Part I Listening and Creating a Flow of Heart-Felt Talk

• A. Providing a Cooperative Atmosphere
• B. Using Active Listening Techniques
• C. Identifying Strengths, Assets, Interests and Talents
• D. Inquiring About the Family’s Own Values and Beliefs
• E. Using Open Communication
• F. Cultural Competence
• G. Building Motivation
• Download Part I

Section I is dedicated to the proposition that purposeful, culturally sensitive conversation informs our process and can change clients’ and families’ health, developmental realities and quality of life. In the process, we health care providers are rewarded with new insights into effective communication and we change as well.

Building resiliency in a family begins by becoming attuned with the family’s own values, often different than our own. Sensitivity in listening to and speaking with people of other cultures with other values helps us understand their approach to the world. As a bonus, our understanding of other cultures may also point to better ways to communicate with those of our own culture who seem difficult to reach. For example, people of some cultures, such as traditional Navajo, believe we are deeply affected by what is said and that we are understood as human beings through the multiple meanings of the words that make up languages. Navajos believe words have the power to create and to change reality. Still other cultures have a present-time orientation, in which thinking about the future is dangerous. In some cultures, individuals do not see themselves as independent actors but more as a self embedded in a larger group. Sensitivity to other worldviews when interviewing helps us understand our clients’ problems and allows us to re-tell their narrative in ways that open possibilities for change.

Information gathering about the history of the problem is most helpful when it includes the child and family and takes into account their interests, values and preferences. The conversations should be respectful, reciprocal, straightforward and reflect a caring approach. Conversations will usually include the child, family (and possibly extended family) and caregivers and helpers. Many of the following ideas related to achieving alliance and non-verbal connection with one client will apply to each person at the meeting in order to solicit attuned, two-way connection. This way of meeting clients offers great diversity of viewpoint and cross-connection because multiple ideas are generated when each person is given a voice.

A. Provide a cooperative atmosphere where the family feels and exhibits increased mutual regard, empathy and warmth. Conversational ways to secure this ambience include making sure the family feels recognized, heard and understood. Experiences of all kinds can be acknowledged and validated. Although helpers have expertise and maintain their helpful position, collaborative work requires a democratic approach.

A curious, “not knowing” approach, creating a flattening of hierarchy, as well as a position of authenticity and transparency where clinical secrets or positioning are not held from the client, may be achieved by being straightforward, using the clients’ language, affect, and patterning, or by mirroring their gestures and movements. Always attempt to convey warmth and positive, unconditional regard along with trust. Trust is dependent on credibility and transparency in the eyes of those with whom we are talking. Many traditional ethnic minorities appreciate being the recipient of a gift from someone as evidence of his or her authenticity, so we have fruit or other small gifts on our table before sitting down to elicit stories from client and family.

Our naturalist process of discovery uses an inductive approach, initially taking information from our client as truthful, regardless of its veracity, and as if it represents reality. It is received first-hand without previous assumptions or hypotheses about pre-established inferences from the culture. Otherwise, our assumptions may foster stereotypes and generalization. Tacit knowledge of what is being revealed is taken for granted as part of a whole, including the complexity of intuition, feelings, contradictions and ambiguities.

B. Use active listening techniques, which means actively attending to what everyone has to say and then pausing for reflection on participants’ answers. Summarizing, paraphrasing and asking open-ended questions can lead to greater understanding and clarity. An awareness of the importance of, and responding to, non-verbal communication and noting people’s emotional tone in the discussion, is very helpful. A cultural competence to apply to everyone is to listen to the person’s narrative. The word “narrative,” from the Indo-European root “gna,” means to know and to tell. It is inherent in us to understand by listening, and to make sense by re-telling.

The rhythm, beat and melody of language may comfort participants and encourage discussion. Thoughtful rephrasing and using a person’s own phrases with attention to their posture and to their frame of reference is also clinically helpful in the conversational exchange. Our ethnocentric assumptions demands direct eye contact in speaking where many ethnic-cultures assume eye contact to be rude, and intruding. Signs of engagement and agreement may be determined by other means in such transactions by watching for a sense of quietness, respectful listening and waiting for acknowledgement through posture or auditory signals.

Case Study

“Promise to Families”

The following is a welcoming and open invitation to dialogue:

We are pleased you have come to be with us today. You will be considered a part of your child’s team as we meet with our members and later when we meet with other members of your family, community and your child’s schoolteachers. We will attempt to better understand your child’s condition and to be in partnership with you to make things better for him and for your family.

We fully respect your personal reasons in coming, as well as your individual and unique family experiences and family culture, which can be useful in meeting the challenges you face. We will strive with you to make sense of what’s occurred and, at the same time, we want to point out what we hear from you and talk about how that will make a difference for your family, especially those things which are likely to be representative of the strengths, values and character bearing on your family’s achievements and those accomplishments which have provided unique coping assets for you to this point.

We know what you will be sharing with us are very private and personal issues that may be full of hurt and despair in the retelling. We want you to know, however, that your being here is testimony to your excellent survival knowledge and may be evidence that you are actually thriving. We, too, have a level of expertise, although different from your own. We, too, are members of the human family and naturally share similar positive coping experiences with you, including needs and inspirational events, which helps our work together. Our conversations and your personal stories will remain confidential and protected, although with your permission, we will seek information from other helpers who are familiar with your family. We will work from an extended family perspective for your child in the school and in his or her doctor’s office.

We also encourage you to participate in helping us to craft and to write this report, because the report is yours. Many times we will offer you a draft report that you should feel free to edit and re-author in any way you prefer. Finally, we know that some questions and personal inquiries can be painful and threatening. If bad feelings come up over our inquiry, we apologize in advance and want you to tell us that you may not be ready to talk about that particular subject yet. Then, we will discuss something else you’re more comfortable with.

We will frequently request your opinions during our conversations, so do tell us how you feel we are doing together. We believe that, to the extent you feel more hopeful, have greater understanding and feel you are being listened to, you will have meaningful, positive outcomes from our meetings. Give us comments directly or by means of the Team Meeting Rating sheet or the Parent Outcome Scale. We also have a suggestion box. If you have a computer, you may e-mail us as well.

We will strive to help you with your purposes for coming to this meeting and we appreciate the confidence you have in us to work with you to discover solutions that make things a bit better.

“Letter to a Child”

Dear ________________ ,

The grown-ups of the team welcome you. We are happy you are going to come visit us.

We like to tell children what they will be doing and what it will be like here when they visit us. When you come here, you will see toys and a children’s computer in the waiting room.
Sometimes children get to go with an adult to use the computer in another room, to draw pictures, and to talk. At the end of doing these things, children get a treat of food or a sticker. Other times, children come with their family into a room where all the grown-ups talk about how to make things better. There are toys in this room too.

People on our team help children with learning and with their feelings at home and school. All the grown-ups are going to work together to help you. See if you can think of something you’d like to change, or something that might make you happier. If you can think of something, we’d like to know about it. Your family is a part of the team and we will all work together for you.

Most children have a pretty good time here. We want your time to be good here, too.

Your Team,

Download Letter to Child

C. By identifying strengths, assets, interests and talents of the child and the family, ways can be found to engage and form an alliance before the problem has been defined. It is helpful to begin interviews this cooperative way, especially for highly stressed or hard-to-reach families. Consider pathways to exceptions to the problem and other unique outcomes. (See Solution-Focused Practice, Part II, Appendix A). We believe this is what Carl Rogers, known for client centeredness, would say about unconditional regard, which is believing people bring many positive traits and prior accomplishments to these meetings along with their problems. In this sense, we embrace the positive first and tackle the problem second. This is especially important where two cultures meet. Values, differences, mind-sets and worldviews may clash. Opening conversations are friendly with small talk and chitchat, and do not get to the point too fast. Transitions are needed first to share each other’s sensitivities, realities, purposes and perspectives.

1. Building Competency. Although the traditional medical model tells us to look at the child and family’s deficits first, especially those with a remediable potential, our approach is to use a strength- and competency-based assessment that leads Adam and his family, our case study, to gain some control and to be empowered to correct what problems they encounter. We told Adam, “What is right with you is more powerful than anything that is wrong with you.” We believe our perspective on appraising strengths allows patients to find out for themselves what their protective factors and personal achievements are, so these strengths can be owned and can become a part of their identity and be used to counter the problem.

From Strength’s Checklist, [See Strength Checklist] Adam’s mother had reported Adam had a good sense of humor; was gentle with small animals; that he was friendly and wanted to reach out to others but didn’t always have the charm and skills to do so. Adam loved physical outlets, his mother reported, the more physical the better. He preferred building and taking things apart (reinterpreted to mean Adam is curious about how things go together, asks questions and is creative in discovery) and he liked working with tools. Adam’s mother said Adam loved music and song and had a natural sense of rhythm. Adam very much liked toy cars, his mother reported, and toy cars were sometimes used to reinforce Adam’s positive behavior.

In addition, Assessing Positive and Negative Reinforcers, [See Assessing Positive and Negative Reinforcers] Adam revealed he liked most foods, except pretzels, and that and he loved to copy, draw shapes and make and look at pictures. Social games, such as Follow-the-Leader, and playing at the park, were especially fun for him. A number of socially reinforceable ideas were identified: Adam said he would love to get money, hugs, praising letters and gold stars, especially if they lead to acquiring toy trucks or to participating in a favorite activity.

Finally, in the Daily Strength Scale [See Daily Strength Scale], which is sampled frequently, such as weekly, Adam revealed that he perceived many parts of his day to be quite positive. These times included enjoyable activities; getting along at school (after the intervention); sleeping (good prognosis), and feeling healthy. Adam also described his family not getting along and his not feeling safe or secure.

Briefly, we used the foregoing information directly for Adam’s behavior-management contingency program, which helped give him structure, boundaries, predictability and improved safety (after checking for possible environmental abuse). Our acknowledgements of Adam’s positive traits lead to building his self-esteem and positive identity and lead to Adam incorporating those positive traits into his daily life. Mentoring, building on continuous flows of interactive chains of affective signaling, which ultimately will lead to the solution-oriented, narrative story-telling included in Part ll, gave coherence to Adam’s positive experiences as described in these reports, and were ways to coordinate Adam’s interests, assets, and resources and to embody them within Adam’s personal world.

D. Inquire about the significance and origin of the family’s own values. Use family values as a resource by linking them to character traits and recognized personal achievements. What is important to the family? What preferences do they have, and what makes a difference to them? Incorporate self-described family values as resources by linking any achievements to recognized character traits. Although formally talked about in Part IV, we note here that planting the seeds of resiliency begins by becoming attuned with the family’s own values.

The following eight values form the basis for multiculturally congruent strategies for communicating with people of color and with many kinds of ethno-systems:

1. Various populations have differing and unique needs.
2. The culture is a predominant force in shaping behavior, values and political systems.
3. The family is the point of intervention for each culture.
4. Healthy cultures serve families well by enabling coping mechanisms and by understanding what to do.
5. Within-culture differences are as important as between-culture differences.
6. Culture differences have important impacts on what services are valued.
7. Process is as important as content.
8. Be aware of the potential conflict of values with dominant culture values. Seek goodness of fit.

Clinician: “All these dangers that you’ve worked so hard to keep Adam safe from, and now you feel the school is attacking him?”

Mother: “Yes, they are punishing Adam. It is not going to help.”

Team member: “I would like the school to know how much you care about Adam. Let’s think about how we can work with the school to help them understand.”

Mother: “I have tried. They don’t know nothing.”

Team member: “Other parents have experienced things improving when we all talk. I have been impressed by your willingness to fight for your son’s well being. I think we can help the school understand that about you and how you want to work for what is best for Adam.”

E. Use open communication throughout the discussions by using the following tools. Open-type questions usually begin with How …?, Describe …?, What …?, Why …?, When …?, and, Where …? Open questions keep the discussion going; closed questioning ends discussion.

1. “I” Messages – These are clear, concise and direct messages that state something about you, or how you feel. Example: “I feel that you don’t listen to me and I have something to say that I think would be helpful here.” This contrasts to, “You don’t listen to me,” which is an accusation and may provoke an argument or defensiveness. Such dialogue is usually helpful for a majority of American-European cultures.
   

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   Other people—including some ethnic-minorities and especially if enculturated into traditional ways—may have problems with “I” messages. Many of these cultures might highly value the collective or defer to decisions made by the family or a paternal or maternal grandparent. Some defer to uncles or aunts for discipline and even may be reluctant to engage in behavior management practices.

   Also ethnographic styles of interviewing suggest taking a global, community, family or friends’ perspective first before a personal style of questioning, e.g., “How would others treat this problem?” “How does your community think such problems occur?” This style affords opportunity to determine more about the context the person is living in and to link the situation relative to other norms and expectations in the cultural group.

2. Harmony and Attunement – Participants should strive for seeking resonance or attunement with each other. Thoughts, feelings and words can become important ways to connect with each other, though it is important to avoid mixed messages. Many times the personal connection is nonverbal, coming from the eyes, face, tone, posture and rhythm of being together.
3. Open Dialogues – Keep the dialogue open, even when a barrier to communication comes from an inappropriate confrontation or from blaming. For example, switch to another topic when things get a little uncomfortable, keep the conversation harmonious. Use questions that invite continuing the conversation rather than ending it. Keep it going with many two-way loops of communication. Working cross-culturally, it is likely that an adversarial style, or confrontation, or any negativity will close the relationship. This explains why solution-focused, narrative and motivation approaches work well.
4. Shared Decision-Making – Strive for win-win situations that enable participants to share decision-making. (Although goals, actions and meanings come later in our model, briefly we say something here because the shared spirit of communication quickly leads to defining needs or wants.) Our decision-balance model incorporates the pros and cons of both sides of the argument, or dilemma, and is brought forth by the client’s words in ways that don’t bring forth resistance or a power struggle.
5. Co-Construct Needs and, Eventually, Goals – What are the wishes and preferences of the person or the group? While keeping personal dreams alive, which are the do-able options given the practical situation? Can goals with concrete, measurable objectives be set and attained? Problems can immediately be turned into goals. Some lifeways value being in the moment with a present orientation where thinking about the future is dangerous. Their goals might be directed to the here-and-now. Some individuals, through reflection of memory and expectations of the future, will reconfigure the past and approach the future as part of an emergent present in the here-and-now.
6. Seek Meanings – Families should form their own interpretations. What stands out for them? How do they make sense of the child’s behavior, or of what happened? We seek meanings by attuning ourselves to each other’s needs, feelings and motivations in recursive ways. Again, when taking an ethnographic pathway, the interviewer should assume a learner’s stance and use the client as an expert guide and teacher in order to discover more about the client’s background and cultural circumstances. Determination of personal and attributed meanings may be delayed until later.
7. Ethnographic Construction – This style of interviewing is needed when families of other cultures and lifeways have worldview beyond the self as an individual and primarily see the self as embedded in a larger group. One should begin by talking about their relationship to the collective and include global questions. Further, there will be such words and phrases called “cover terms,” or use of terms specific to that culture or family’s experience, which will require a number of descriptive questions to be asked for clarification purposes. These are verbal markers of high symbolic importance.

Such words as “hard knocks”, “mentality”, or “gang member” can be asked about further. Descriptive questions about space, time and the characters involved should be formulated. Remember to leave out the word “you” and include “other.” For example, “Would you describe what your friends might say about local gangs?” “How would hard knocks be understood by the gang members?” Give me an example of what your community would say of the gang mentality?” What might be some of the words and sentences in which one might use these expressions? More understanding about this comes from "Communicating for Cultural Competence", by James Leigh.

Case Study

“Listening-and-Sharing Conversations”

The heart of generative conversations are attempts to create curiosity and interest about your topic, to begin to relate and engage sufficiently so that affect, the emotional reactions associated with experience, can be used to transform an idea into something more valuable. We see this skill as evidence of the caretaking glory of our species, inherent in our evolution and driving our intellect toward fulfilling our social, problem-solving humanity.

Adam’s mother, Ella, entered our room stiff, with a chip on her shoulder, angry because she was referred to us by the school. Adam was angry, too. Ella was on guard and defensive and scolded the school for their treatment of Adam (who had several suspensions).

We listened without interrupting. Ella related the story of her own school experience, which lead to failure. She told us about her first marriage, which erupted and ended with Adam’s natural father leaving. She told us about her high-risk pregnancy with Adam, resulting in his premature birth and small birth size. She told us about Adam’s hospital readmission for a near-lethal encounter with a toxic virus, resulting in his need for long-term medication. “He could have died,” sums up her sense of vulnerable-child syndrome and of her motherly experience of threats to, and near-loss of, his young life. Ella spoke more than once about Adam being a Mommy’s Boy.

We continued to listen in an open and active way, clarifying ambiguity, seeking Ella’s subjective opinion, including the meaning to her of related events, and we continued soliciting responses about her intentions and goals. This amplified our understanding of her decisions. Our goal in this first visit was to become attuned with her, redirecting her anger by holding her in our positive, unconditional regard, which allowed us to talk in genuine and transparent ways.

We felt Ella perceived our trust as she started to drop her defensiveness. We believe she understood that we felt her pain and sorrow over the fright of Adam’s near-death. Empathy helped lay the groundwork for the mutual perception that Ella is committed to Adam as a healthy, proud boy and Ella would like to be perceived by teachers and helpers as a competent and a nurturing parent. We understood that Ella felt she was taken for granted, considered uncooperative, irresponsible and complicit with her conduct-disordered, oppositional child. Now we understood Adam less as oppositional and more as acting-out, looking to fulfill secure attachment needs.

We can all discover new ideas from a heart-felt conversation. We can be more like teachers to other healthcare providers, faculty and parents who are building on these adaptive ideas. We must take time to listen to our patients broken stories, read between the lines, look for patterns, take less for granted, and then help them repair their own narratives.

F. Multicultural Competence – In working with families whose values are different from yours, it is helpful to try to gain an understanding of their worldviews, ethnicity and traditions, and to celebrate this heritage [Go to click on Multi-Culturalism-part II.] Race, national origin, socioeconomic, geographic, and physical circumstances, class, age, gender and education will need to be defined to determine how they play into cultural understanding. Appreciate that these likely apply to everyone. If we don’t tune into their cultural melodies first, we will be perceived as foreign and incongruent. Try to determine the family’s acculturation stresses and successes. Are they trying to maintain their own cultural identity? What is their cultural identity level? Ask yourself, “What is my knowledge and appreciation of ethnic lifestyles? Do I have biases and prejudices from my culture that may be racist and may incur resistance? How do I perform in the presence of foreign cultures?” Be mindful that having a conversation with a traditional Native American may not call for a Rogerian (client-centered) interview involving reflection of feelings and “I” messages. Acknowledge, validate, use solution-focused, narrative and ethnographic approaches.

Father: “My son got kicked out of school for standing up for himself. He finally stood up for himself, and now the school is blaming him. Well, no son of mine is going to get pushed around!”

Clinician: “So you are proud of your son for being brave.”

Father: “Yeah. Because he is such a wimp, a little pansy all the time. I finally felt like he was my son.”

Clinician: “Yes, I can see how both you and your son have courage. For one thing you have had the courage to come here and to work for things to be better for your son and you can see things that he has done that have taken courage and conviction. For example, like the time he went into the teacher and talked about the assignments he was missing. He was brave then. I saw that as a time he stood up to his fears and showed the family strength—his heritage. That strength you inherited from your grandparents who were living out on the land. I think you are taking that same strength into a different environment now.”

We can measure the client’s level of acculturation on a continuum from Level One, which exemplifies a level of assimilation in which the client overvalues, and idealizes the dominant ethnic group’s experience and is submissive to the dominant culture while being passive about one’s minority position; awareness may be restricted to the dominant ethnic group’s position. Level Three, in which the acculturating person recognizes the reality of oppressive power structures and racism while overvaluing and idealizing one’s own ethnicity, and so excludes others. Level Five is valuing both cultures for what they are and may be considered bicultural and even bilingual and is usually associated with the healthiest position. (Level Two and Four are intermediary positions.)

“Tell us about how this influence this has played out in your life.”

Is there a good reason to take the time to discover something about the heritage and cultural origins of this Caucasian family? Yes, it is just as important to inquire about E.K.’s unique Anglo background as it would be for people of color or of visible folk ethnicity. How else can we immerse ourselves in the family’s cultural reality to better understand their experience? The term “diversity” may refer to differences other than ethnicity by which people define themselves. For example, age, roles, gender, sexuality, spirituality and religion, social class, or residential or geographic location. So, we asked the family to “Tell us what in your background is important to you?”

It was difficult drawing out potential cultural differences from the E.K. family. Their assumed identity was affiliated with a fierce independence: “We pull ourselves up by our own bootstraps.” Our question: “What’s it been like growing up being your own person? Can you tell us what the challenges have been?” E.K.: “We’re Americans and proud of it.”

But responses disclosed two important premises. Generations ago, both parents (including stepparents) came from England and Nordic countries and lived on the land. Our question was: “Now that you think about this, can you draw any strengths from it?” In addition, Ella’s sweatshirt gave us a symbol of a mystical and spiritual niche, it was a stream cascading through mountains and seemed to connect metaphorically with Ella’s ancestry, the outdoors, personal autonomy and with taking care of one’s own. This fit with the fact that she preferred herbal preparations for Adam. Our question was: “What spiritual resources are close to you in nature?” Ella eventually acknowledged she would like her children to re-enter their church and she told us that they do volunteer work and that Adam had begun a martial arts program. Our questions were: “So how did all of this begin, and why? Might Adam benefit from the meditative and disciplinary features of martial arts? How might the martial arts program link to your family’s value system and help connect to others?”

We asked the family to interview a great-grandparent and ask about stories of pride, courage, bravery, endurance and then to reflect on how these stories may be sources of support in tough times. Through this process, photographs were uncovered of earlier generations camping out in the mountains and this helped connect values shared between generations. Our question was: “What meanings might be carried forth from this to a different future for Adam?” This is an ideal opportunity to use a family tree, or genogram, [See Genogram and Family Chart and Ecogram] to uncover other sparkling relatives and other social supports, which may include important friends and cousins.

In this way, more perspectives are gained. When they were leaving, we asked the family to take some photographs of events and items that are important to them, such as ritualized experiences, and to start a scrapbook of their past and present. Our question was: ”Knowing what you know now, what resources from your background are you most likely to call upon from these revived memories?” Hopefully they will continue to look for empowering narratives and have their multicultural influences become sources of strength and hope.

G. Build the motivation for ideas that support intention and personal agency as outcomes. Motivation may be a cooperative venture and the helper may contribute to encouraging resistance or to keeping things open. Motivational enhancement practices are those behavioral-cognitive and efficacy-based methods that elicit ways to strengthen ownership in exploring and resolving ambivalence around health-bound decisions and lifestyle choices in managing chronic health conditions.

We look for ways to elicit further self-motivational statements and language that reflect the clients’ intention and purposes. We attempt to assess readiness for change and stages of change. With solution-focused technologies, we look for progress toward goals and the accomplishment of needs. Inconsistencies, contradictions and discrepancies are highlighted as possibilities for behavioral change.

The concept of motivation has several elements of which can be exploited to create hope for a better solution. Motivational interviewing is a communication style useful for strengthening clients’ pathways in the direction they want to go by exploring and resolving uncertainty. Motivational interviewing uses empathy and reveals the discrepancy between a client’s current behavior and broader goals and values, and rolls with resistances rather than opposes them; it supports confidence in the possibility of change. We look for establishing an agenda for the client’s preferences by working on lifestyle goals and by determining their willingness, or sense of urgency, to make changes. Explore reasons for and against what they want to do through reflection and summarizing. Ask if the clients want information and their own interpretation of it. Use 1-10 scales to check where their importance, confidence and readiness is. Strategies are available for building each area. Check on "Health Behavior Change", by Stephen Rollnick, et al.

Adam: “I hate school. I’m not going.“

Mother: “His grades are getting worse and worse. He is not doing anything.”

Father: “Oh, he’s just lazy!”

Team member: “I have noticed that there are times when Adam has had good energy, like the clever way he thought of taking a photo of himself resting. When he took this picture, he showed his imagination.”

Dad: “Yeah, one picture. Big deal.”

Team member: “I think it is a big deal because of what he did do, and because it shows what he can do. I think our job is to figure out how to protect that wonderful ability in Adam so he can use it.”

“Motivation For Change Is In The Interaction”

Building motivation, hope and incentive for a more resilient child and family is the idealized goal from our efforts. In the short term, we may want to elicit further conversations-for-change in the form of talking about a more positive story than the problem-saturated story. Sometimes just being at the point of improved management of difficult behavior, or just arriving at a sense of greater cooperation and trust, or just by achieving a sounder alliance, or just by having more congruency in mutual statements and less resistance, are achievements themselves. Next, we may schedule a follow-up visit or refer the family to an outside agency.

Adam’s family wanted their son back in a regular school with fewer hassles for themselves. At the same time, they wanted a safer environment for Adam and more successes, so they could be proud of him. We focused on the discrepancy between Adam’s recent third suspension from school and the foregoing goal of his parents. That gap promoted many incentives to move in a positive direction. It was important for the parents to get there by their own efforts. We compromised on medication for Adam’s regulatory diagnosis, settling on the mother’s preference for herbal remedies for calming, which was a concession that allowed for a more acceptable type of medication later. The perceived stigma of the family’s referral to mental health professionals required alternative counseling and frequent notes home and telephone calls, and required making sure there was plenty of good news communicated. We quickly gained support from the school psychologist and the school district office and achieved the parent’s goal of getting Adam into another school. This satisfied the parents and promoted their self-confidence in negotiating solutions.

Subjective reporting by the parent showed improvement from 3- to 6-of-10, with 6 signifying the beginning of optimal change. Readiness for more work was at 7-of-10. We asked, “How did you make this happen? What would it take to get to a 7? What would look different at 7?” These solution-focused strategies consolidate small successes by speaking of them in a way that acknowledges direction, movement and implies momentum.

“Time for Feedback”

We now want to determine the parent’s feelings about how the conversation is going and whether any adjustments or changes are needed. This feedback is helpful at the end of each encounter, allowing for improvements next meeting. For example, if the idea of “hope” was underscored this time, we may want to sound it out next time, querying about their confidence. The Family-Team Rating Scale is a 1-10 satisfaction scale, combining many of the above features of a two-way conversation. Sometimes aspects of the scale may be asked as we talk. For example, “Are we on track and talking about what’s important to you now? Is this what you want to discuss or is there something else? And, how is it going for you?” [See Family-Team Management Scale]

Now, what about our own feelings about the conversation? This is also a time for the helper to check in on his or her state of mind. Sometimes when we hear stories of bad things happening to good people, we experience a range of intense emotions, including anger, wanting to rescue, wanting to overstep our bounds and take the agency away from the parent. Or, we may feel numb if there was trauma, or feel overwhelmed and helpless. It helps to consider our own vicarious traumatization. Bearing witness, as important as it is, may also evoke things in us that require awareness of what’s happening and then taking care of ourselves so we don’t take these feelings home. This counter-transference is important in understanding the family, however. When feelings in us come up about hesitation or gladness when so-and-so doesn’t show up for their appointment, we may see a connection between the family being stuck and our own defensiveness. Careful attention to our reflective supervision, using our team members for support, is therapeutic.