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Teaching Exercises

All our courses are based on real scenarios brought by participants. We use little role play, working instead mainly with "live" narratives from people's current working lives. Before they attend, we ask them to think about this question:

What current dilemmas do I have that would benefit from talking things through with a supportive colleague? This can be in relation to your work as a clinician, clinical teacher, team member or manager:  NB: These scenarios need to be:

CURRENT:  (not already solved / in the past)

REAL:  (not a hypothetical situation

YOUR OWN:  (not someone else’s problem)

INDIVIDUAL: (dealing with a particular individual or team, not generic issues

HOT (causing you concern but also suitable for sharing in confidence with the group)"

Our core exercise is to use a small group where one person supervises another on their dilemma, while other members of the group act as observers, A tutor acts as a coach, helping the supervisor to improve their questioning skills, and inviting the observers to offer their reflections. In the initial stages of learning we ask supervisors to keep to these four simple rules:

1.Mainly ask questions. Single, Open, Short

2. Make your question follow from something already mentioned

3. Don’t share your interpretations or hypotheses – use these as a basis for questions instead

4. Save advice and solutions to the end and then only if requested or needed 

There are some more details of our small group teaching approach in this article: Supervision quartets

With larger groups, we often make use of "reflecting teams", as described in this article: Clinical case discussion using a reflecting team


Reading material

Below are three essays we use as part of our reading for courses Conversations inviting Change. The references at the end of each essay list some further reading. There are three short essays:

1. What is a good question?

2. What is supervision?

3. An introduction to theory

Please note these essays are here for private study, and for participants in CIC courses and workshops. They are not for reproduction or use on other courses without permission, and they do not constitute training in CIC. All materials are copyright John Launer, 2008-2016

1. What is a good question?

To be an effective professional, you need to understand the point of asking good questions. The purpose isn’t just to find out information, and it isn't meant to influence someone to see things your way, or to solve problems for them. Instead, the aim is to create as many opportunities as possible for patients or colleagues to think about their stories in new ways. The understanding they reach and any action they decide to take as a result may not be what you expected or what you hoped for. We don’t prejudge what is right for the client – unless we think the patient is in danger or the client is at risk professionally. Often, the change that occurs in the conversation is a cognitive one rather than a concrete decision. For example, clients may realise through the conversation that what they were already thinking or doing was right all along, and feel more comfortable about it. Alternatively, they may reach an entirely different view of the problem, perhaps seeing their own part in it rather than feeling it was somebody else’s fault.

Good questioning is not the only kind of utterance in effective conversations, but it is a better way of creating openness and possibility than any other form of speech. Good interviewers can demonstrate how well they have understood a client simply by asking questions that correspond appropriately to the language and the emotions present in the conversation. This is why we discourage the familiar routine of empathic noises (eg ‘I hear what you’re saying’),  reflecting back (eg ‘so what you’re saying is…’), reformulation (eg ‘it sounds to me as if…’),  and interpretation (eg ‘I think what’s really going on here is…). Unlike some other methods, we try to avoid direct inquiry into emotions (including the ubiquitous ‘how did you feel about that?’). For some clinicians this question has become an automatic response. It is sometimes asked without real sincerity and may not be what the other person wants to speak about. If someone is feeling strong emotion and chooses to express this, it is perfectly possible to allow this to happen through sensitive questioning without insisting on it. A question like ‘how did this experience affect you?’ will nearly always be more helpful than a statement like ‘you must have felt very angry’. Although this may have been said with the intention of expressing empathy it can be experienced as clumsy and may be off the mark anyway. 

We draw on the ideas of a group of therapists known as the 'Milan Team ' who proposed three principles for good questioning: hypothesising, circularity, neutrality. Later one of the team, Gianfranco Cecchin, proposed a fourth principle: curiosity.

Hypothesising

There are instances when it is useful to form a series of conscious working hypotheses in one’s mind as a conversation proceeds and to use these to generate appropriate questions. However, some people do seem able to question clients through intuition without necessarily identifying the hypotheses that led to them – or only becoming aware of these afterwards. 

Where hypotheses are fully conscious, we advise against sharing these openly with clients, because this may lead to the supervisor’s assumptions taking over and suppressing what the client can actually say or think. In the case of the example above, it is easy to imagine that declaring each hypothesis as it arose could be helpful if the supervisor was right about every single one of them (and the client had already thought through all these aspects of the problem in advance). However this can be oppressive if they turn out to be wrong – and possibly based on the supervisor’s own experience alone – or if they are more or less correct but badly mis-timed because the client is only realising them with some difficulty during the interview itself. For every one occasion when a supervisor shares a totally accurate hypothesis and moves the interview forward with great speed as result, there are probably a hundred examples where supervisors are convinced they are absolutely right and hijack the interview by offering their own version of events, leaving their clients somewhat worse off than if they had never asked for supervision in the first place. 

One advantage of identifying one’s own hypotheses and examining them critically is to help you avoid barking up the wrong tree. Sometimes an interviewer will pursue a whole line of questioning based on a single unexamined assumption, perhaps based on their own experience: this is called ‘being wedded to your hypothesis’. When it’s clear that an interview is going nowhere, it’s always worth reviewing whether an assumption of this kind is present and then adjusting it.

Circularity

One of the most fundamental principles of narrative-based practice is that questions should be linked to something the client has already said. Whenever possible it is worthwhile for interviewers to pick up on words or phrases from the client’s own narrative rather than choosing these from their own vocabulary, or substituting other words and phrases that may seem almost identical but have significant differences for clients. Following another person’s exact language is a way of showing empathy and interest through careful listening.

Effective professionals have an ability to sense cues that have ‘life’ or ‘weight’ in them and to tune out of everything superfluous, while others seem to pick cues at random from the client’s flow of words and hence ask questions that are irrelevant or trivial. One corrective to this, particularly for learners, is to check constantly with clients which among several cues it might be most helpful for the supervisor to follow, and to be willing to review the conversation or wind it backwards whenever a question seems to lead down a blind alley or makes the interview go slack (e.g. ‘you mentioned earlier that there were two aspects to this problem: which of them is foremost in your mind at the moment?’). Another approach is to ask the other person how the conversation is going for them, what they are getting out of it, and what is still missing for them.

With good conversations, there is a circularity of emotions as well as words. Some poor supervisors meander, while others go straight for the jugular vein. Effective ones seem to move forward at exactly the right pace to keep the conversation taut without provoking either boredom or defensiveness in clients. When the client seems vague or unfocussed, they become more precise and assertive in their questioning. When the client tenses up and they sense they have run up against a ‘wall’ in the conversation, they ease up gently but not too much (or they pause to talk with the observer or team if there is one). 

Neutrality

Neutrality as a term sometimes causes confusion because it implies that professionals have no views or opinions of their own. This is obviously impossible. However supervisors can still follow the discipline of not showing their views or opinions to clients. 

For most learners it isn’t easy to master to process of turning a hypothesis (whether conscious or intuitive) into a question, and then making sure that the question doesn’t give everything away by its wording or intonation. That is one of the reasons for using structured training methods in small group work. With practice the process becomes internalised and hence easier. For some people it fits so well with what they believe to be effective and ethical conversational practice that it becomes effortless.

There are sometimes situations where the interviewer stands in a significant power relationship with the client (for example as trainer and trainee, or employer and employee) or the two people normally work together in a shared context like a team or practice where their own interests may differ. In such situations, attempts by supervisors to show neutrality can be dishonest. They can turn into ‘narrative-based manipulation’, where the interviewer performs apparently neutral interviewing while actually aiming to influence the client to consent to one pre-meditated outcome. Neutral interviewing of a client in this situation is certainly possible, but only up to a point. For example an interviewer can show curiosity into why a trainee or colleague takes a particular position, if he or she accepts that the other person’s position is entirely reasonable from their own perspective. 

However at some point the interviewer will need to declare his or her own position (if this isn’t already obvious) and will need to conduct the rest of the conversation based on the fact that there is a real difference of opinion: both parties now need to address how to manage that difference. This may entail an interviewer in a position of power exerting their authority and declaring that they cannot be neutral about the action they need to take. Where the supervisor and client are equals within the same power structure, the next step may be to explore together what the consequences of their difference will be within the wider system and who else might be implicated by it. If this cannot strictly be conducted in a neutral way, there is certainly no reason why it cannot be amicable.

Curiosity

Patients often report that it wasn’t the questioning that helped most in a conversation (at least so far as they can remember) but the overall stance of curiosity in their interviewer. Indeed, we have often seen clunky questions do the trick so long as the interviewer was genuinely engaged and curious. ‘Text book’ questioning can achieve nothing at all if delivered in a way that seems rehearsed or inauthentic. There may be a few specific questions in any interview that stop clients in their tracks and lead them to say ‘that’s a really good question’.  There may be other questions that they chew over during the course of the following week so that the interviewer may never even learn what a good question it was. However many of us have had the humbling experience of being congratulated by a client after an interview for asking fantastic questions that we never actually asked: our clients imagined that they heard the questions that they really wanted.  In these instances, it is probably the quality of the interviewer’s curiosity that enables the client to imagine the perfect question even though the supervisor hasn’t actually asked the ‘right’ ones at the time.

Tomm’s framework for asking questions

The principles of the Milan Team were later developed into a framework for questioning by Karl Tomm, a Canadian professor of psychiatry. He called it “interventive interviewing”, implying that conversations, conducted through questions, can make a difference to how people view and understand things and are therefore really ‘interventions’. We prefer to call these interviews “conversations inviting change”. 

From watching videos of the Milan Team at work, Tomm drew up a theoretical framework for using questions as interventions. Although his original premise was that therapeutic conversations aim to relieve mental pain and suffering and produce healing, the concepts are not restricted to therapy. Tomm has argued that you can transfer the underlying principles to any conversation where someone is trying to help someone else (or a group) view a problem or dilemma in new ways, including supervision and team facilitation. 

Tomm’s scheme is helpful in promoting self-awareness in relation to the quality, variety and effects of different questions, particularly in the early stages of learning narrative-based practice.  As he points out, the taxonomy doesn’t map very well onto many real-life conversations. Our observation is that it can also can hamper people if they try to follow it slavishly. Like riding a bike, it is probably best learned then forgotten. 

However it is useful for learners to know the distinctions Tomm makes between lineal questions (e.g. ‘who else works with you?’), strategic ones (e.g. ‘what would happen if you raised this problem at a practice meeting?), circular ones (e.g. ‘who gets most upset in your practice if you don’t always follow clinical guidelines?’) and reflexive questions (e.g. ‘if the doctors couldn’t resolve their disagreements, who do you think would be the first one to leave?’). It’s certainly worth noting that all these questions are open ones, in the sense that they don’t begin with verbs and hence open the possibility for narrative development rather than inviting the answer ‘yes’ or ‘no’. 

Lineal questions

You may feel more comfortable calling these ‘linear’ questions. These are investigative questions with which clinicians are very familiar as they form the basis of medical history taking: what, who, why, when, where? They are very useful questions that help the interviewer and interviewee orient themselves, set the context and gain clearer understanding of the interviewee’s story. They are based on ‘lineal assumptions’ that assume that things have simple causes and effects. They bring out facts but the drawback is that they tend to establish an existing story that does not necessarily help the interviewee to see new paths or options. Unless used with caution this type of question may convey a judgmental attitude and embed pathology and an unchanging narrative.

Some examples:

 What has happened?

 How long has this been an issue for you?

 Who else is involved?

 Who else believes……..?

 What have you done about.......?

Circular questions

These could be also be thought of as interactional questions. They are exploratory and assume that everything is connected with everything else (‘circular assumptions’). Circular questions are used to bring out patterns that link events, perceptions and behaviour. They are founded on curiosity to create a dynamic view of the interviewee’s situation. There are many different types of circular questions but most fall into the categories of “difference questions” and “contextual questions”.

 Some examples:

 How do you think x sees you?

 How do you imagine x thinks you see her?

 When x gets angry what does y do?

 When the consultant/senior partner is stressed what effect does that have on the receptionist?

 Was the nurse more likely to show this attitude problem before or after her colleague went on sick leave? 

Strategic questions

These are corrective, leading questions where the interviewer embeds advice in the question. They can be helpful when a supervisor needs to act as an instructor. They are a way of saying “If I were you I would do...” but offering advice as a question leaves some room for the interviewer to reflect on their response. These questions can be experienced as reassuring and supportive or as challenging and constraining and may get interviewer and interviewee into an oppositional stance. They should therefore be used sparingly.

Some examples:

What do you think would happen if you:

           started a disciplinary procedure?

            just ignored this?

            spoke to one of the partners/the clinical lead about this?

            got some legal advice?

 What would the advantages and disadvantages be if you:

            said exactly what you think?

            asked x to do y?

            just told her what to do?

            asked what she would like?

            pointed out what it says in her contract about this?

Reflexive questions

Tomm thinks of these as the most facilitative questions. They invite people to consider something familiar in a new context. The aim is to perturb the interviewee’s thinking in order to help them develop new and more constructive ideas. Using reflexive questions assumes that people are autonomous and cannot be instructed directly. They may offer a more creative approach but can sometimes make people feel confused.

 Some examples:

 What will happen if nothing changes? / How long do you think you could put up with the situation if it doesn’t change?

 What would be happen if you did nothing? / Who else do you think would be the first to act if you did nothing yourself?

 What’s the best thing / worst thing that could happen of you asked the team to discuss these issues?

 If we could find a solution to this problem what other problems might be exposed as a result?

 What can we do to move this conversation forward?

 What would you do if this happened again?

 From these examples it should be clear that the same question may fit into different categories depending on why and how it is asked. There may be a difference between the interviewer’s intention in asking a question and the actual effects of that question on the interviewee. This may be because there is a difference between the interviewer’s intentions and what they actually do, or because there is a difference between what the interviewer asks and how this is heard by the interviewee. These mis-matches can be minimised by experience and by close attention to language, both verbal and non-verbal. However, the interviewer has to take responsibility for asking questions without always knowing what their effects might be. Although some questions elicit an immediate response, the interviewer may not always be aware of the inner reflections that may be generated and some questions may linger for a long time beyond the immediate conversation.


References: 

Cecchin, G. ‘Hypothesizing, circularity, and neutrality revisited:
An invitation to curiosity’,  Family Process 1987; 26: 405-413.


Halpern H, McKimm J. Supervision. In J. McKimm and Swanwick T. (Eds) Clinical Teaching Made Easy. London: Quay Books, 2010.

Launer J. Narrative-Based Primary Care: A Practical Guide. Abingdon: Radcliffe., 2003

Launer J. Training in narrative-based supervision: Conversations inviting change. In: Sommers LS, Launer J, eds. Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement. New York NY: Springer, 2013, pp.163-176.

Palazzolli-Selvini, M., et al. ‘Hypothesizing-circularity-neutrality. Three guidelines for the conductor of the session’, Family Process 1980; 19: 3-12.
 
Tomm, K. ‘Interventive Interviewing: Part III. Intending to ask lineal, circular, strategic or reflexive questions?’ Family Process 1988; 27, 1-15.



2. What is supervision?

The word supervision is used a wide variety of senses. Most doctors and dentists use the term only in the context of formal training (eg in educational and clinical supervision for juniors). However, in other professions the term is used for a wider variety of conversations including case discussions between established clinicians. For example, in nursing it is understood as:

‘An exchange between practising professionals to enable the development of professional skills.’(Butterworth)

In our courses, we use the word supervision in this wider sense, to mean any focussed conversation between professionals about their work. The implication is that supervision is something that should happen throughout professional life, from student days to lifelong learning.

It is helpful to think of supervision in terms of two circles – development and performance. Sometimes supervision can be purely developmental and sometimes purely oriented towards performance. However in most supervision both are involved. Much depends on context ie who is asking for what to be done, who is reporting to whom and why. Although it is conventional to make a distinction between supervision, mentoring, coaching and career guidance but it practice many conversations will range between these. 
 
What does supervision address?

Cases:

Most supervision takes place in order to address cases. These may be addressed in terms of technical management but often they raise broader issues, for example:
• when there is no one easy answer
• ethical issues
• complex cases

• ‘grey area’ cases: eg somatisation, frequent attenders, chronic fatigue, irritable bowel
•  complaints, distressed families, angry patients, unlikeable patients

Contexts.

Cases never occur in a vacuum. Case management often depends on trying to achieve coherence among the professionals. Supervision may need to address:
• professional or interprofessional rivalries
• problems concerning communication
• teamwork issues
• roles and boundaries
• the differing expectations of patients and clinicians
• money, politics, gender, sexuality and power

Careers.

Case conversations quite often bring up issues about careers, for example:
• the need for further training
• work place conditions and job prospects
• longer term career aspirations

A narrative approach to supervision skills

There is evidence that skilled supervision sustains morale, increases job satisfaction, lessens stress, prevents burnout and dropout, and reduces complaints and litigation. Supervision skills are similar to good consultation skills and to effective team communication. All of these share the same micro-skills (hypothesising, open questions, empowerment) and model a reflective attitude (respect, thoughtfulness, seriousness, complexity).

People doing supervision use all sorts of approaches: informal chat, eclectic methods, approaches based on educational theory or counselling, psychodynamic ones etc. The approach taught in the London Deanery is a ‘narrative’ one: we have found that this approach makes sense to many clinicians and is easier to learn and teach than some other approaches.

A narrative approach to supervision does not reject other frameworks such as evidence based medicine, clinical science, psychodynamic understanding etc. What it offers instead is an overarching framework that allows people to value these as helpful contributions that can generate useful ways of looking at the world that may or not make a difference to someone’s story. It encourages us to see different discourses as sources of helpful hypotheses rather than absolute truths, and lets us move flexibly between these. A narrative approach encourages the exploration of ‘polyphony’ ie valuing the different stories that anyone is capable of telling about the same experience. Hence, agreed ‘truths’ are established by the process of dialogue itself.

There is a close connection between narrative ideas and systemic ones: ie the idea that we continually create our realities in conversation with people around us, and that families, societies and cultures are defined through their shared stories. In other words, our understanding of the world is always ‘dialogical’ in its origins and can be developed further through dialogue. We have spent the last decade at the Tavistock Clinic and London Deanery (now Health Education England) trying to make use of narrative and systemic ideas and skills for everyday consultations and supervision. We see our approach as one that completes the triangle between narrative studies, narrative approaches to therapy, and medicine.

Helen Halpern has formulated these in terms of the following ‘rules’ in relation to narrative-based supervision.
 
• The supervisor is not considered to be in a position of authority over the supervisee unless circumstances absolutely require this (eg concerns about performance). The supervisor’s role is to help the supervisee reflect and expand the narrative they present in a non-judgemental way.
• It is not necessarily expected that the conversation will lead directly to any solution but may simply help shift the dilemma or narrative in a more helpful way for the supervisee.
• The supervisor should not offer advice unless specifically requested by the supervisee.
• The conversation does not at first set out to explore the supervisee’s feelings, although their emotional response may become an important factor to consider.
• The supervisor asks questions rather than offering interpretations.
• Each question that is asked should be based on the response to the previous question.
• In general the supervisor should not ask a question if they think that both they and the supervisee already know the answer.
• The supervisor needs to pay close attention to the language used by the supervisee and to track this and its meaning.
• The supervisor notes non-verbal cues and body language and uses this to help frame subsequent questions.
• The supervisor will necessarily base their questions on their own knowledge and experience but needs to be wary of making assumptions and imposing these on the supervisee. Indeed one of their roles may be to challenge the supervisee’s assumptions.


References
Burton J and Launer J (eds) Supervision and Support in Primary Care. Abingdon, Radcliffe, 2003.

Launer J. New Stories For Old: Narrative-based primary care in Great Britain. Families, Systems and Health 2006; 24: 379-389

Launer J. Supervision, mentoring and coaching. In T. Swanwick, (ed.), Understanding medical education: evidence, theory and practice, 2nd edition. London, UK: Wiley-Blackwell, 2013.

Launer J and Halpern H.  Reflective Practice and Clinical Supervision: an approach to promoting clinical supervision among general practitioners. Work Based Learning in Primary Care 2006;4:69-72
 
3. An Introduction to Theory

We teach an approach to supervision for clinicians that is based on a particular attitude of mind, and a set of techniques that convey that attitude. This paper offers a brief description of the theoretical ideas behind the attitude and the techniques. We want to emphasise two things from the start. Firstly, the attitude of mind is more important than the theory. Some people instantly grasp the attitude but are bored by the theory (which is fine).  Others get very excited by the theory but don’t seem able to apply it in live supervision (which isn’t fine). So if you struggle to understand some of these theoretical ideas it may not matter. Equally, if you fall in love with them it still may not mean that you can supervise well. Secondly, we are applying ideas that we have learned through our training in family therapy. This mystifies some people since they wonder how on earth ideas from therapy with families can possibly be relevant to supervising doctors, dentists and other clinicians. However, the ideas have a history that is quite independent of family therapy, and these days they are increasingly being used elsewhere including management and education. You do not have to be a family therapist to understand them or apply them skilfully to supervision.

Our approach draws on two distinct but related fields of thought: systems theory and narrative studies. The following sections describe each of them in turn, with a linking section that describes a school of thought that in some ways bridged the two sets of ideas.

Systems theory

Systems ideas have been around since the middle of the twentieth century. They arose in many different disciplines including engineering, physics, cybernetics, biology and anthropology. They are associated with a number of names that have largely been forgotten outside specialist disciplines. These include Norbert Wiener, Heinz von Foerster and Ludwig von Bertalanffy. The best known of all the systemic thinkers was a man named Gregory Bateson. He was British but lived much of his life in California.

Bateson was something of a polymath. His essays covered a huge range of interests including evolution, political theory, religious mysticism, art and psychiatry. Unfortunately he was not a very clear writer and his arguments can be hard to follow but they can all be summed up by a single idea: everything in the world is ultimately connected with everything else, through a complex pattern of interactive loops that never really has any beginning or any end. Because of this fact, all that we can ever perceive of any phenomenon is only partial and provisional. Moreover, we ourselves as observers are really only a part of the pattern of interactive loops and can never really stand outside it and be entirely objective.

A typical example of Bateson’s thinking relates to the problem of schizophrenia. Rather than focussing on the individual person with schizophrenia, Bateson preferred to talk about ‘schizophrenic interaction’. While recognising that some people might have a genetic tendency towards schizophrenia, he pointed out that this could only be a small part of a much wider pattern. People behaving in a schizophrenic way would inevitably have an effect on everyone around them, and these effects would then have other effects. For example, family members might react by treating them as weird or dangerous, and this in turn might make them more likely to be so.

Or, in a more complex way, people who showed schizophrenic behaviour might be likely to choose partners who behaved in similar ways to themselves. This would result in children who would have an additional genetic tendency to the same kinds of behaviour but would also be nurtured in an environment where these kinds of interactions were more common. The social circle around them would then respond in turn by marginalising them, thus adding to their problems. If anyone caught up in such multiple interactions saw a psychiatrist, the problem might then be amplified further, especially if the psychiatrist dwelt only on the abnormal aspects of the person's behaviour and emphasised the diagnosis rather than ever engaging in normal conversation with them.

Bateson argued that this kind of ‘systemic’ thinking was useful not just in clinical fields but in every area of human experience. Let me give a personal example. I regularly visit a café near my workplace where there is a young black waitress whom I used to find very bad tempered. I used to respond in kind by giving her fairly curt requests and not leaving tips. One day I noticed her laughing with a group of young black customers and I began to wonder if she was grumpy with me because she expected me as an older white man to behave exactly as I was doing: namely being curt and ungenerous. I altered my behaviour and of course she did too. Hopefully we both learned from this, in a way that may make a small contribution to lessening racism, sexism and ageism more widely. Of course we are likely to have less impact on the wider social contexts that determined her previous behaviour and mine, or on the enduring effect of colonialism on black and white people, nor indeed on a range of wider contexts including the relations between males and females, or between in-groups and out-groups across all human cultures. But you never know.

Bateson was not himself a clinician but he worked for a time with psychologists and psychiatrists. He was particularly influential on a group of people who became the founders of family therapy in the 1950s and 60s. These people started to use his ideas not just with schizophrenia but with alcoholism, behaviour problems in childhood, marital discord and a host of other problems. Instead of seeing any problem as ‘belonging’ to a single individual, they started to focus on how people interacted with each other and how this could make any problem far worse - or far better. They would see patients together with their close relatives, and work with the whole family system to try and understand and help what was going on.

Although family therapy has changed in many ways since its earliest days, family therapists continue to use Bateson's ideas. In particular, they tend not to make interpretations about the ‘cause’ of a problem, nor to give advice about how to deal with it. Instead, they ask questions in order to stimulate everyone’s interest in the nature of the problem, how it arose, and what is keeping it going. They hope that by  thinking about such questions, everyone involved may become more aware of their own contribution towards the situation in the ‘here and now.’ By working in this way, they aim to help people question the objectivity of their own fixed judgements and labels, and to explore new ways of seeing the world around them and their part in it. It is also from Bateson that we take the idea of “the difference that makes a difference”. This informs our thinking about how to help people think about change. People need to do something different but not too different so we ask about the smallest steps they can take that might be useful.

In the context of supervising healthcare professionals, we find that Bateson’s thinking, and systemic ideas generally, are helpful in all kinds of ways. They can make people aware of how any problem may only become a problem in the context of human interactions, and how those interactions can contribute to it, or make it better. Systemic ideas can also help people to see that any understanding of a problem can only ever be partial or temporary, and that solutions - or resolutions - can only really be generated by the parties involved. The role of supervisors is therefore to be curious and sympathetic but also to be challenging - in the sense that they will never simply accept the supervisee’s account as the only possible description of what is going on, or as the ‘truth’ of the matter.

The Milan team: a bridge from systems to narratives

Like every other branch of psychology, systemic thinking and family therapy have given rise to many different schools of thought. However, the followers of Bateson who have most influenced us are a group of Italians  known as the Milan team. These were four psychiatrists who were also psychoanalysts. In the 1970s they became frustrated and disaffected by some aspects of psychoanalysis including its emphasis on the individual and its apparent certainty about the mind and how it works. Using principles derived from Bateson, they developed a way of working with families (and later with individuals, and then in supervision) that depended almost entirely on using questions to open up new ways of thinking for their clients. Eventually they proposed that their approach could be understood in terms of three simple guidelines: hypothesising, circularity and neutrality.

When they talked about hypothesising, the Milan team were trying to draw attention to the fact that it is quite impossible not to form ideas in your mind about causes, reasons, explanations and interpretations for anything you hear about. However there are two quite different ways of responding to these ideas. On the one hand you can assume that your own ideas are right and to try and persuade other people of this. On the other hand, you can regard these ideas simply as different descriptions of
what is going on, and then to try and find out if these descriptions are of any interest or use to the other person.

The conversion of hypotheses into questions is one of the key skills of systemic questioning. It not only involves identifying what you are thinking in the first place, but it also includes the discipline of becoming sceptical about your own ideas at the same time, and then asking a question that gives no hint of your opinion.  To use the example I gave earlier of the ‘bad-tempered’ waitress, somebody listening to me talking about her might quite reasonably form the idea that I was being unfair or prejudiced in my description of her. In normal circumstances they might just tell me so – but at the risk of offending me and therefore not helping me to think about my behaviour. If they questioned me on Milan principles instead, they would ask me something like: ‘Does she seem grumpy with everyone or have you ever seen her behave in a different way?’ Ideally, they would ask this in a way that showed genuine curiosity and no hint of criticism of me, making me more inclined to reflect on what had happened from an interactional perspective.

The Milan team's next guideline of circularity covers the idea that the person doing the questioning in a systemic interview (whether in a consultation or when doing supervision) should always note in careful detail what the response is to each question, and use this to frame the questions that follow. This involves a willingness to ‘go with the flow’ of a conversation even if it is going in a quite different direction from the expected one. One of the necessary skills for the interviewer here is what the Milan team called ‘not being wedded to your hypotheses’. This implies the ability to respond with equal interest whether or not the ideas in one’s own mind are confirmed.

Taking the ‘grumpy waitress’ example once more, I might conceivably respond to the interviewer’s question by asserting stoutly that I had only ever seen her being grumpy, whoever she dealt with. A good interviewer would take this at face value and move on immediately to a different hypothesis and a different question, for example: ‘Can you imagine any situation outside her work where she might not be so grumpy?’ Another possibility is that I might confess that I had indeed seen the waitress behave cheerfully with young black people, opening the way for a further question like: ‘What explanation do you have for why she behaves differently to you?’. The Milan team’s view, and our own experience, is that such a question would be far more likely to induce me to explore my own set ideas and alter them.

The Milan team's third guideline - neutrality - really flows from the previous two. It expresses the idea that interviewers should constantly maintain an open, tolerant stance that allows their client or patient the maximum possible space, unimpeded by the intrusive beliefs or prejudices of the interviewer. The Milan team were at pains to emphasise that this did not mean that interviewers should have no beliefs and prejudices of there own. Nor did they ever rule out the possibility of situations (including dangerous or life-threatening ones) where it was legitimate and ethical to declare these. What they did argue, however, was that clinicians very often found themselves in situations where they could do more harm by inappropriate certainty than by carefully considered neutrality.

In time, one member of the Milan team named Gianfranco Cecchin wrote a further paper in which he boiled down the approach of the team into one word: Curiosity. If one felt and expressed adequate curiosity, he suggested, everything else necessary for a systemic interview would follow automatically. This would not only include a helpful exploration of the nature and content of the problem, but also the client's response to the interview itself.  (‘How is this conversation going for you? How helpful are you finding it? Are there any other questions I should have asked you? Am I getting the balance of questions to advice about right? Am I showing any prejudices that are getting in the way of your thinking?’ and so on.)

In our trainings in supervision skills we have used the ideas of the Milan team in all sorts of ways, but the most important of these are probably the stress we place on attentiveness to language, and on following feedback. In our experience many doctors are quite empathic and sensitive to the general tone of feeling in a conversation but they may have inadequate skills in noticing the tiny, giveaway, words and phrases that can act as cues for curiosity and helpful questions (eg the word ‘always’ in the expression ‘always grumpy’). Equally, they may never have been trained to be sufficiently aware of their own certainties, so that they are inclined to plough on with a particular, pre-determined line of questioning even when every response is indicating that it would be better to pursue a different set of ideas.

One specific point worth making here is whether it is useful to impart a list of systemic questions (sometimes referred to as ‘circular’ questions) that are useful in many different situations. The answer is probably ‘Yes and no’. We do sometimes give as set reading a famous paper by a follower of the Milan team named Karl Tomm, who systematised their approach to questioning (although they repudiated his system as too rigid and militating against spontaneity). From time to time we also ask groups to generate their own list of ‘favourite effective questions’. However on the whole we regard such approaches to questioning as essentially anti-systemic. By definition, a set of prepared questions cannot possibly relate to the specific language cues given by individuals in particular conversations. However, when they are learning this technique some people find it very helpful to have a few “favourite questions” handy to refer to in their consultations or supervision conversations.

The Milan team never explicitly described themselves as narrative therapists or narrative practitioners. However, in their preoccupation with language and its importance they were very much in accord with a rising interest in narrative that was also emerging around the same time.

Narrative ideas

The narrative movement that emerged in the 1980s was entirely distinct from the world of systemic thinking. However, like systems theory, it emerged in a whole range of different and apparently unrelated fields including the social sciences, philosophy and literary studies. Pioneers of narrative thinking included the psychologist Jerome Bruner, the literary critic Paul Ricoeur, the philosopher Charles Taylor and the Russian linguistician Mikhail Bakhtin - who had actually written much of his important work fifty years earlier but was now being rediscovered.

A narrative is simply a story. People within the narrative movement have taken all sorts of different theoretical positions, but they all basically share the same central ideas: human beings are story-telling creatures. This means that we make sense of our realities by telling each other stories (or bits of stories) and we experience our lives in ways that resemble stories - in other words with characters, plots, motives, suspense, beginnings and endings and so forth. Another feature that narrative thinkers generally have in common - and that Bakhtin emphasised - is that stories are made up not by single individuals but between them. Who a story is being told to (and where, and when, and why) is just as important as who is doing the telling.

This is not the place to explore the relationship between the narrative movement and other similar movements from the late twentieth century including post-modernism and social constructionism. Nor is it the place to examine the different approaches that narrative thinkers have taken to the philosophical question of whether stories approximate to something that really exists, or whether the only reality we can ever know consists of the stories that we tell ourselves and each other. What is important, however, is to notice the points of similarity and overlap with systemic thinking. These include a crucial emphasis on interaction (who is telling what to whom) and on context (how our story-telling is determined by our various identities and relationships in terms of family, culture, belief systems and so forth).

Narrative thinking has affected family therapists just as profoundly as systemic thinking. It is probably true to say that many or most family therapists working in the UK nowadays would probably describe themselves as working within a narrative framework as much as a systemic one. Narrative ideas have also affected other schools of psychology as well, including psychoanalysis. There is in fact an emerging consensus in many schools of psychological thought that people’s problems are changed not so much by helping them find the ‘real reason’ or the ‘best answer’ to their problems, but by helping them to find a coherent story that provides them with a satisfactory meaning for what they are going through.

In our work in supervision skills training, we particularly use the concept that clients usually bring a ‘stuck story’ to supervision. They may have told the story over and over again to themselves and to others, so that the story itself (often involving a sense of being helpless or overwhelmed) has become part of the problem. We promote the idea that thoughtful and sensitive questioning can invite people to retell their experiences to themselves in a different way. Quite often, for example, we notice that someone will start to present a problem in supervision with a phrase like ‘Well, it’s a very complicated story...’ Fifteen or twenty minutes later, they may actually say ‘I guess it's really fairly simple and I’ve known all along what I ought to do’. People also sometimes start by presenting something for supervision that they think is fairly simple but the process of supervision develops something more complex. They may be entirely unconscious of how they have been helped to reconstruct their narrative in this way unless they review the process on video.

Contexts and power

From a practical point of view, good supervision often involves attention to contexts rather than content. Attention to context provides richer meaning to what is going on. It moves the conversation away from a homeostatic tendency towards a dynamic one, and from a ‘vertical’ plane to a ‘horizontal’ one. Questions about content tend to encourage the solidification of the narrative. Questions about context lead to more flexibility and negotiability.  In this respect, questions about different contexts can be particularly powerful: different perspectives, different backgrounds, different beliefs, different values.

Family is not the only context that defines us but is nearly always the most important and the most powerful. Most of our conversations take place there, and most of our narratives about ourselves and our lives are forged there. Both in clinical work and in supervision, family therapists work from the premise that the family and the individual are in a constant process of mutual redefinition. Many therapists work on their own geneograms as part of their training in order to understand the perspectives from which they think and work. In supervision, it is unusual to come across a case where inquiry into the identified patient’s family network is not relevant in some way. Inviting clients to reflect on what they know - or do not know - about the patient’s family context will very often produce new understanding.

Working as professionals, in many ways our teams are our families. These teams take many forms: partnerships, medical teams, primary care teams, practices and so forth. We and they mutually define our realities in the same way that families do. When patients and their literal families come into contact with us and our teams, we can often only make sense of this by understanding how things are happening across the whole network: ours and theirs. Many problems brought to supervision are not the problems of one practitioner but of several. Often they relate to how different practitioners are operating differently, or how different family members are interacting with different team members. Drawing the lens back to see the wider dance of family and team will provide a wider and often more helpful context for understanding the difficulties of a single consultation or a single relationship.

Power is a feature of every encounter involving doctors. It is power due to medical knowledge, power due to social position, and power due to privileges or perceived privileges (prescribing, referring, certification, advocacy etc). Cases brought to supervision often involve contexts of power that have been ignored or denied. In particular, doctors may see themselves as neutral or benign agents when it is clear that they are being seen in a very different way by the patient or by other players in the drama. Supervision also sometimes needs to address the ways in which doctors try not to acknowledge or own their power. It may also need to look at how they might use power ethically and transparently. In remedial work, it is nearly always important to be transparent about the power issues involved.

Culture can be understood in a fairly thin way (‘He is a Catholic’ ‘They are a Somali family’) It can also be understood in a thicker way: not in terms of who this person is in the practitioner’s eyes, but who the person is in their own eyes. For some people, the cultural identity or identities will provide the overarching context for who they are, while for others it may seem irrelevant. In supervision, it can be important to establish what is known and what is not known about the way that patients define and understand themselves in cultural terms and what this means to them. The same is true of such definitions as ‘refugee’, ‘second generation’, ‘immigrant’ and so on. One very effective reflexive question can be to ask practitioners who come from majority cultures: what does it mean to you to be white, British, part of the dominant culture?

Gender, like culture, is not a fact. It is a lens. It is one way in which difference can be examined. What does it mean to a male doctor that the patient is of the opposite sex, or of the same one? What seems to be the patient’s understanding of  the part that gender is playing in their lives, their problems, or the consultation? How might things have been different if one or both parties had been of the opposite sex, or of a different sexuality? Almost any consultation, and almost any problem, can be profitably examined under the lens of gender.

From a theoretical point of view, contexts are what give meaning to any utterance we ever make. The words we used are embedded in sentences that are embedded in conversations within relationships that take place in human networks that form cultures that are part of historical systems. Communication theorists talk of how these different levels are recursive: in other words, culture and relationships determine speech acts, but speech acts also contribute to the construction of relationships and culture. It is often hard to understand any utterance without clarifying the ‘higher levels’ of meaning within which it is being uttered.

This can be particularly important when muddles occur in communication (something that you can often pick up intuitively or somatically). The muddles may be the result of two people competing at a higher level in terms of their assumptions. The only way out of this may be to look for an even higher level eg a description of the muddle and why it is happening.

A common example of this is when a kind, thoughtful supervisor has to talk to a junior about a lapse of judgement or a poor decision. Since all their previous conversations have been positive and friendly, the supervisor starts out by trying to elicit the junior’s account of events, in the hope that the junior will spontaneously come out with an admission that things went wrong, and with an apology. However it sometimes happens that the junior does not realise anything was amiss, and describes the case as if nothing went wrong. The supervisor then starts asking more and more persistent questions until the trainee starts to feel first puzzled and then harassed. If the process goes on for long, the supervisor the junior may redefine the supervisor as somebody inconsistent, untrustworthy and a bully. This might have been avoided if the supervisor had offered a simple context marker: ‘Look, I know you’re normally a great doctor and most of the time all I have to do is to praise you and help you develop even further, but on this occasion I need to talk to you about something you’ve got wrong’. This statement hopefully preserves the  context of being a caring supervisor while making it clear that one of the roles of such a supervisor is also to talk about mistakes.

Our own synthesis

Our use of systemic and narrative ideas changes all the time. The emphasis we put on different elements of systemic and narrative ideas inevitably alters, in response to each course we teach. The account we give of our thinking also changes. We make use of ideas from other fields as well. For example, some psychoanalytical ideas (like  the word ‘unconscious’ in the previous paragraph) still inform our hypotheses and our language at times - not least because they are so embedded in popular thinking and in medical culture. However we also try to remain sceptical about our hypotheses and the language we use, and open to challenge in all our teaching and our ideas.

We recognise that our own particular area of interest - supervision for practising doctors, dentists and other health professionals - requires a theoretical approach that draws on systemic and narrative thinking but is not entirely dominated by it. Broken bones, strokes and death are not just words: they are real. We realise the need to balance the scepticism and relativism of systems theory and narrative ideas on the one hand, with an ethical sense of what is solid and non-negotiable in medicine and health care on the other hand. Having said that, we find time and again that what supervisees (and patients) find most helpful in an interviewing stance is the one thing that Cecchin said most characterised the systemic approach to helping people: Curiosity.

References

Andersen T. The general practitioner and consulting psychiatrist as a team with ‘stuck’ families. Family Systems Medicine 1987; 4: 468-481

Bateson G. Steps to an Ecology of Mind. New York: Ballantine, 1972

Cecchin G . Hypothesising, circularity, and neutrality revisited: an invitation to curiosity. Family Process 1987; 26: 405-413. 

Launer J. Narrative-based Primary Care: A Practical Guide. Abingdon: Radcliffe, 2002.

Launer J. New Stories For Old: Narrative-based primary care in Great Britain. Families, Systems and Health 2006; 24: 336-344

Launer J and Halpern H. Reflective Practice and Clinical Supervision: an approach to promoting clinical supervision among general practitioners. Work Based Learning in Primary Care 2006; 4:69-72

Palazzolli Selvini M, Boscolo L, Cecchin G, Prata G. Hypothesising-circularity-neutrality: three guidelines for the conductor of the session. Family Process 1980; 19:3-12.

Tomm K (1988) Interventive interviewing: Part III. Intending to ask lineal, circular, strategic or reflexive questions? Family Process 27:1-15. 


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