy;
neutrality.
Milan family therapy's process of circular questioning and neu-
trality has held a great deal of interest and centrality in the
Milan
family therapy literature (e.g., Matthews, 1984; Burroughs,
1985;
Nitzberg, Patten, Spielrnan, & Brown, 1985; Reder, 1985;

Speed,
Michael J. Scheel, PhD, is assistant professor in the Department
of Educational
Psychology, 324 Milton Bennion Hall, University of Utah, Salt
Lake City, UT 84112.
Collie W. Conoley, PhD, is professor in the Department of
Educational Psychology, 709
Harrington Ed. Bldg., Texas A&M University, College Station,
TX 77843. Reprint re-
quests should be sent to the first author.
221
Contemporary Family Therapy, 20(2), June 1998
® 1998 Human Sciences Press, Inc.
CONTEMPORARY FAMILY THERAPY
1985; Mauksch & Roesler, 1990). Others have objected to
neutrality,
proposing that its practice perpetuates power differentials in
families
(Avis, 1988; Bograd, 1988; Hoffman, 1990). Boscolo and
Cecchin ac-
knowledge that neutrality is controversial in its function of non-
blame (Boscolo, Cecchin, Hoffman, & Penn, 1987). Even so,
neutrality
is viewed as essential to systemic practice (Selvini Palazzoli,
Boscolo,
Cecchin, & Prata, 1980). Whether in favor of or opposed to the
prac-
tice of neutrality in family therapy, a clearer understanding of
what
neutrality is and when it occurs in the context of systemic

family
therapy is needed. This study investigates the relationship
between
types of circular questions and the maintenance of client
perspectives
of therapist neutrality during family therapy.
The fundamental aims of the Milan method of family therapy
are
twofold: a) to provide the therapist and family a systemic
description
through an efficient method of information gathering, and b) to
feed
back to the family contextual information upon which to base
change.
Change develops through disruption of dysfunctional cycles of
inter-
action and symptom supporting beliefs (Fleuridas, Nelson, &
Rosen-
thai, 1986; Tomm, 1984).
Circular questioning is the Milan interviewing method used to
gain descriptive assessments and deliver interventions through
ques-
tions to a family (Penn, 1982; 1985; Tomm, 1985; 1987;
Boscolo et al.,
1987). The process was developed by the Milan Associates and
is
based on the work of Gregory Bateson.
Circular questioning was developed by the Milan team to
connect
individual family member's arcs (pieces) of understanding into
circu-
lar views about a situation within a family (Selvini Palazzoli et
al.,

1980). Circular questioning is described as a Socratic method in
which the therapist asks questions and family members respond.
The
questions are inquiries about differences within the family. The
ques-
tions are designed to discover and reveal systemic processes.
When a
family presents an opening, differences in beliefs among family
mem-
bers are explored through questions. Differences lead to
systemic hy-
potheses of the family dynamics. Question presentation is
guided by
the therapist's developing hypotheses (Boscolo et al., 1987).
Family
openings are the family members' beliefs which take the form of
la-
bels or diagnoses. An intent of the circular questioning process
is to
expand these beliefs beyond the meanings which the family
currently
holds.
For example, during this study one mother was asked, "Who do
you think is the saddest about the fighting?" She responded, "I
don't
222
MICHAEL J. SCHEEL AND COLLIE W. CONOLEY
know. I grew up in a family with no fighting." Her experience
with
fighting was different than other family members' experiences.

This
information was regarded as an opening. The consultation team
hy-
pothesized that because of her female status and family of
origin his-
tory the mother saw herself as helpless to do much about the
fighting
between her three sons. The mother's opening was explored by
ask-
ing, "What is it like in this family being the only female?" Also,
the
sons and husband were asked, "How could you get her (the
mother) to
like being upstairs (where the fighting occurs) with you more?"
THE VIOLATION OF NEUTRALITY
Neutrality was originally presented in the Milan method as the
basic therapeutic stance of being on everyone's and no one's
side in
the family at the same time (Selvini Palazzoli et al., 1980).
Therapist
neutrality toward the family allows the therapist freedom to
work
without defensiveness, scapegoating, or resistance by family
mem-
bers, because the therapist is not being perceived as taking sides
(Boscolo et al., 1987). Neutrality (Cecchin, 1987) also has been
de-
scribed as a state of curiosity about many perspectives of the
family's
problem which allows exploration and invention of alternative
views.
When the therapist violates neutrality more than momentarily
by an overemphasis on one family member or one solution, the

thera-
pist is believed to lose some family member's open
communication.
Therapeutically open communication leads to a more systemic
under-
standing and change. As Tomm (1987) asserts, the therapist
becomes
non-neutral for a moment to deliver an intervention. Non-
neutrality
exists because the therapist sides with someone when a
suggestion
occurs, then others may feel sided against. Intervention in this
frame-
work is the process of focusing on one part of the system
because
multiple foci at one time perhaps cannot occur. Attempting
change via
focusing may leave certain members of the system feeling
excluded,
blamed, or upset.
For instance, with the question "How do you think your child's
behavior would be different if you and your husband agreed
more?,"
the parents may easily feel that their husband-wife interaction is
be-
ing blamed. Another question could have been posed as "How
do you
think your husband and wife interaction would be different if
your
child were more cooperative?" This statement may not be as
upsetting
to the parents, but more upsetting and blaming to the child.
223

One intervention seldom, if ever, includes all family members'
perspectives. If all perspectives were included the intervention
would
be truly systemic. At the moment of intervention when the
process
loses its systemic quality, the intervention suggests a belief in
one
solution and one problem, a more linear causal relationship
(Boscolo
et al., 1987). The danger is that individuals feel blamed, leading
to
unproductive processes. In other approaches the unproductive
pro-
cesses have been called resistance or oppositional behavior.
Through
multiple hypotheses that eventually include all family members
(a
systemic relationship), each member may have a sense of
influencing
the problem system and, more importantly, the solutions.
Violation of neutrality is believed to endanger therapeutic prog-
ress. Families may not return if members with more power in
the
system feel sided against or extremely uncomfortable. If
families re-
turn after violations of neutrality, some members may adopt
defen-
sive positions which prevent the emergence of more circular
perspec-
tives (Boscolo et al., 1987).

Two indicators of violated neutrality have been introduced in
the
Milan literature. Selvini Palazzoli and associates (1980)
proposed
that the member's perception of the therapist taking sides was
indica-
tive of neutrality. Boscolo and colleagues (1987) added that
members'
upset or aroused feelings were signs of violated neutrality. The
feel-
ings were believed to be related to non-neutral, more linear,
question
interventions. The present study assesses neutrality by client
reports
of therapist side-taking and client discomfort associated with
circular
questions. The client reports are solicited as the individual
client pri-
vately observes videotape re-plays of circular questions being
asked
during family therapy sessions.
INTERVENTIVE AND DESCRIPTIVE CATEGORIES OF
CIRCULAR QUESTIONS
Circular questioning originally was described as a means to in-
vestigate the family system without violating neutrality (Selvini
Pal-
azzoli et al., 1980; Penn, 1982). Later writings (Tomm, 1985;
Penn,
1985; Fleuridas et al., 1986; Boscolo et al., 1987) proposed that
cer-
tain kinds of circular questions are more interventive than
others.
Interventive questions tend to violate neutrality because
intervention

is inherently non-neutral (Tomm, 1985; Boscolo et al., 1987).
Circular
questions have become the primary intervention in the Milan
method
224
of systems therapy (Penn, 1985; Tomm, 1985; 1987; Boscolo et
al.,
1987), an evolution away from delivering interventions through
pre-
scriptions at the end of a session. Facilitating change via
circular
questions makes the process more constructivistic (Boscolo et
al.,
1987). The function of circular questioning developed into a
process of
delicately balancing the introduction of interventions within a
family
interview with the maintenance of the therapeutic stance of neu-
trality. Because of the dual nature of circular questions several
au-
thors have suggested typologies to distinguish between the
interven-
tive (non-neutral) and descriptive (neutral). Questions seen as
more
interventive are: (a) future-oriented, (b) hypothetical, and (c)
hypoth-
esis-revealing (Boscolo et al., 1987; Penn, 1985; Tomm, 1987).
Ques-
tions seen as more neutral by asking for descriptions of present
real-

ities are: (a) problem definition questions, (b) questions asking
for
comparisons between family members or issues, (c) questions
asking
for family member classifications, and (d) questions asking
about
agreement (Boscolo et al., 1987; Penn, 1985).
A problem definition question such as "What is the problem in
your family right now?" is descriptive. It asks the family to
report
what exists in the present. A future-oriented question such as
"What
would it be like in the family in five years if things were to
continue
as it is now?" is more interventive. It asks the family to
generate new
meanings through speculation. Perturbations in the existing
meaning
systems are likely (Boscolo et al., 1987; Penn, 1985). A
hypothesis
revealing question such as "What do you think about the idea
that
there is a connection between your daughter's anorexic behavior
and
you two fighting?" is also associated with perturbation (Boscolo
et al.,
1987; Penn, 1985). Tomm (1987) differs from the previous
authors by
differentiating upon the basis of the therapist's intent rather
than the
structure of the circular questions. Tomm (1985) points out that
all
circular questions have the potential to trigger the therapeutic
system's reflexive process which alters family meanings and
conse-

quently promotes change. While Tomm's presentation is
persuasive,
the structural qualities of the circular questions were used in
this
study because of their possible heuristic value.
HYPOTHESIS OF THE STUDY
This study investigated the proposition that interventive circular
questions would more likely violate neutrality than descriptive
ques-
225
tions. Interventive circular questions were future-oriented,
hypotheti-
cal, and hypothesis-revealing questions. Violations of neutrality
were
defined as a) client perceptions of the therapist taking
someone's side
in the family, and b) client reported discomfort. This study is
signifi-
cant because it investigates the theorized relationship between
neu-
trality and types of circular questions. Also, the study
introduces a
procedure for measuring neutrality from the client's viewpoint,
and
categorizing circular questions as interventive or descriptive.
METHODOLOGY

Procedure
Three families received four sessions of Milan systemic family
therapy. Each of the three families was seen by a different
therapist
for four sessions, with session length ranging between 60 and
90 min-
utes. A consultation team assisted each session from behind a
view-
ing mirror. The therapist initiated consultation breaks and
conferred
with the team at least twice during each session regarding new
ideas
or feedback about what had just occurred in session. The
consulta-
tions were to develop multiple ideas (hypothesizing) linking
together
the elements in the problem situation that help the family
toward
their goals. Circular questioning, neutrality, and hypothesizing
were
verified as occurring in this study. The Milan Associates
designated
those three ingredients as essential to conducting a family
interview
in a systemic manner (Selvini Palazzoli et al., 1980).
After each family session there was a 15-minute break followed
by individual sessions with each family member lasting about
30 min-
utes. During the 15-minute break two experimenters readied the
video-taped circular questions from the session. The two
experiment-
ers jointly selected three descriptive and three interventive
questions
to use as stimuli. One interventive and one descriptive question

was
selected from each third of the interview in order to exert some
con-
trol over the influence of when a question was asked. Questions
with
similar content were not used.
The individual interviews consisted of one team member
meeting
individually with a family member. Family members separately
viewed
the videotaped circular questions and reported their perceptions
of
therapist side-taking and the level of discomfort for each
question. An
initial practice question was included at the beginning of each
inter-
view so the families could become accustomed to seeing
themselves.
The therapy team members were blind to the purposes of the
study
226
and had no knowledge of whether questions sampled in the
videotape
replays were categorized as descriptive or interventive.
The categorization of the circular questions underwent a correc-
tion procedure. The in-session categorization of the circular
questions
was corrected by a set of four raters who could work in a less

pres-
sured manner after the sessions were over. This allowed for a
more
thoughtful, reflective final categorization. Twelve of the 72
questions
sampled changed categories as a result of rater judgment.
Conse-
quently, there was a slightly unequal number of descriptive and
in-
terventive questions sampled (37 interventive and 35
descriptive).
Participants
Three families were given the option of receiving family
therapy
when they sought services at a university training clinic. All
three
families had male and female parents and at least one child
identified
as a behavioral problem. All family members were Caucasian.
The
identified children were scored by their parents in the clinical
range
of the Achenbach Child Behavior Checklist (Achenbach &
Edelbrock,
1983). All three were boys, and were rated as uncommunicative,
ag-
gressive, and delinquent. None of the three scored in the
clinical
range for schizoid-anxious, somatic complaints, social
withdrawal, or
social activities subscales.
Family A had three boys, ages 10, 8, and 8 with the oldest
identi-

fied by the parents as the problem. Family B had one boy, age
7, who
had been referred by the family physician. Family C had three
boys,
ages 11, 10, and 6 with the oldest referred by his school.
The three therapists received three years of training in the
Milan
method and were experienced family therapists. Two therapists
had a
masters degree and five years of experience as family
therapists, and
one had a doctoral degree and 20 years of experience as a
family ther-
apist.
The observation team consisted of five graduate students who
had taken a semester-long class in family therapy and four two-
hour
sessions of information and role-playing specifically on the
Milan
model. Two experimenters acted as content selectors during the
ses-
sions. The experimenters were graduate students who received
the
same training as the observation team, and additional training in
identifying types of circular questions. The four raters were
graduate
students who received training in identifying types of circular
ques-
tions.
227

Measures
Type of circular question. The criteria used to discriminate be-
tween the two categories of circular questions were: (a) the
content of
the circular question and (b) the origin of the question. If the
content
of the question was future-oriented, hypothetical, or
speculative, re-
vealed an hypothesis of the therapist, or contained an embedded
sug-
gestion, then the question was classified as interventive. All
other
questions were considered descriptive. Descriptive questions
were
about the problem definition, comparing family members or
issues,
classification, and agreement questions. If the question clearly
origi-
nated from a family statement the question was descriptive. If
the
origin of the question came from therapists' hypotheses, the
question
was interventive. If the origin of the question was from a family
open-
ing but the content was hypothetical or hypothesis-revealing,
the
question was classified as interventive.
An example of a question coded interventive is: "What would
hap-
pen if you two had a night a week alone?" It has future-
oriented/
hypothetical content. The family is asked to speculate, and the
verb
tense is future. Additionally, the question originated from

hypotheses
presented by the consultation team. The question, "How do they
no-
tice the competition?" was coded as descriptive. It has
descriptive con-
tent, originated from a family discussing competition, and the
verb
tense is not future.
Reliability for the identification of categories of circular
questions
was established at 90% agreement for the four raters through
prac-
tice. The interrater reliability calculated after the study was an
85%
agreement and a Cohen Kappa of .76.
Neutrality measure. Neutrality was assessed from two client
self-
reports: the clients' perception of the therapist taking sides
(Selvini
Palazzoli et al., 1980), and the clients' level of discomfort with
a ques-
tion (Boscolo et al., 1987). Side-taking was assessed through
the indi-
vidual interview with a three-point anchored Likert-type scale.
Each
parent was asked. "From your viewpoint, while the counselor
asks
this question, does it seem she or he: (1) takes someone's side,
(2)
partially takes someone's side, or (3) takes no one's side in
particu-
lar?" The children were asked a similar question with less
complex
wording. "While the counselor asks this question, is he or she:

(1) on
someone's side, (2) a little bit on someone's side, or (3) not on
some-
one's side?"
228
Level of discomfort was also assessed during the individual
inter-
view. The parents were asked: "How comfortable were you
feeling af-
ter the counselor asked the question? (1) the same comfort level
as
before the question, (2) some discomfort, (3) uncomfortable, (4)
much
less comfortable, and (5) extremely uncomfortable." Children
were
asked: "How did you feel after the counselor asked the
question? (1)
the same as before the question. (2) a little bit worse than
before the
question, (3) worse than before, (4) bad, or (5) really bad."
RESULTS
A decision was made prior to analysis to not consider responses
from children under the age of 10. The interviewers reported
that the
younger children did not appear to respond seriously. Some
freely

admitted they were providing answers not related to interview
item
content. For instance, one young participant reported all the
same
answers without listening to the interviewer. Another answered
ques-
tions before the questions were asked.
Aggregate neutrality scores for each question were tabulated
using the following procedure: For each question raw score
ratings
from family members of side-taking and of discomfort were
summed
and converted to z-scores for each family. The resultant side-
taking
and discomfort z-scores for each question were then summed to
con-
stitute a single neutrality score for each question. Means and
stan-
dard deviations of neutrality scores for interventive and
descriptive
questions and t-ratios comparing the types of questions are
displayed
in Table 1.
An overall t-ratio resulting from the combined responses of the
three families indicated a significantly greater (p<.005)
tendency for
violations of neutrality with interventive questions than
descriptive
questions. Table 2 summarizes questions which were associated
with
the most (-1 or less standard score from the mean) neutral and
least
(+1 or greater standard score from the mean) neutral responses.

DISCUSSION
Findings
Our findings were supportive of the theorized relationship be-
tween neutrality and types of circular questions most
prominently
229
forwarded by Boscolo, Cecchin, Hoffman, and Perm (1987) as
well as
Tomm's (1985) hypothesized link between interventiveness and
neu-
trality. Specifically, our findings were as follows.
1. Violations of neutrality occurred more often during interven-
tive circular questions than descriptive circular questions.
Evidence
not supporting the research hypothesis was also present. The
non-
supportive data were largely circular questions rated as
interventive
that were not viewed as side-taking or uncomfortable by family
C
members. As researchers we would like to predict the influence
of
circular questions upon neutrality with precision. As clinicians
we be-
lieve that if we are to err, it is better to be perceived as neutral
when
we expected non-neutrality.

We are interested in creating finer distinctions in our
operational
definitions of interventive and descriptive circular questions.
There-
fore, we used the data as suggestive of a further refinement in
devel-
oping a typology of interventive and descriptive circular
questions.
2. One area that appeared clear from the data was that Family C
was comfortable with several future oriented circular questions
that
we predicted would be non-neutral. These questions explored
the fu-
ture existence of the presenting problem. However, when asked
about
father feeling vulnerable rather than the presenting problem
about
230
TABLE 1
Means, Standard Deviations, and T-ratios of Neutrality Scores
for
Interventive and Descriptive Questions
Measure
Family A
Interventive
Descriptive
Family B
Interventive

Descriptive
Family C
Interventive
Descriptive
Families A, B, & C
Interventive
Descriptive
N
11
12
13
11
11
13
35
36
Mean
85
-.73
.78
-.91
.20
-.17
.62

-.58
SD
1.48
1.00
2.10
.87
1.13
1.31
1.69
1.11
T-Ratios
t(21) = 2.98
t(22) = 2.04
t(22) = .65
t(69) = 3.57
P
p<.025
p<.05
p>.10
p<.005

TABLE 2
The Most and Least Neutral Questions for All Three Families
Family A — Violations of Neutrality (Greater than + 1 z-scores)
IV: How might you get people to act nice toward you in this
family?
IV: So what would you say if I said I think a problem this
family has
is that they don't have enough ways to get attention from one
an-
other?
IV: What could the running away mean?
IV: How could you two (the parents) show affection?
IV: What do you think is going to happen if you keep ignoring
your
mom when she says something?
IV: How might you know if someone in the family is going to
get mad?
Family A — Neutral (Less than - 1 z-scores)
D: Do you think more fighting occurs when Dad is gone ?
IV: Who is the saddest in the family that there are fights?
D: How does it feel to be the only female?
D: Who do you love more?
D: Were they nice to you when you came out of the basement?
D: How do you notice the competition?
D: Was there tension in the family today?
Family B — Violations of Neutrality (Greater than + 1 z-scores)
IV: When things are going well between the two of you. how
does that
affect your parenting with R (the son)?
IV: Does the grandmother show you more affection now since R
(the

IF) taught Grandma that?
IV: Is it safer to not touch even with your wife?
IV: If someone would have been able to help you back then,
how do
you think things things would be different today?
D What have you done to make sure it doesn't stop (the
progress)?
IV: How would you like things to be a year from now?
Family B — Neutral (Less than - 1 z-scores)
D: Who enjoyed the touching the most?
D: What kind of changes have you noticed that are different
than
before?'
D: How has the counseling helped?
IV: If R wasn't so active, how would things be different?
D: Have you noticed any differences when you changed
schools?
Family C — Violations of Neutrality (greater than + 1 z-scores)
IV: How are things going to be in 5 years down the road?
231
the children, a strong non-neutral response was received. We
ten-
tatively interpret this as meaning that Family C had talked and
thought about the misbehavior of the boys enough to develop a
com-
fort with the discussion (not to be confused with a comfort with
the
misbehavior). However, when exploring the novel systemic link
of fa-
ther's feeling of general life inadequacies, there were strong

percep-
tions of discomfort. The implications lead us to suggest that
interven-
tive questions that ask about the presenting problem within the
context of the family's presentation, tend to be less non-neutral
than
questions addressing allied issues or different contexts.
3. This study contributes to the teaching of Milan systemic ther-
apy. Training in the use of circular questioning is difficult
(Fleuridas
et al., 1986). This study supports a simple taxonomy of
interventive
and descriptive questions on the empirical finding of the degree
of
neutrality. This taxonomy has relevance because understanding
the
likely emotional effect of interventive questions helps the
therapist to
guard against an overly threatening atmosphere. Practically, this
may allow the therapist to investigate sensitive areas of family
func-
TABLE 2 (Continued)
IV: Did you (Dad) give it a chance to think about how you
might pre-
fer for people to show you they care about you?
IV: What might be more preferable ways to feel important in
this
family?
IV: If you became disabled, do you think the family would love
you
any less?
D: Do you ever feel forgotten?
IV: How can you help her right now?

Family C — Neutral (less than — 1 z-scores)
IV: How hopeful are you that things will get better?
IV: How would you like people in your family to show you
really mat-
ter?
IV: What would be helpful for T (second youngest child)?
IV: What would be helpful in getting R's (youngest child) needs
met?
D: What makes you important to the family, A (the IP)?
D: What do you do to get people to listen to you (the father)?
D: A ( the IP) do you have an idea why T (second youngest) has
a hard
time staying involved?
IV-Interventive D-Descriptive
232
tioning (Tomm, 1987), and keep client families from dropping
out be-
cause the therapist may have lost neutrality. Future research
may
also clarify whether interventive questions do perturb family
mem-
bers in a manner that facilitates productive evolution.
4. An important unanticipated finding was the difference be-
tween side-taking and discomfort. The two measures of
neutrality
had almost no overlap of meaning (r=.06). An interpretation of
the
difference between the measures is that neutrality is

multidimensio-
nal. In retrospect it makes sense that neutrality is a broad multi-
faceted concept. But it also suggests that the concept of
neutrality is
not well described in the literature. This research is helpful in
indi-
cating there may be different types of neutrality. We suggest
that Cec-
chin's description of neutrality as an attitude of curiosity be
incorpo-
rated into future research. An important question might be, "Can
curiosity about multiple possible solutions exist when
individuals are
experiencing discomfort or perceiving sidetaking?"
5. There are clinical implications from the findings. Some ques-
tions were more associated with perturbation of family members
than
others. This indicates that question heuristic as well as question
con-
text should be considered by a therapist. Clinicians should ask
them-
selves whether they are balancing the introduction of
interventions
with the gathering of meanings through description from all
members
of a family. How much does a question diverge from family
members'
existing realities? If the divergence is too great family members
may
demonstrate resistance or feel too anxious to be different than
past
problematic patterns. If clinicians tip the scales too much
toward in-
tervention, families may feel overwhelmed and misunderstood.
On

the other hand if questions cumulatively are too descriptive and
lack
intervention, a session may be perceived as bland and
ineffective by
family members. Side-taking through questions must be
balanced
among all family members. Therapists should ask themselves
whether
the outcome of a session is an achieved balance for the
dimensions of
neutrality and interventiveness among family members. Even in
cases in which some family members are clearly disempowered,
the
therapist must be cognizant of how influence can be gained
from all
family members. A tool to achieve influence may come from
aware-
ness of the type of question being posed. A family member who
previ-
ously was not defined as part of the problem may perceive
blaming
and react defensively when interventive questions are posed if
the therapist has not first sought that family member's
viewpoint
through descriptive questions.
233
Limitations
There were several limitations inherent in this study. One
limita-
tion concerns the generalizability of results to other families
with dif-

ferent characteristics. The data were gathered from only three
fami-
lies, all of whom were two-parent intact families from the
majority
culture. A second possible limitation was our application of the
Milan
model. We attempted to use the Milan method and adhere to the
guidelines of the process as we understood them. Still, our
version
may differ from others who use it. A third limitation is related
to the
research design. Each circular question was treated as an
indepen-
dent event through the research methodology employed. Other
factors
such as previously posed questions or past family or therapy
events
may have also influenced the measurement of neutrality.
This process research contributed to the literature by using real
client populations to investigate theorized principles of Milan
sys-
temic family therapy. We believe this is a very difficult area to
re-
search because of the phenomenological nature of the premises
under
investigation. The concepts of neutrality and interventiveness of
cir-
cular questions were operationalized based upon the literature.
The
results suggest that the manner of distinguishing between
interven-
tive and descriptive questions supports the theory and should be
in-
cluded in the teaching of circular questions. We believe this
study

lays the groundwork for future studies.
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