Solution-Focused Counseling: Advanced Techniques and Applications (Handout)Jeffrey Guterman
Handout for Education Session, "Solution-Focused Counseling: Advanced Techniques and Applications" presented by Jeffrey Guterman Ph.D. and Clayton V. Martin, M.S. at the American Counseling Association's 2014 Conference & Exposition, Orlando on March 14, 2015. More information: http://jeffreyguterman.com/advanced2015.html
Brief therapy, sometimes also referred to as short term therapy (usually 10 to 20 sessions) , is a generic label for any form of therapy in which time is an explicit element in treatment planning.
Advanced Techniques for Solution-Focused CounselingJeffrey Guterman
Handouts for education session, "Advanced Techniques for Solution-Focused Counseling" presented at the American Counseling Association's 2010 Annual Convention.
Guidance and Counselling: Assessment and InterventionAri Sudan Tiwari
The document explains various methods of assessment used in the process of guidance and counselling. The methods discussed in detail are: Intake interview, case study, mental status examination, psychological assessment tools; such as, cognitive and personality assessment. The document further elaborates some intervention techniques; such as, relaxation training, assertion training, bio-feedback, systematic desensitisation, A-B-C model of cognitive behaviour approach, rational-emotive therapy, etc. employed in guidance and counselling.
The Relational Arts: A Case For Counselling And Psychotherapycyberscribe
Master psychotherapist, author and academic Hugh Crago makes a convincing and readable case for the relational arts.
How does counselling work?
Why doesn't it work for everyone?
How is it different from psychology?
Amputation is the removal of a limb or part of a limb by a surgical procedure in order to save the life of a person. Amputation is a triple threat. It involves loss of function, loss of sensation, and loss of body image.
A PowerPoint Presentation that shows about Solution-focused Brief Therapy that I created originally for a presentation for the Crisis Residential Center Staff where I used to work and also for Tri-Cities Community Health's Case Managers.
Qualitative study of therapists working at Stangehjelp in Norway who are applying the principles of deliberate practice in their efforts to deliver more effective treatment services.
- A brief and concise report on Narrative Therapy which includes a brief introduction, therapeutic goals, therapeutic relationships, therapeutic techniques and procedures
- For USTGS 1st semester 2013-2014
Solution-Focused Counseling: Advanced Techniques and Applications (Handout)Jeffrey Guterman
Handout for Education Session, "Solution-Focused Counseling: Advanced Techniques and Applications" presented by Jeffrey Guterman Ph.D. and Clayton V. Martin, M.S. at the American Counseling Association's 2014 Conference & Exposition, Orlando on March 14, 2015. More information: http://jeffreyguterman.com/advanced2015.html
Brief therapy, sometimes also referred to as short term therapy (usually 10 to 20 sessions) , is a generic label for any form of therapy in which time is an explicit element in treatment planning.
Advanced Techniques for Solution-Focused CounselingJeffrey Guterman
Handouts for education session, "Advanced Techniques for Solution-Focused Counseling" presented at the American Counseling Association's 2010 Annual Convention.
Guidance and Counselling: Assessment and InterventionAri Sudan Tiwari
The document explains various methods of assessment used in the process of guidance and counselling. The methods discussed in detail are: Intake interview, case study, mental status examination, psychological assessment tools; such as, cognitive and personality assessment. The document further elaborates some intervention techniques; such as, relaxation training, assertion training, bio-feedback, systematic desensitisation, A-B-C model of cognitive behaviour approach, rational-emotive therapy, etc. employed in guidance and counselling.
The Relational Arts: A Case For Counselling And Psychotherapycyberscribe
Master psychotherapist, author and academic Hugh Crago makes a convincing and readable case for the relational arts.
How does counselling work?
Why doesn't it work for everyone?
How is it different from psychology?
Amputation is the removal of a limb or part of a limb by a surgical procedure in order to save the life of a person. Amputation is a triple threat. It involves loss of function, loss of sensation, and loss of body image.
A PowerPoint Presentation that shows about Solution-focused Brief Therapy that I created originally for a presentation for the Crisis Residential Center Staff where I used to work and also for Tri-Cities Community Health's Case Managers.
Qualitative study of therapists working at Stangehjelp in Norway who are applying the principles of deliberate practice in their efforts to deliver more effective treatment services.
- A brief and concise report on Narrative Therapy which includes a brief introduction, therapeutic goals, therapeutic relationships, therapeutic techniques and procedures
- For USTGS 1st semester 2013-2014
The Annapurna Circuit is known as Nepal's classic trek and it offers more variety than any other equivalent length trek, taking us through virtually every type of scenery that Nepal has to offer. There are superb views of the Annapurnas and Dhaulagiri, and an amazing variety of landscapes ranging from sub-tropical through alpine to an arid semi-desert akin to Tibet. The scenery changes every day from rice paddies and pine forests to Tibet-like countryside on the northern slopes of the Himalayas in the district of Manang.
Langtang Valley Trek is a superb introduction to trekking in Nepal among some of the most beautiful scenery in the whole country. Langtang Valley is the nearest Himalayan Region from Kathmandu valley. Despite being very close to Kathmandu, the Langtang Region is as wild as any Tibetan highlands with idyllic rural landscape.
Natraj Trekking is the one of best tour operator in Nepal for organizing Luxury Holidays in Nepal. Please contact us for the more details at anil.blon@gmail.com
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The short presentation explains the need and stages of innovative entrepreneurship, linking it to a famous Buddhist sloka. It then describes a 7 ‘I’ framework for industry associations to facilitate entrepreneurship.
Response to diseases: Sensitizing scientists in India for bridging leadership. Miftahul Barbaruah
The presentation attempts to sensitize young scientists engaged with research in broader areas of disease biology and therapeutics to go beyond knowledge creation in their respective sub-domain. It urges scientists to reflect on 'bigger picture' for ownership of larger problem. This should help them to thrive for co-ownership of such problems involving related stakeholders across various disciplines in order to facilitate technological innovation. It also urges scientists to engage in 'co-creation' of responsive programme and services by ensuring institutional arrangement at various levels of value chain and empowerment of people so that they can access and use the technological solution thus developed.
See full paper at : http://dx.doi.org/10.13140/2.1.2696.3524
Highlighting the inner meaning of the famous verses of Buddhism, the short presentation summarizes the challenges and way forward for augmenting development of enterprises in North East India.
learning objectives 16 16.1 Who seeks therapy and what are the goa.docxcroysierkathey
learning objectives 16 16.1 Who seeks therapy and what are the goals of therapy? 16.2 How is the success of psychotherapy measured? 16.3 What are some of the factors that must be considered to provide optimal treatment? 16.4 What psychological approaches are used to treat abnormal behavior? 16.5 What roles do social values and culture play in psychotherapy? 16.6 What biological approaches to treating abnormal behavior are available? Most of us have experienced a time or situation when we were dramatically helped by talking things over with a relative or friend. Most therapists, like all good listeners, rely on receptiveness, warmth, and empathy and take a nonjudgmental approach to the problems their clients present. But there is more to therapy than just giving someone an opportunity to talk. Therapists also introduce into the relationship psychological interventions that are designed to promote new understandings, behaviors, or both on the client’s part. The fact that these interventions are deliberately planned and systematically guided by certain theoretical preconceptions is what distinguishes professional therapy from more informal helping relationships. An Overview of Treatment The belief that people with psychological problems can change—can learn more adaptive ways of perceiving, evaluating, and behaving—is the conviction underlying all psychotherapy. Achieving these changes is by no means easy. Sometimes a person’s view of the world and her or his self-concept are distorted because of pathological early relationships that have been reinforced by years of negative life experiences. In other instances, environmental factors such as an unsatisfying job, an unhappy relationship, or financial stresses must be the focus of attention in addition to psychotherapy. Because change can be hard, people sometimes find it easier to bear their present problems than to challenge themselves to chart a different life course. Therapy also takes time. Even a highly skilled and experienced therapist cannot undo a person’s entire past history and, within a short time, prepare him or her to cope adequately with difficult life situations. Therapy offers no magical transformations. Nevertheless, it holds promise even for the most severe mental disorders. Moreover, contrary to common opinion, psychotherapy can be less expensive in the long run than alternative modes of intervention (Dobson et al., 2008; Gabbard et al., 1997). Numerous therapeutic approaches exist, ranging from psychoanalysis to Zen meditation. However, the era of managed care has prompted new and increasingly stringent demands that the efficacy of treatments be empirically demonstrated. This chapter will explore some of the most widely accepted psychological and biological treatment approaches in use today. Although we recognize that different groups of mental health professionals often have their own preferences with respect to the use of the terms client and patient, in this chapter we use ...
chapter10Issues in Theory and PracticeIntroductionEthical JinElias52
chapter
10
Issues in Theory and Practice
Introduction
Ethical practice requires a solid theoretical framework. Therapists’ theoretical positions and conceptual views influence how they practice. Ideally, theory helps practitioners make sense of what they hear in counseling sessions. In this chap- ter we address a variety of interrelated ethical issues, such as why a theory has both practical and ethical implications, the goals and techniques that are based on a theoretical orientation, the role of assessment and diagnosis in the therapeutic process, issues in psychological testing, and issues surrounding evidence-based practices (EBPs).
Clinicians must be able to conceptualize what they are doing in their coun- seling sessions and why they are doing it. Sometimes practitioners have difficulty explaining why they use certain counseling interventions. When you first meet a new client, for example, what guidelines would you use in putting into a the- oretical perspective what clients tell you? What do you want to accomplish in this initial session? Can you explain your theoretical understanding of how peo- ple change in a clear and straightforward way? Think about how your theoretical viewpoint influences your decisions on questions such as these:
• What are your goals for counseling? • What techniques and interventions would you use to reach your goals? • What value do you place on evidence-based treatment techniques? • What is the role of assessment and diagnosis in the counseling process? • How do you make provisions for cultural diversity in your assessment and
treatment plans? • Does the client’s presenting problem influence the specific assessments you
choose to use? • How does your theoretical viewpoint influence the specific assessment mea-
sures you choose to use with clients? • How flexible are you in your approach? • What connections do you see between theory and practice? • Do you consult with colleagues on matters pertaining to theory and practice?
LO1
Developing a Counseling Style
Theories of counseling are based on worldviews, each with its own values, biases, and assumptions of how best to bring about change in the therapeutic process. Contemporary theories tend to be oriented toward individual change and are grounded in values that emphasize choice, the uniqueness of the individual, self-assertion, and ego strength (see Chapter 4). Many of these assumptions are inappropriate for evaluating clients from cultures that focus on interdependence, de-emphasize individuality, and emphasize being in harmony with the universe. In some cultures, basic life values tend to be associated with a focus on inner expe- rience and an acceptance of one’s environment. Within cultures that focus more on the social framework than on development of the individual, a traditional
therapeutic model has limitations. In addition, it is not customary for many client populations to seek professional help, and they will typically turn first to informal system ...
4 Basic Rapport Building, Goal Setting, and ImplementationCHAPTER OB.docxalinainglis
4 Basic Rapport Building, Goal Setting, and ImplementationCHAPTER OBJECTIVES
After reading this chapter, you will be able to:
· 1. Understand the importance of the therapeutic alliance.
· 2. Know the different skills necessary for the formation of a positive therapeutic alliance (practical and interpersonal).
· 3. Understand the need for problem identification.
· 4. Identify various types of coping techniques.
· 5. Be familiar with the process of goal setting and implementation as well as the termination of the counseling relationship.PART ONE: THE THERAPEUTIC ALLIANCE
According to various researches, the therapeutic alliance is one of the most powerful constructs, within a counseling relationship, able to produce positive changes in behavior and cognition. It is important to understand that the therapeutic alliance is largely an intellectual concept that describes both practical and interpersonal skills. And, one of the problems with intellectual concepts is that they can often be difficult to define. In fact, a working definition of a therapeutic alliance for one counselor may be wholly different from the definition provided by another counselor. This is because the therapeutic alliance is as much subjective as objective, or as much art as science.
Generally, the therapeutic alliance is a concept that describes the process of counselors and offenders collaboratively identifying goals and tasks to be accomplished within the counseling relationship. The most important component of this relationship, however, is the degree to which counselors and offenders are able to establish an interpersonal bond through which much of the healing and corrective action takes place. Bordin (1979) describes the therapeutic alliance as the vehicle through which psychotherapies are effective. In essence, it is not so much the counseling modality that is important, but rather the degree to which counselors and offenders are able to establish an affective bond that produces the necessary trust that fosters an environment in which an offender is willing to psychologically and emotionally expose himself or herself in order to heal.
Offenders are more likely to respond positively to counseling when counselors are able to consistently portray themselves as nurturing and understanding allies. A number of studies have found that the therapeutic alliance is directly related to such outcomes as whether or not a person will continue counseling (CSAT, 2005). Petry and Bickel (1999) found that among clients with moderate to severe psychiatric problems, less than 25% of those reporting weak therapeutic alliances completed treatment. Obviously, this is an important point, largely because it is unlikely that offenders will undergo substantive change without structured and professionally delivered services aimed at reconfiguring cognitive and behavioral responses to certain stimuli likely to produce criminal behavior. Green (2004) provides additional support by stating he beli.
Self disclosure in addiction counseling: To tell or not to tell?wrule1154
This is also an NYS OASAS approved continuing education course for renewal certification.
More info and online course catalog at: https://imustnotuse.com
11Introduction and Overview1. Understand the author’s.docxaulasnilda
1
1Introduction and Overview
1. Understand the author’s
philosophical stance.
2. Identify suggested ways to use this
book.
3. Differentiate between each
contemporary counseling model
discussed in this book.
4. Identify key issues within the case
of Stan.
5. Identify key issues within the case
of Gwen.
L e a r n i n g O b j e c t i v e s
63727_ch01_rev03.indd 1 18/09/15 9:39 AM
Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
2 CHAPTER ONE
Introduction
Counseling students can begin to acquire a counseling style tailored to their own
personality by familiarizing themselves with the major approaches to therapeu-
tic practice. This book surveys 11 approaches to counseling and psychotherapy,
presenting the key concepts of each approach and discussing features such as the
therapeutic process (including goals), the client–therapist relationship, and spe-
cific procedures used in the practice of counseling. This information will help you
develop a balanced view of the major ideas of each of the theories and acquaint
you with the practical techniques commonly employed by counselors who adhere
to each approach. I encourage you to keep an open mind and to seriously consider
both the unique contributions and the particular limitations of each therapeutic
system presented in Part 2.
You cannot gain the knowledge and experience you need to synthesize various
approaches by merely completing an introductory course in counseling theory. This
process will take many years of study, training, and practical counseling experience.
Nevertheless, I recommend a personal integration as a framework for the profes-
sional education of counselors. When students are presented with a single model
and are expected to subscribe to it alone, their effectiveness will be limited when
working with a diverse range of future clients.
An undisciplined mixture of approaches, however, can be an excuse for failing
to develop a sound rationale for systematically adhering to certain concepts and to
the techniques that are extensions of them. It is easy to pick and choose fragments
from the various therapies because they support our biases and preconceptions. By
studying the models presented in this book, you will have a better sense of how to
integrate concepts and techniques from different approaches when defining your
own personal synthesis and framework for counseling.
Each therapeutic approach has useful dimensions. It is not a matter of a theory
being “right” or “wrong,” as every theory offers a unique contribution to understan ...
1. Discuss the factors that led to deregulation of U.S. financial .docxjackiewalcutt
1. Discuss the factors that led to deregulation of U.S. financial markets in the 1980s.
2. Explain how banks are financial intermediaries. What are reserves? What are excess reserves? Explain how the Fed can affect the quantity of excess reserves in the banking system.
3. What are the differences between M1 and M2?
4. What are the three functions of money, and why are they important?
5. How can the Fed affect the money supply by using the discount rate?
6. Explain how the short-run Phillip curve, the long-run Phillip curve, the short-run aggregate supply curve, the long-run aggregate supply curve, and the natural rate hypothesis are all related. How do active and passive views of these concepts differ?
7. Explain why the Fed can attempt to target either changes in the money supply or changes in interest rates, but not both.
8. How does monetary policy affect aggregate demand in the short run? How does monetary policy affect aggregate demand in the long run?
9. What is meant by the demand for money? Which way does the demand curve for money slope? Why?
10. Explain how an active policy differs for a passive policy.
11. What is foreign aid and what is the goal of foreign aid? Does foreign aid promote economic development? Explain briefly.
12. Describe developing countries and how they differ from industrial market economies. How can international trade aid development? In what ways does the international economy impose problems on developing countries?
13. Why can't all the balance of payment accounts be in surprise? What factors determine the demand for British pounds in foreign exchange markets? How are exchange rates determined under a flexible exchange rate system?
14. How can two countries both be better off as a result of trade? How can tariffs protect U.S. jobs? Do tariffs lead to a net increase in jobs? Explain. Who are the winners and losers from trade restrictions? Given that trade restrictions impose losses on an economy, why are trade restrictions so common?
15. How did the Bretton Woods system operate? What caused its collapse? Some think the current system of managed but floating rates is too unstable. What would generate the instability?
Week 1/BSHS 312 Week 1 DQ 1 (Theoretical Framework for Helping and Creating Change).docx
BSHS 312
Week 1
Discussion Question # 1
Why is it important for human services workers, and the professionals they assist, to have a theoretical framework for helping and creating change?
Unlike many in other professions, counselors are particularly vulnerable to legal troubles and ethical dilemmas. For this reason it is essential that students of counseling become familiar with the basic legal and ethical issues pertaining to the field. The bedrock of legal and ethical standing in counseling is virtue—a disposition to do what is morally right. A sound counseling practice is built on knowing the law and understanding client rights. Counselors have an obligation to their clients and to thei ...
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Interventive3
1. Interventive Interviewing: Part 111. Intending to Ask Lineal, Circular, Strategic,
or Reflexive Questions?*
KARL TOMM, M.D.t
_______________________________________________________________________
Every question asked by a therapist may be seen to embody some intent and to arise from certain
assumptions. Many questions are intended to orient the therapist to the client's situation and
experiences; others are asked primarily to provoke therapeutic change. Some questions are based on
lineal assumptions about the phenomena being addressed; others are based on circular assumptions.
The differences among these questions are not trivial. They tend to have dissimilar effects. This article
explores these issues and offers a framework for distinguishing four major groups of questions. The
framework may be used by therapists to guide their decision making about what kinds of questions to
ask, and by researchers to study different interviewing styles.
Fam Proc 27:1-15, 1988
__________
* The support of Alberta Mentai Health Services for the Family Therapy Program in which these ideas
were elaborated is gratefully acknowledged.
t Family Therapy Program, Department of Psychiatry, University of Calgary, 3330 Hospital Drive,
N.W., Calgary, Alberta, Canada T2N 4Nl.
FROM THE PERSPECTIVE of an observer, the psychotherapies are essentially conversations.
However, they are not ordinary conversations. Therapeutic conversations are organized by the desire to
relieve mental pain and suffering and to produce healing. They occur between therapists and clients
within the context of consensual agreement that the therapist will contribute intentionally toward a
constructive change in the problematic experiences and behaviors of clients. Whereas other
conversations may have therapeutic effects (for instance, personal discussions among family members,
friends, work associates, acquaintances, and even strangers), these would not be considered "therapy"
unless there were some agreement that one participant accepted responsibility for guiding the
conversation to be therapeutic for the other. Thus, a therapist always assumes a special role in a
conversation for healing. This role entails a commitment to be helpful with respect to the personal
problems and interpersonal difflculties of the other.
The therapist's position in a therapeutic conversation not only implies special responsibilities, it also
confers special privileges. One example of the latter is that a therapist can legitimately inquire about the
clients' personal and private experiences. To do so can often expose the clients' vulnerabilities.
Consequently, the potential for further trauma exists alongside that for healing. It is the manner in
which such an inquiry is carried out that makes the difference. Some patterns of conversing are much
more conducive to being therapeutic than others. One of the factors contributing to such variations is
the nature of the questions asked.
During a conversation that is intended to be healing, the therapist usually contributes both
statements and questions. These are quite different kinds of utterances. In general, statements set forth
issues, positions, or views, whereas questions callforth issues, positions, or views. In other words,
questions tend to call for answers and statements tend to provide them. At the same time, however,
2. these characteristics are not exclusive; there is considerable overlap between questions and statements.
For instance, questions can be posed in the form of statements. "You must have had some reason to
come to see me"; "Most people come because something is troubling them very deeply." Alternatively,
statements can be made in the form of questions: "Isn't it interesting that you came so late again?";
"Why didn't you leave earlier, when you knew the traffic would be so heavy?'' l
_________
I One could claim that every statement raises certain questions and every question implies certain statements. This "reality"
may be valid from the perspective of an observer performing an in-depth analysis of verbal transactions, but it is usually not
experienced by those who actively participate in the conversation. Nevertheless, the complexities of what is being suggested
or implied (in what is said or asked by the therapist) may be brought forth by the client upon deliberate reflection.
Despite this overlap, it seems reasonable to expect that the predominant linguistic form of a therapist's
contributions will have an important effect on the nature and direction of the evolving conversation.
There seem to be some advantages for a therapist to ask mainly questions, especially in the early
and middle parts of an interview. For instance, doing so tends to assure a client-centered conversation.
The perceptions, experiences, reactions, concerns, goals, plans, and so on, of the client are repeatedly
called forth and take center stage. If the therapist responds to the client's answers with further questions,
the experiences and beliefs of the therapist remain in a supportive role as the conversation unfolds.
Thus, when the balance is in favor of questions over statements, the "work" of the session naturally
centers on the client, not on the therapist. Another advantage is that questions constitute a much
stronger invitation for clients to become engaged in the conversation than do statements. The
grammatical form of a sentence that poses a question arouses the social expectation for an answer. The
cadence, tone, and ensuing pause in the therapist's speech add to the expectation for a response. When
the therapist also conveys a clear commitment to listen, and to hear the clients' answers, the expectancy
is strengthened even further. Thus, through questioning, clients are actively drawn into dialogue with
the therapist. Indeed, even withdrawn and/or mute clients find it difflcult to escape entering into a
process of silent conversing when questions are addressed to them. A further advantage in therapists
asking mainly questions, and refraining from making statements, is that clients are thereby stimulated
to think through their problems on their own. This fosters client autonomy and allows a greater sense of
personal achievement for family members when therapeutic change takes place, rather than inducing
dependency on the "special knowledge" of the therapist.
There are, however, limiting conditions to a predominance of questions over statements. A therapist
may, in effect, hide behind the perpetual questions and fail to enter into the relationship as a real
person. This could constitute a major disadvantage by limiting the development of a therapeutic
alliance. Clients usually need to experience the therapist as someone with coherence and integrity in
order to extend their confidence and trust. For this, the therapist does have to make statements from
time to time and take a position on certain issues (even if the position taken is deliberately not to take
one, such as whether a couple should separate or remain together). Furthermore, the social expectancy
for answers can be experienced as a demand and become an imposition. Certain questions can be
extremely intrusive or threatening. A long series of questions may be experienced as an inquisition or
as punishment. These possibilities highlight the need for therapists to monitor the conversation
continually and switch to making statements when their questions become countertherapeutic. On the
other hand, some of these difflculties may be dealt with by changing the kind of questions being asked.
The balance between questions and statements, as utterances made by the therapist, tends to vary
with different schools of therapy. For instance, the Milan systemic approach depends heavily on asking
questions whereas the structural and strategic approaches depend on making statements as well. Among
3. the variables that influence the balance between questions and statements in a particular session are the
theoretical orientation and personal style of the therapist, the types of problems, beliefs, expectations,
and interaction styles presented by clients, and the idiosyncratic pattern of interaction that evolves
among them. As far as I am aware, the effects of this balance have not yet been systematically explored
in marital and family therapy research, nor has the effect of deliberately altering the ratio of questions
to statements during the course of the interview been examined.
Although this article focuses predominantly on questions and on the differences among them, it is
not intended to imply that a therapist should only ask questions. When clients are simply unaware of
basic information or do not have the knowledge resources to answer coherently, it is appropriate that
therapists provide answers for them. In addition, provisional "if-then" statements that clarify mental
process can contribute enormously to a family's awareness and understanding of relevant events. For
example, if parents repeatedly demand disclosure from a child, they sometimes inadvertently teach the
child to lie. The child may learn to invent any kind of answer that might satisfy the parents' demands
for an immediate response. Furthermore, ironic and improbable statements by a therapist are sometimes
the most effective means to awaken questions in the minds of clients and to enhance their capacity to
make pertinent discoveries on their own.
THERAPIST INTENTIONS AND
ASSUMPTIONS
Every question may be assumed to embody some intent. Whether consciously or not, the therapist
has some purpose in asking. This intent or purpose arises from the conceptual posture of strategizing
(see 4) that guides the therapist's moment-tomoment decision making during the conversation. The
most common intention behind the questions asked by a therapistis to find out something about the
clients or their situation. With the use of questions, the therapist invites clients to share their problems,
experiences, histories, hopes, expectations, and so on. The immediate intent in the asking is to develop
the therapist's understanding. The questions are designed to trigger responses from clients that will
enable the therapist to become coupled linguistically with the clients, to draw relevant distinctions
about their experiences, and to generate clinically useful explanations regarding their problems. The
questions are chosen to support the therapist's activity in the conceptual postures of circularity and
hypothesizing (see 4). Family members are expected to answer according to the understanding they
already have. They are not usually expected to change as a result of these questions. In other words,
during such questioning the primary locus for intended change is the therapist, not the client or family.
The goal at those moments in the interview is for the therapist to become oriented to the problematic
situation and the idiosyncratic experiences of the client and family members. As the therapist constructs
impressions and images from the family's verbal and nonverbal responses, further questions are asked
in order to fill in blanks, clarify ambiguities, and resolve inconsistencies that arise in the mind of the
therapist. Thus, in the early parts of an interview the therapist asks predominantly orienting questions.2
____________
2 In an earlier publication (3), I referred to these questions as "descriptive" because they invited clients to describe their
situation and experiences. However the adjective "descriptive" could imply that family members provide objective accounts
of events and experiences and, thus, it can be misleading. I now prefer "orienting" because it is more precise and coherent
with a second-order cybernetic explanation of what takes place during an interview. The family's answers simply orient the
therapist in his or her subsequent actions; the answers are not necessarily taken as statements about an objective "reality."
4. However, during the course of assessing the clients' situation, occasions frequently arise in which
therapeutic interventions seem particularly opportune. The therapist recognizes "a good moment" or "an
opening" in the conversation to influence the family's perceptions or beliefs. In other words, the
situation is conducive to an action on the part of the therapist that might enable family members to
change their views, and consequently their behavior. The therapist could alter the pattern of asking
questions and make some statements. If, however, the therapist decides to continue the inquiry, he or
she can still take advantage of these opportunities by introducing therapeutic interventions in the form
of questions. Indeed, for various reasons the therapist may prefer to use questions to influence the
client, rather than resort to making statements. The therapist then formulates influencing questions, the
kinds of questions that are liable to trigger therapeutic change. In this case, the primary locus for
intended change is the client or family, not the therapist. This does not mean that the therapist is not
open to further change in his or her understanding as a result of the client's answers to these questions.
On the contrary, the therapist always remains open to change following an influencing question;
otherwise the question becomes purely rhetorical. However, this change in the therapist is secondary
with respect to the therapist's predominant intent in formulating that particular question.
Thus, one basic dimension for differentiating questions is a continuum regarding the intended locus
of change that lies behind the question. At one extreme of the continuum is a predominantly orienting
intent, for change in oneself, and at the other end is a predominantly influencing intent, for change in
others. Orienting questions are designed to invite a response to alter the therapist's own perceptions and
understanding whereas influencing questions are designed to trigger a response that might alter the
family's perceptions and understanding. Any particular question may, of course, entail mixed intentions
and fall anywhere along the continuum. This distinction between orienting questions and influencing
questions constitutes an invitation for therapists to become more mindful of their intentions during the
process of strategizing about what to ask.
A second major dimension for differentiating questions has to do with varying assumptions about
the nature of mental phenomena and the therapeutic process. It seems reasonable to assume that a
network of assumptions and presuppositions concerning the issues being asked about exists in the mind
of the therapist as a foundation or rationale for the question. For the most part, these underlying
assumptions or presuppositions tend to remain nonconscious during the conduct of an interview. They
may, however, be brought into consciousness and deliberately be modified in one direction or another.
In other words, these assumptions may be plotted along a continuum as well. At one extreme of this
continuum might be predominantly lineal or cause-and-effect assumptions, and at the other,
predominantly circular or cybernetic assumptions.
The distinction between "lineal" and "circular" was imported into family therapy from Bateson's
pioneering work in exploring the nature of mind (1, 2). Since then, a rich network of ideas, concepts,
and associations has evolved around this distinction. These ideas now permeate the family therapy
literature. Lineal assumptions tend to be associated with reductionism, dormative principles, causal
determinism, judgmental attitudes, and strategic approaches. Circular assumptions tend to be associated
with holism, interactional principles, structure determinism, neutral attitudes, and systemic approaches.
These associations do not necessarily imply identity or isomorphism within each cluster of concepts.
Nor do they imply that lineal and circular assumptions are mutually exclusive. Because the distinction
between lineal and circular may be regarded as complementary, and not just as either/or, these
assumptions and their associations may overlap and enrich one another. Most therapists have
internalized these concepts to varying degrees and probably operate with both sets of ideas, but in
differing ways, with differing consistency, and at different times. Although these assumptions and
presuppositions tend to exert their effects covertly and nonconsciously, they still have a significant
effect on the nature of the questions asked. Hence, this second dimension adds considerable depth to an
understanding of differences among the questions asked.
5. An intersection of these two basic dimensions (therapist intentionality and therapist assumptions)
yields four quadrants, which may be used to distinguish four basic types of questions. This is indicated
in the framework of Figure 1. The horizontal axis represents the degree to which the therapist's
intentionality is oriented toward changing the self, or toward changing the other. The vertical axis
represents the degree of lineality or circularity in the therapist's assumptions about the relevant mental
process. If the therapist assumes that the events being explored occur predominantly in a lineal or
cause-and-effect manner, the orienting questions will reflect this and may be considered "lineal
questions." If the therapist assumes that the events being explored are circular, recurrent, or cybernetic,
the orienting questions are labelled "circular questions." If the therapist assumes that it is possible to
influence others directly through information input or instructive interaction, then the influencing
questions may be regarded as "strategic questions." If the therapist assumes that influence only occurs
indirectly, through a perturbation of preexisting circular processes in or among
Orienting Intent
Circular Assumptions
Lineal Assumptions
Influencing Intent
confronta tion
que stions
le ading que stions
obse rve r pe rspec tive questions
hypothe tic a l future
questionsbehaviour effect
questions
difference questions
proble m definition
que stions
problem expla nation
FIG. 1. A framework for distinguishing 4 major groups of questiong.
family members, the influencing questions are considered "reflexive questions."
Because specific questions may reflect differing degrees of lineality and circularity as well as
varying intentionality, they could be plotted anywhere on the diagram. However, certain kinds of
questions will tend to fall into a particular quadrant. For instance, the common kinds of problem
definition questions and problem explanation questions tend to reflect a lineal inquiry. Difference
questions and a series of behavioral effect questions suggest an exploration of a circular process.
Leading questions and confrontation questions tend to be regulatory and strategic. Future oriented
questions and observer perspective questions tend to be reflexive. Different kinds and sequences of
questions may be expected to have very different effects in the evolving therapeutic conversation. For
instance, the manner in which a specific historical event is reported by the client is influenced by the
wording and tone of the therapist's question. A lineal question invites a lineal description whereas a
6. circular question invites a circular description. A further sketch of these major groups of questions with
a few examples of each will be provided before examining their differential effects more closely.
FOUR MAJOR TYPES OF QUESTIONS
Lineal Questlons
These are asked to orient the therapist to the client's situation and are based on lineal assumptions
about the nature of mental phenomena. The intent behindthese questions is predominantly investigative.
The therapist behaves much like an investigator or detective trying to unravel a complex mystery. The
basic questions are "Who did what?, Where?, When?, and Why?" Most interviews begin with at least
some lineal questions. This is often necessary in order to "join" the family members through their
typically lineal views of their problematic situation. With this mode of inquiry, the therapist tends to
adopt a reductionistic stance in trying to determine the specific cause of the problem. Efforts are made
to tease things apart so that the origin of the problem eventually becomes clearly delineated.
For instance, a therapist may begin a session with a sequence of lineal orienting questions as
follows: "What problems brought you in to see me today?" (It's mainly depression); "Who gets
depressed?" (My husband); "What gets you so depressed?" (I don't know); "Are you having difficulty
sleeping?" (No); "Have you lost or gained any weight?" (No); "Do you have any other symptoms?"
(No); "Any illnesses lately?" (No); "Do you have a lot of morbid thoughts?" (No); "Are you down on
yourself about something?" (No); "There must be something troubling you. What could it be?" (I really
don't know); "Why do you think your husband gets depressed?" (I don't know either, he's just not
motivated, he lies in bed all the time); "How long has he been so depressed?" (Three months, he has
hardly been out of bed in three months); "Did something happen that started it all?" (I can't remember
anything in particular); "Does anyone try to get him up?" (Not really); "Why not?" (Well, I get fed up
after a while); "Do you find yourself getting frustrated at lot?" (Quite a bit); "How long have you been
so frustrated with him?"; and so on.
The conceptual posture of lineal hypothesizing (see 4) contributes to the content issues and subject
focus for generating these lineal questions. Included in this posture is the habit of thinking in dormative
terms, that is, in maintaining the presupposition that certain characteristics, such as depression, are
intrinsic to the person, rather than to the distinctions made about the person. Consequently, lineal
questions about problems tend to convey a judgmental attitude, namely, that something in the
individual is wrong and ought not be the way it is. This often evokes shame, guilt, and defensiveness in
the client or family. Because people generally do not like to take blame onto themselves, these
questions may stimulate family members to become more critical of one another as they provide
answers.
Circular Questions
These are also asked to orient the therapist to the client's situation, but they are based on circular
assumptions about the nature of mental phenomena. The intent behind these questions is predominantly
exploratory. The therapist behaves more like an explorer, researcher, or scientist who is out to make a
new discovery. The guiding presuppositions are interactional and systemic. It is assumed that
everything is somehow connected to everything else. Questions are formulated to bring forth the
"patterns that connect" persons, objects, actions, perceptions, ideas, feelings, events, beliefs, contexts,
and so on, in recurrent or cybernetic circuits.
Thus, a more systemic therapist may begin the interview differently: "How is it that we find
7. ourselves together today?" (I called because I am worried about my husband's depression); "Who else
worries?" (The kids); "Who do you think worries the most?" (She does); "Who do you imagine worries
the least?" (I guess I do); "What does she do when she worries?" (She complains a lot, mainly about
money and bills); "What do you do when she shows you that she is worrying?" (I don't bother her, just
keep to myself); "Who sees your wife's worrying the most?" (The kids, they talk about it a lot); "Do
you kids agree?" (Yes); "What does your father usually do when you and your mother talk?" (He
usually goes to bed); "And when your father goes to bed, what does your mother do?" (She just gets
more worried); and so on. These questions seek to reveal recurrent circular patterns that connect
perceptions and events. They tend to be more neutral and accepting. The responses they elicit from
family members are also less liable to be judgmental.
Circular questions tend to be characterized by a general curiosity about the possible connectedness
of events that include the problem, rather than a specific need to know the precise origins of the
problem. If the therapist has established a Batesonian cybernetic orientation toward mental process, and
has developed skills in maintaining a conceptual posture of circular hypothesizing, these questions will
come easily and freely. Two general types of circular questions, "difference questions" and "contextual
questions," have been associated with Bateson's fundamental patterns of symmetry and
complementarity. Several subtypes, including categorydifference questions, temporal-difference
questions, category-context questions, and behavioral-effect questions, have been described in an
earlier paper (3).
Strategic Questions
These are asked in order to influence the client or family in a specific manner, and are based on
lineal assumptions about the nature of the therapeutic process. The intent behind these questions is
predominantly corrective. It is assumed that instructive interaction is possible. The therapist behaves
like a teacher, instructor, or judge, telling family members how they erred and how they ought to
behave (albeit indirectly in the form of questions). On the basis of hypotheses formulated about the
family's dynamics, the therapist comes to the conclusion that something is "wrong," and through
strategic questions tries to get the family to change, that is, to think or behave in ways that the therapist
thinks is more "correct." The directiveness of the therapist may be covert, because the corrective
statement is packaged in the form of a question, but it is still conveyed through the content, context,
timing, and tone. Some families are offended by this mode of inquiry, but others find it quite
compatible with their usual patterns of interaction.
Giving examples of influencing questions is more diflficult because hypotheses about some of the
mechanisms involved in the problematic situation are necessary for the formulation of the question.
But, continuing on with the hypothetical family being interviewed above, the therapist might try to
influence the couple by asking: "Why don't you talk to him about your worries instead of the kids?" (He
just won't listen, and stays in bed); "Wouldn't you like to stop worrying rather than being so
preoccupied by them?" (Sure, but what am I going to do about him?); "What would happen if for the
next week at 8 a.m. every morning you suggested he take some responsibility?" (It's not worth the
effort); "How come you're not willing to try harder to get him up?" (I'm tired and disappointed. He
won't move and it just gets me more frustrated); "Can you see how your withdrawal gets your wife
disappointed and frustrated?" (What do you mean?); "Can't you see how just going to bed instead of
talking about what is bothering you is getting your family upset?" (Well, I...); "Is this habit of making
excuses something new?" (I didn't know I had one); "When are you going to take charge of your life
and start looking for a job?"; and so on.
It is quite apparent from these examples that by asking strategic questions the therapist is imposing
his or her views of what"ought to be" upon the client or family. Sometimes a directive or confrontation
8. by the therapist is needed to mobilize a stuck system, but too much directiveness in this mode of
inquiry may risk a disruption in the therapeutic alliance.
Reflexive Questions
These are intended to influence the client or family in an indirect or general manner, and are based
on circular assumptions about the nature of the process taking place in the therapeutic system. The
intent behind these questions is predominantly facilitative. It is assumed that family members are
autonomous individuals and cannot be instructed directly. Thus, the therapist behaves more like a guide
or coach encouraging family members to mobilize their own problem-solving resources. One major
presupposition behind these questions is that the therapeutic system is coevolutionary and what the
therapist does is to trigger reflexive activity in the family's preexisting belief systems. The therapist
endeavors to interact in a manner that opens space for the family to see new possibilities and to evolve
more freely of their own accord.
Numerous examples of reflexive questions have already been provided in Part II (5) of this series of
articles. However, to provide an indication of what they might be like in this scenario, the therapist
could ask: "If you were to share with him how worried you were and how it was getting you down,
what do you imagine he might think or do?" (I'm not sure); "Let's imagine there was something that he
was resentful about, but didn't want to tell you for fear of hurting your feelings, how could you
convince him that you were strong enough to take it?" (Well, I'd just have to tell him I guess); "If there
was some unfinished business between the two of you, who would be most ready to apologize?" (She
would never apologize!); "Would you be surprised if she did?" (Sure would!); "Suppose that it was
impossible at this moment for her to recognize or to admit to any mistakes on her part, how long do you
think it would take before you could forgive her for being unable to do so?" (Humm ...); "If this
depression suddenly disappeared, how would your lives be different?"; and so on.
These questions are reflexive in that they are formulated to trigger family members to reflect upon
the implications of their current perceptions and actions and to consider new options. Even though
reflexive questioning is also intended to influence a family in a therapeutic direction, it remains a more
neutral mode of inquiry than strategic questioning because it is more respectful of the family's
autonomy. Well-developed skills in maintaining a conceptual posture of neutrality contribute to the
probability that an influencing question will be reflexive rather than strategic.
What is missing in all these examples is the emotional tone used in asking the questions. The
differences between these groups would become even more apparent if the therapist's vocal cadence,
tone, and accompanying nonverbal behaviors were present. What bears emphasis here is that the
differentiation of these questions does not depend on their syntactic structure or their semantic content.
It depends on the therapist's intentions and assumptions in the asking. Indeed, the exact same sequence
of words could constitute a lineal, a circular, a reflexive, or a strategic question. For example, if a
therapist asked a child "What does your mother do when your father comes home late, and dinner has
already gone cold?" only to find out how the mother responds when provoked by the father, it would be
a lineal orienting question. If it were asked as part of a planned sequence of behavioral effect questions
(to be followed by something like "And what does your father do when your mother yells at him?") in
order to explorethe circular interaction between the parents, it would be a circular orienting question. If
the original question were asked to trigger the parents to become observers of their own behavior and to
mobilize their awareness to modify their own behavior, it would be a reflexive question. If it were
asked because the therapist anticipated what the child probably would say, and wanted this information
released at that moment to confront either the mother or the father on their intolerant or inconsiderate
behaviors, it would be a strategic question. Thus, precisely the same words can mean and do very
9. different things in the course of a single interview. It is usually the therapist's emotional posture in the
asking that makes the difference in what the client hears in the question. These emotions are, in turn,
associated with the therapist's intentions and assumptions.
THE EFFECTS OF DIFFERENT
QUESTIONS
Before discussing the differential effects of these kinds of questions, it is important to acknowledge
the discontinuity between a therapist's intentions in asking certain questions and their actual effects on
clients. Recognizing and accepting this cleavage between intent and effect reduces therapist frustration
when therapy is not progressing well, and it opens space for the therapist to consider alternative courses
of action. From the perspective of an observer of the therapeutic process (who is usually the therapist
observing himself or herself at work), there are two points, one minor and one major, at which
discontinuities occur. The first is between what the therapist intends to do and what the therapist
actually does do. This gap can be steadily narrowed as therapists seek greater personal integration and
develop better skills in implementing their intentions. The second is the discontinuity between what the
therapist actually asks and how this is heard by family members. There is an absolute limitation here.
The listening and responses of clients are always determined by their own biological autonomy. At the
same time, however, the responses of family members are not arbitrary; they are triggered by and
contingent to what the therapist says and does. There is much that a therapist can do to improve the
contingencies between intent and effect by enhancing his or her linguistic coupling with clients through
the conceptual posture of circularity (4). But, ultimately, the intentions of a therapist in asking specific
questions never guarantee any specific effect on clients; nor could more highly refined precision in the
wording and tone of the questions do so. What actually happens to the client or family always depends
on the uniqueness of their own organization and structure at each moment. The importance of
recognizing and accepting this cleavage between intent and effect, between therapist action and client
responses, cannot be overemphasized. The actual effects are always unpredictable.
Nevertheless, a therapist can and does compute probabilities. For instance, it is more likely that
clients will become interested in their own interaction patterns through a series of circular questions
rather than lineal ones, or feel blamed more by strategic questions than by reflexive ones. Because the
therapist cannot know in advance what the actual effects of any particular question will be, yet must
make choices about what to ask before asking, these choices are made on the basis of anticipated
effects. The therapist can envisage the probable, possible, improbable, and impossible effects of various
questions. This process of anticipating is an important aspect of the conceptual posture of strategizing.
The following generalizations about the more probable effects of different questions may be
incorporated into a therapist's nonconscious habits ofstrategizing and may guide the process of deciding
what questions to ask.
Lineal Questions
These tend to have a conservative effect on the client or family. Because family members usually
think of their difficulties in lineal terms before coming to therapy, there is little "news of difference" for
the family when the therapist invites them to articulate their prior views (of what happened, who was
involved, and how) with lineal questions. Family members answer the questions but remain virtually
unchanged. (3) However, one hazard of lineal questioning is that it may inadvertently embed the family
even more deeply in lineal perceptions by implicitly validating preexisting beliefs. Unfortunately, this
happens far more often than clinicians realize while they are conducting ordinary "assessment"
10. interviews. The interviewer is seldom aware of the fact that further entrenchment of pathogenic
perceptions and beliefs is taking place. This process is particularly liable to occur if, during the course
of the inquiry, the therapist does not ask the kinds of questions (or make statements) that implicitly (or
explicitly) challenge the family's prior beliefs. Another risk with lineal questioning is that the
reductionistic thinking involved tends to activate judgmental attitudes. As the therapist brings forth "the
cause" of a presenting problem or of an undesired situation, negative judgments are automatically
directed toward it because the problem is unwanted. Thus, while lineal questions are necessary to
develop a clear focus of the problem, and are helpful in establishing an initial engagement, it is useful
for therapists to remain mindful of potential hazards as well.
_________
3 Obvious1y, if the answer of the respondent includes information that other family members (who are listening) were not
aware of previously, this could be important news and have significant effects. However, this may occur with all kinds of
questions. It is a general effect of the method of conjoint interviewing in marital and family therapy, and not specifically an
effect of the kind of question asked.
Circular Questions
Circular questions, however, do have the potential of having liberating effects on the
family. As the therapist asks questions to identify patterns for a circular or systemic understanding of
the problematic situation, family members who are listening to the answers make their own connections
as well. Thus, they may be able to become aware of the circularity in their own interaction patterns.
With this increased awareness, they may be "liberated" from the limitations of their prior lineal views
and subsequently be able to approach their difficulties from a fresh perspective. For instance, if through
a series of behavioral effect questions a husband begins to see that it is not simply his wife's worrisome
complaints that activates his depression but also that his depressiveness activates her complaining, he
may be liberated to act differently rather than by just becoming despondent when she worries and
complains. He has more space to recognize that some constructive initiative on his part may activate a
different response from her. He is also likely to become more accepting and less judgmental of her
"worrying response" to his depressive behavior. The main risk with circular questions is that as the
therapist explores larger and larger areas of interaction, the inquiry may drift into domains that seem
irrelevant to the immediate concerns and needs of the family. Another risk is that clinicians who are
learning to use circular questions may use them in a rather stylized fashion. The questions then seem
repetitive or trivial and, thus, can become irritating to the family. On the whole, however, circular
questions are more liable than lineal ones to have inadvertent beneficial effects.
Strategic Questions
These tend to have a constraining effect on the family. The therapist tries to influence the client (in
a lineal fashion) to think or do what the therapist considers more healthy or "correct." The questions are
intended to constrain the probability of family members continuing along the same problematic path. A
common side effect is for family members to feel guilty or ashamed for having taken the path they are
on in the first place. The constraint may be of two forms: not to do something that the therapist thinks is
"wrong" and is contributing to the problem or to do only what the therapist thinks is "right" and would
be helpful. Both tend to confine the family's options to what the therapist thinks is best, whether it
actually fits for them at that moment or not. Thus, these questions tend to be more manipulative and
controlling. In the extreme, they can be like the questions a good lawyer might employ in
11. crossexamining witnesses in a courtroom. The lawyer uses strategic questions to lead, seduce,
intimidate, or coerce a witness into saying precisely what the lawyer wants the judge and jury to hear.
Similarly, a therapist can "force" an individual into saying things that the therapist wants to hear, or
wants other family members hear, even when the person really doesn't think or feel that way. Because
of the potentially coercive nature of strategic questions, too many of them could have inadvertent,
countertherapeutic effects.
On the other hand, occasional strategic questions can sometimes be extremely constructive in the
therapeutic process. These questions can be vigorously used to challenge problematic patterns of
thought and behavior without having to resort to direct statements or commands. If the questions are
carefully worded, clients often can be confronted with the limitations, constraints, or contradictions in
their own systems of belief. Alternatively, strategic questions sometimes can be employed to lead the
family quite directly to recognize and embrace an obvious solution.
Reflexive Questions
These questions are more liable to have a generative effect on the family. The therapist's
influencing intent is moderated by respect for the autonomy of clients and, hence, the tone of these
questions tends to be much softer. Family members experience themselves as being invited into
entertaining new views instead of being pushed or pulled into them. The questions tend to open space
for family members to entertain new perceptions, new perspectives, new directions, and new options.
They also enable a reevaluation, without duress, of the problematic implications of the family's current
perceptions and behaviors. As a consequence, family members tend to generate new connections and
new solutions in their own manner and time. The most likely complication of reflexive questioning is
that it could foster disorganizing uncertainty and confusion. Opening a multiplicity of new possibilities
without providing adequate direction can easily become confusing. However, such confusion may not
necessarily be problematic for the overall therapeutic process. Depending on the domain of the
confusion, it may, in fact, be very therapeutic. For instance, when certain family members "know the
Truth" or "have all the answers" in a manner that keeps them stuck in problematic patterns and blind to
novel alternatives, the confusion can be quite liberating.
Finally, I would like to draw attention to the possible effects on the therapist of asking different
kinds of questions. The therapist is influenced by the questions as well. His or her thinking is
influenced not only by the assumptions and presuppositions aroused during the formulation of the
questions, but also by responding to the clients' responses to the questions. Lineal questions tend to
foster further lineal thinking in the therapist just as they do in the clients. Consequently, the therapist is
also more liable to become judgmental. The effect of circular questions on the therapist is to enhance
his or her neutrality and capacity to accept the client and family as they are. This acceptance itself has
healing potential in the therapeutic system by countering the immobilizing effects of blame, which is so
ubiquitous in symptomatic families. The effect of strategic questions on the therapist is that they tend to
lead him or her toward an oppositional stance with the family. On the other hand, reflexive questions
tend to guide the therapist toward becoming more creative in the questions asked. If one question
"doesn't work" in opening space for the family to evolve more freely, the therapist searches for another
one that is more likely to release the natural healing capacity of the clients.
Figure 2 summarizes the predominant intent and the more probable effects associated with each set of
questions. Included in the diagram are the effects of the questions on the therapist as well as on the
family. The parentheses are intended to indicate that the actual effects always remain unpredictable.
Depending on the momentary structure of a family, a strategic question could have a generative effect
instead of a constraining one. A lineal question could have a liberating effect, and a reflexive question
12. could have a constraining one, and so on. All that one can say is that it is more likely that family
members will experience respect, novelty, and spontaneous transformation as a result of circular
questioning and reflexive questioning, and judgment, cross-examination, and coercion as a result of
lineal and strategic questioning. If family members begin to feel judged or manipulated, the session
often becomes tense or "frozen." This could become a cue to the therapist to change the kind of
questions to those that are more neutral and accepting (or temporarily to abandon the process of
questioning altogether). Alternatively, if family members have become too comfortable and complacent
in the therapy process, perhaps a few well-placed strategic questions could stimulate them to consider
new directions. What is being proposed here is that the use of these distinctions could enable therapists
to choose those kinds of questions that are more liable to guide the interview to actually become a
conversation for healing.
ORIENTING
CIRCULAR ASSUMPTIONS
LINEAL ASSUMPTIONS
INFLUENCING
exploratory
intent
facilitative
intent
corrective
intent
investigative
intent
(Liberating
Effect)
(Generative
Effect)
(Conservative
Effect)
(Constraining
Effect)
FIG. 2. Predominant intent and probable effects of differing questions.
CONCLUDING COMMENTS
The impossibility of predicting actual effects points to the importance of the therapist's ongoing
activity of monitoring the immediate reactions of family members and revising hypotheses as the
session unfolds. However, the actual effects of a question often cannot be observed; the reactions of
family members are altogether too difficult to "read." Sometimes the effects may not even materialize
at the time of the interview. The pertinent realization may dawn on family members only after the
session, perhaps the next day, or even later. There are some questions that linger in the minds of clients
for weeks, months, and occasionally years, and continue to have an effect. To a large extent, a therapist
always has to "work in the dark" and never knows the final outcome of specific questions. This leaves
13. even more responsibility on the therapist's intentionality in making decisions about what to ask. In other
words, therapists need to take responsibility for the questions being asked without ever knowing what
their full effects might be. At the same time, however, much can be done in personal professional
development to increase the probability that a therapist's spontaneous behavior in an interview is more
liable to be therapeutic than nontherapeutic or countertherapeutic. One has to bear in mind that, to a
significant degree, the question "prefigures" the response in that it structures the domain of an
"appropriate" answer. That is, a question presupposes a particular answer, or at least an answer in a
particular domain. To ask a particular question, then, is to invite a particular answer. The kinds of
questions a therapist chooses to ask depends on what kinds of answers the therapist would like to have
heard. Whether or not the client accepts the therapist's invitation to provide an answer in the
"appropriate" domain is quite another matter, but to select the question is to restrain the range of
"legitimate" responses. This selectiveness gives the therapist an enormous amount of influence in
setting and maintaining a direction for the conversation.
The distinctions in this article reflect the results of some qualitative research I have been engaged in
for the past several years. If an empirical researcher wanted to explore these issues further and, for
instance, establish whether a particular question was lineal, circular, strategic or reflexive, he or she
would have the problem of identifying the intentions and assumptions of the therapist in asking it. The
most direct route for this would be to ask the therapist to try to articulate his or her thoughts while
formulating questions. This could perhaps be achieved during a review of a videotape immediately after
the session. An outside observer could also evaluate each question in its context. Subsequently, these
ratings could be compared for degrees of fit and set alongside descriptions of the moment-to-moment
experiences of clients who also reviewed the tape. Further studies along these lines may contribute a
great deal to a deeper understanding of the process of interventive interviewing.
REFERENCES
1. Bateson, G. Steps to an ecology of mind. New York: Ballantine Books, 1972.
2. _______. Mind and nature: A necessary unity. New York: E.P. Dutton, 1979.
3. Tomm, K. Circular interviewing: A multifaceted clinical tool. In D. Campbell & R.
Draper (eds.), Applications of systemic therapy: The Milan approach. London:
Grune & Stratton, 1985.
4. _______. Interventive interviewing: I. Strategizing as a fourth guideline for the
therapist. Family Process 26: 3-13, 1987.
5. _______. Interventive interviewing: II. Reflexive questioning as a means to enable self healing.
Family Process 26: 167-183, 1987.
Manuscript receied and accepted May 11, 1987.
Fam. Proc., Vol. 27, March, 1988.