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Summarize the readings

Implicit Spiritual Assessment: An Alternative
Approach for Assessing Client Spirituality

David R. Hodge

To provide optimal services, a spiritual assessment is often administered to understand the
intersection between clients’ spirituality and service provision. Traditional assessment
approaches, however, may be ineffective with clients who are uncomfortable with spiritual
language or who are otherwise hesitant to discuss spirituality overtly. This article orients
readers to an implicit spiritual assessment, an alternative approach that may be more valid
with such clients. The process of administering an implicit assessment is discussed, sample
questions are provided to help operationalize this approach, and suggestions are offered to
integrate an implicit assessment with more traditional assessment approaches. By using ter-
minology that is implicitly spiritual in nature, an implicit assessment enables practitioners to
identify and operationalize dimensions of clients’ experience that may be critical to effective
service provision but would otherwise be overlooked.

KEY WORDS; assessment; cultural competency; religion; spirituality; therapy

I t is increasingly realized that spirituality plays
an important role in fostering health and well-
ness (Koenig, King, & Carson, 2012). To help

social work practitioners understand this relationship
in cHents’ lives, a spiritual assessment is commonly
recommended as a routine component of practice
(Canda & Furman, 2010; Fumess & Gilligan, 2010).
Administering a spiritual assessment—as part of
a larger bio-psycho-social-spiritual assessment—
provides a more holistic understanding of clients’
realities, which in turn provides the basis for subse-
quent practice decisions.

As a result of the time constraints that exist in ther-
apeutic settings, spiritual assessment is widely con-
ceptualized as a two-stage process: a brief preliminary
assessment followed—if clinically warranted—by
an extensive comprehensive assessment (Canda &
Furman, 2010; Pargament, 2007; Shafranske, 2005).
The brief assessment consists of a few questions that
are typically administered to all clients (for example,
“I was wondering if you are interested in spirituality
or religion?”). The purpose of the preliminary assess-
ment is to determine the clinical relevance of spiritu-
ality and to ascertain whether a comprehensive
assessment is needed. In situations where cHents’ spir-
itual beKefs and practices intei-sect service provision,
practitioners can select from an array of comprehen-
sive assessment tools to explore this intersection
(Hodge & Limb, 2010).

Although this explicit approach to spiritual assess-
ment represents an important contribution to the
literature, it may not be effective with all clients
(Nelson-Becker, 2005). Some clients may benefit
from what might be called an implicit spiritual
assessment. In this approach, the use of traditional
spiritual or religious language is avoided. Instead,
practirioners use terminology that is impHcidy spiri-
tual in nature to explore potentially relevant con-
tent. As such, an implicit assessment provides a
method to identify and operationalize dimensions of
clients’ experience that may be critical to effective
service provision but would otherwise be over-
looked in an explicit spiritual assessment.

Approximately two-thirds of direct practitioners
affiliated with NASW believe social workers need
to become more knowledgeable about spirituality
(Canda & Furman, 2010). Indeed, studies have
repeatedly found that most direct practitioners
report receiving minimal training in spirituality
during their graduate educations (Canda & Fur-
man, 2010; Sheridan, 2009). This article addresses
this knowledge gap by orienting readers to the pro-
cess of conducting an implicit spiritual assessment as
a supplement to existing assessment approaches.

The article begins by defining spirituality and
religion and noting contexts in which an implicit
spiritual assessment may be particularly gemiane.
The process of administering a spiritual assessment

doi: 10.1093/sw/swt019 ©2013 National Association of Social Workers 223

is discussed, and sample questions are provided to
help practitioners implement this approach in prac-
tice settings. The article concludes by offering
some suggestions for integrating an implicit assess-
ment with more traditional explicit approaches to
assessment.

CONCEPTUALIZING SPIRITUALITY

AND RELIGION

Spirituality is understood and expressed diversely
among social workers (Hodge & McGrew, 2006)
and the general public (Gallup & Jones, 2000).
One way to conceptualize spirituality is in terms of
connectedness with what is perceived to be sacred
or transcendent (Hodge, 2001; Koenig et al.,
2012; Pargament, 2007). As such, spirituality can
be seen as a fundamental human drive for transcen-
dent meaning and purpose that involves connect-
edness -with oneself, others, and ultimate reality
(Canda & Furman, 2010; Cnsp, 2010).

Religion can be conceptualized as a shared set of
beliefs and practices that have been developed over
time with people who have similar understandings
of the sacred or transcendent (Geppert, Bogen-
schutz, & Miller, 2007; Koenig et al, 2012). These
beliefs and practices, which are designed to medi-
ate an individual’s relationship with the sacred, are
transmitted through community-based structures
or organizations (Canda & Furman, 2010). These
organizations can be traditional, such as the Catho-
lic Church, or of more recent origin, such as the
New Age or Syncretistic movement. As such, reli-
gion is relatively objective, concrete, and commu-
nally oriented, whereas spirituality tends to be
more subjective, private, and personal.

Understood in this sense, spirituality and reli-
gion are overlapping but distinct constructs.

Spirituality is posited to be a universal human
impulse that may or may not be expressed in reli-
gious forums (Derezotes, 2006). Thus, whereas spi-
rituality is commonly manifested in an individual’s
relationship with God (Wuthnow, 2007), a per-
son’s connection with the transcendent may be
displayed in many forms, including those that
might be considered secular in nature (Crisp,
2010). In other words, the drive to construct a
sacred reality is expressed in a variety of relationally
oriented settings. This understanding of spirituality
suggests two contexts in which an implicit spiritual
assessment may be particularly germane.

CONTEXTS IN WHICH AN IMPLICIT

ASSESSMENT IS ESPECIALLY RELEVANT

Research with various samples suggests most clients
want to have their spiritual and religious beliefs
integrated into the therapeutic conversation
(Arnold, Avants, Margolin, & Marcotte, 2002;
Dermatis, Guschwan, Galanter, & Bunt, 2004;
Mathai & North, 2003; Rose, Westefeld, & Ans-
ley, 2001, 2008; Solhkhah, Galanter, Dermatis,
Daly, & Bunt, 2009). A brief preliminary assess-
ment helps to legitimize the topic and provides a
forum for clients to explore issues that might other-
wise have remained undiscussed (Nelson-Becker,
Nakashima, & Canda, 2007; Richards & Bergin,
2005). There are, however, at least two contexts in
which an implicit spiritual assessment is particularly
useful; (1) when spiritual language is perceived to
be irrelevant, and (2) when practitioners’ level of
spiritual competence is questioned.

Spiritual Language Is Irrelevant
For some clients, the spiritual or religious language
used in an explicit preliminary assessment does not
resonate with their personal worldviews. As
implied by the above conceptualization of spiritu-
ality, essentially anything can be imbued with tran-
scendent significance (Crisp, 2010). In many cases,
people construct a sense of meaning, purpose, and
identity outside the confines of traditional spiritual
and religious settings.

For example, the sacred can include art, collect-
ing, gardening, sports, nature, and a myriad of
other activities and entities (Griffith Sc Griffith,
2002; Pargament, 2007). These endeavors can pro-
vide a transcendent sense of meaning, purpose, and
connectivity for some individuals. Although the
beliefs and practices might be considered sectilar,
they are effectively accorded a sacred role in clients’
lives. In other words, the fundamental human
drive to construct a sacred reality is manifested in
secular activities that provide people with a tran-
scendent sense of meaning and purpose in their
lives (Crisp, 2010; Pargament, 2007).

For such individuals, typical spiritual terminol-
ogy can seem like a culturally foreign language
that is irrelevant to their lived experience. Indeed,
some secular individuals consider the use of spiri-
tual terminology to be offensive (Paley, 2008,
2010). Even though secular activities may serve
what is essentially a spiritual function, these clients

224 Social Work VOLUME 58, NUMBER 3 JULY 2013

may be uncomfortable or even unwuling to discuss
these functions in the context of an explicit spiri-
tual assessment. In such cases, an implicit spiritual
assessment provides a vehicle to identify the role of
the sacred in clients’ lives. Indeed, for such clients,
an imphcit assessment may be the only way their
understanding of the sacred can be explored.

Clients’ Perceptions of Practitioners’ Level
of Spiritual Competence
Alternatively, some clients may question practi-
tioners’ level of spiritual competence. Chents in
this category are comfortable with spiritual lan-
guage but are unsure about the degree to which
they can trust practitioners with a topic that is often
intensely personal and private (Lewis, 2001). In
short, they are hesitant to trust practitioners with
such a private dimension of their being untü practi-
tioners have demonstrated themselves to be com-
petent and trustworthy handling spiritual issues
(Richards & Bergin, 2005).

The helping professions have long struggled
with the issue of spiritual diversity. Committed
atheists from Freud (1927/1964) to Ellis (1980)
have attempted to pathologize devout spiritual
belief. Clients are often extremely sensitive to these
biases and may assume practitioners hold similar
views (Richards & Bergin, 2005). Indeed, concerns
about practitioners’ level of spiritual competence
are underscored by the fact that most social work-
ers report receiving Uttle, if any, training on spiritu-
ahty during their graduate educations (Sheridan,
2009). Practitioners may inadvertently communi-
cate disrespect for chents’ spiritual beliefs and prac-
tices because of a lack of training and awareness
regarding potentially sensitive issues.

Consequently, some chents may indicate that
they are uninterested in discussing spirituaHty dur-
ing the initial preliminary assessment (Richards &
Bergin, 2005). Trust may be developed over time,
however, as clients interact with practitioners. An
implicit assessment provides a way to gently ease
into the topic at a later point in therapy. An
implicit approach provides a forum in which prac-
titioners can communicate interest, openness,
receptivity, and respect for clients’ beliefs and
values (Canda & Furman, 2010). In other words,
when clients question practitioners’ level of spiri-
tual competence, an implicit assessment may offer
a way to buüd mutual trust and respect. The

process of operationalizing such an assessment is
discussed in the next section.

MOVING TOWARD AN IMPLICIT SPIRITUAL
ASSESSMENT
It is important to note that assessment is, in a cer-
tain sense, an ongoing process (Canda & Furman,
2010). Although a biopsychosocial assessment is
typically conducted at the beginning of therapy,
practitioners must remain open to revising their
initial suppositions as additional information is
obtained during subsequent sessions. Simüarly, one
should remain open to the possibüity that spiritual-
ity plays an important role in chents’ lives, even
though the initial preliminary assessment indicates
that spirituality is not a sahent ufe dimension.

Toward this end, practitioners’ “spiritual radar”
should be turned on throughout the counseling
process. The aim is to develop sensitivity to inter-
actions that suggest the possibüity that spirituality is
a relevant dimension in clients’ lives (Griffith 6f
Griffith, 2002). Particularly helpful in this regard is
listening for implied spiritual content in clients’
narratives and attending to emotional shifts in cli-
ents’ affect as they relate their stories.

Listening for Language that Connotes
the Spiritual
A key component in operationalizing an implicit
spiritual assessment is listening for language that
hints at the presence of the spiritual. As noted
above, explicit spiritual language may not resonate
with some clients. In the same way, practitioners
may not pick up on implicitly spiritual language
(Pargament & Krumrei, 2009). Accordingly, it is
important to listen for phrasing that suggests the
existence of spiritually relevant topics in the course
of the clinical dialogue (Griffith & Griffith, 2002).

For example, speaking in extremes or using
major polarities may offer insight into clients’ spiri-
tuality (Pargament, 2007). When clients refer to
something as faultless, perfect, or flawless, they
may be attributing aspects of divinity to the entity.
Alternatively, clients may fixate on the negative.
For example, when clients demonize someone, it
may be a sign that the individual has violated what
is perceived to be sacred.

Language that parallels spiritual thoughts and
behaviors can indicate the existence of spiritually
significant content. Clients may describe beliefs.

HODGE / Implicit Spiritual Assessment: An Alternative Approach for Assessing Client Spirituality 225

practices, and experiences that do not seem explic-
itly spiritual but reflect an underlying spiritual
dimension. For example, cHents may participate in
certain activities on a regular basis that are per-
ceived to be highly meaningful. Such activities
may represent rituals or ceremonies and may serve
a transcendent purpose in clients’ lives, engender-
ing a sense of profound meaning and purpose
(Crisp, 2010).

In short, practitioners should Hsten carefully for
terms and phrases that signal the presence of spiri-
tual issues below the surface. Clients often describe
thoughts, experiences, and feehngs that parallel the
spiritual. These descriptions can signify the exis-
tence of clinically relevant topics that require fur-
ther exploration.

Attending to Emotional Shifts
In addition to listening to clients’ language, practi-
tioners should also attend to clients’ emotions.
Many people experience spirituality primarily
through their feelings (Pargament & Krumrei,
2009). Indeed, spiritual experiences can produce
especially strong emotions.

Encounters wth the transcendent often engen-
der positive feelings (Exline, Park, Smyth, &
Carey, 2011). Interactions with the sacred fre-
quently result in feelings of awe, reverence, and
solemnity; pleasure, joy, and excitement; and
meaning, hope, and purpose. Although positive
emotions are perhaps more commonplace, interac-
tions with the sacred can also produce negative
emotions, such as anger, discouragement, and
regret. For example, upon moving to a new geo-
graphic location, a client might express deep regret
over having to give up a sacred activity that nour-
ished her soul.

Practitioners should be alert for changes in client
affect during the flow of conversation (Griffith &
Griffith, 2002). The presence of an emotion may
indicate that a spiritually relevant topic has been
touched on. For example, a hint of emotion in a
client who is otherwise depressed—such as a spar-
kle in the eye or a smile—may indicate that the
practitioner has broached a spiritually relevant
topic.

Understanding what elicits powerful emotions
can provide important insights into clients’ rela-
tionship with the transcendent. In addition to
watching for these types of emotional displays,
practitioners can also facilitate this process through

active exploration (Crisp, 2010). The next section
discusses how practitioners can facilitate such an
assessment.

CONDUCTING AN IMPLICIT SPIRITUAL

ASSESSMENT

When clients’ language or affect raises the possibil-
ity that spirituality may be related to service provi-
sion, it is usually appropriate to explore this
possibility in more depth. In such circumstances, it
is critical that client autonomy be respected
(Nelson-Becker, 2005). Effective therapy is predi-
cated upon the creation and maintenance of a non-
coercive atmosphere in which self-determination is
respected (Richards & Bergin, 2005). Practitioners
must carefully monitor clients’ reactions to ensure
they remain supportive of the process throughout
the exploration.

With this caveat in mind, the possible presence
of spirituality can be explored through the use of
various questions that imphcitly tap spirituality.
Sometimes called psychospiritual (Pargament,
2007) or existential (Griffith & Griffith, 2002) ques-
tions, these items are designed to elicit content
about clients’ relationship to the sacred or transcen-
dent dimensions in a context in which a more
direct exploration of spirituality is contraindicated.
Some sample questions for conducting an implicit
assessment are provided in Table 1. Adapted from a
variety of sources, these questions can be used to
indirectly explore the role of spirituality (Canda &
Furman, 2010; Griffith & Griffith, 2002; Hodge,
2001; Pargament, 2007; Pargament & Krumrei,
2009).

Toward this end, various questions from this
table can be integrated into the flow of conversa-
tion as needed. In a traditional comprehensive
assessment, it is common practice to flesh out cli-
ents’ spiritual stories across their life spans, typically
moving from childhood through to the present,
and even on into the future (Canda & Fumian,
2010; Hodge, 2001; Pargament & Krumrei, 2009).
Although the questions are presented in keeping
with this convention, it should be stressed that this
framework may not be applicable when conduct-
ing an implicit assessment. Practitioners should be
alert to the possibility that spirituality may be clini-
cally relevant at any time and ask questions that
invite a deeper exploration of spirituality when cli-
ents’ words or emotions allude to the presence of
the sacred.

226 Social Work VOLUME 58, NUMBER 3 JULY 2013

Table 1: Implicit Spiritual Assessment Questions
Past spirituality

What sort of experiences stood out for you when you were growing up?

When you think back, what gave you a sense of meaning (or purpose, or hope for the Eiture)?

When were you happiest (or most joyful)?

As you consider your life, what accomplishments are you particularly proud of?

How did you cope with chailenging situations in the past?

Present spirituality

Understanding how the transcendent or sacred is manifisted

When do you feel most fully alive?

Who/what gives you a sense of purpose and meaning in life?

What causes you the greatest despair/suffering?

Can you describe recent experiences (for example, “aha moments”) that sparked new insights?

What things are you most passionate about in life?

If you had a magic wand, what would you change to make your life more meaningful?

What helps you feel most aware (or centered) ?

Who/what do you rely on most in life?

Who/what do you put your hope in?

For what are you most deeply grateftd?

To whom/what are you most devoted?

To whom/what do you most freely express love?

What pulls you down and discourages you?

When in your life have you experienced forgiveness?

What are your deepest regrets?

Who best understands your situation?

Understanding how spirituality facilitates healthy Wellness, and coping

What rituals/practices are especially important (or significant) to you?

What kinds of experiences provide you with the deepest sense of meaning in life?

How do you commemorate special occasions/accomplishments?

At the deepest levels of your being, what strengthens (or nurtures) you?

Wliat sustains you through difficulties?

What sources of strength do you draw on to keep pressing forward?

What nourishes your soul?

Where do you find a sense of peace (or inspiration)?

When you are in pain (or afraid), where do you turn for comfort?

How have difFicult situations changed your life for the better?

What gives you the strength to carry on day after day?

What helps you get through times of difficulty (or crisis)?

Who supports you in hard times? How so?

Future spirituality

What are you striving for in life?

What are your goals for the future?

If you had just a year to live, what are the most important things you would like to accomplish?

Why is it important that you are here in this world?

After you are gone, what legacy would you like to leave behind?

How would you like people to remember you after you are gone?

The first set of questions—past spirituality—is
designed to explore the intersection between spi-
rituality and clients’ past, and perhaps particu-
larly, their family of origin. Understanding how
transcendent dimensions of existence functioned
in the past provides the context for under-
standing how these dimensions function in the

present (Hodge, 2001). Similarly, understanding
how clients coped with previous challenges
suggests possible coping strategies that iTiight be
leveraged to ameliorate current problems (Canda
& Furman, 2010).

The second set of questions—present spirituality—
addresses client’s contemporary experience of the

HODGE / Implicit Spirittial Assessment: An Alternative Approach fir Assessing Client Spirituality 227

transcendent. This set is broken into two related
groups. As implied by the heading, the first group
examines how perceptions of the transcendent are
manifested. These questions may be parricularly
helpful in fleshing out clients’ understanding of the
sacred. The second group examines how spirituality
may facilitate health, Wellness, and coping. Ques-
tions from this group can be used to explore strate-
gies that might be used to address problems. For
example, in the face of present difficulties, rituals or
practices that foster Wellness may have been ignored.
Identifying and reinsdtuting such salutary pracrices
may assist cHents on their joumey toward Wellness
(Saleebey, 2009).

The final question set—future spirituality—
explores the role of the transcendent in future
plans. Future aspirations are also a part of clients’
sacred narratives. In the same way that past and pre-
sent beliefs can shape current beliefs and practices,
clients’ views regarding their future can also shape
present functioning. Accordingly, the exploration
of future plans, goals, dreams, and expectations can
provide important therapeutic insights (Hodge,
2005).

It is important to note that there is no single
method for asking these questions in therapeutic
settings. Assessment is a complex, mulrilevel pro-
cess in which every client affirms a unique under-
standing of reahty (Fumess & Gilligan, 2010).
Accordingly, the questions should be adapted and
integrated into the therapeutic conversation in a
•way that makes sense in the context of clients’ indi-
vidual value systems (Hodge, 2001). Asking
implicit spiritual questions, listening for language
that connotes the sacred, and attending to emo-
tional shifts is a complex process that varies from
setdng to setting. Yet, as the following example
illustrates, this process can lead to significant thera-
peutic breakthroughs.

Ken, a 50-year-old Latino male, sought therapy
for persistent feeHngs of fatigue and depression. A
preliminary assessment revealed no religious affilia-
tion or interest in spirituality. Counseling pro-
duced little improvement. That changed,
however, when the practitioner asked about prac-
tices that had formerly nourished his soul. A spark
appeared in Ken’s eyes, and the tone of his voice
became slightly more animated as he spoke about
the place that music once occupied in his life. In
college. Ken had an extensive album collection,
played in a band, and was iiTmiersed in the local

music scene. As the demands of his accounting
career steadily increased over the years, his passion
for music was slowly pushed to the margins of his
Hfe. Sensitivity to the spiritual dimension aHowed
the practitioner to engage Ken in a discussion
about how his drive for professional success had
resulted in Ken’s neglect of a sacred activity that
helped animate his life. Facilitating Ken’s transition
toward a more personally authentic path that nur-
tured his soul became a central focus of subsequent
sessions.

Assessment focuses on understanding the inter-
section between the sacred and Wellness. The goal
is to understand the relationship between clients’
understanding of the transcendent and service pro-
vision. In some cases, this may entail moving from
an implicit assessment to a comprehensive assess-
ment, a topic discussed in the following section.

MOVING FROM AN IMPLICIT ASSESSMENT TO
A COMPREHENSIVE ASSESSMENT
The administration of an implicit assessment may
reveal the presence of spirituality as a clinically rele-
vant factor. As the above example illustrates, some
clients report secular activities that funcrion as
sources of spiritual meaning in their lives (Crisp,
2010). Alternatively, in situations where clients are
initially hesitant to trust practitioners, an implicit
assessment may reveal more traditional understand-
ings of spirituality. In either case, it may be helpful
to use a comprehensive assessment to provide bet-
ter understanding of the role of spirituality in cli-
ents’ lived experience.

A conceptual model for integraring an impHcit
assessment with an explicit spiritual assessment is
depicted in Figure 1. As can be seen, the process
begins with a brief preliminary assessment. If the
brief assessment reveals that spirituaHty is potentiaHy
related to service provision, then the practitioner
generally moves directly to a comprehensive assess-
ment. If the brief assessment indicates spirituaHty
is unrelated to service provision, the practitioner
adopts an impHcit approach exploring potential
expressions of spirituaHty if cHents’ language or affect
suggest such an exploration is warranted.

If an implicit assessment indicates that the tran-
scendent plays a salient role in clients’ lives, then
one of the many comprehensive tools that have
been developed can be used to flesh out clients’
spiritual reality. A comprehensive tool can often be
used regardless of whether or not cHents view

228 Social Work VOLUME S8. NUMBER 3 JULY 2013

Figure 1 : Conceptual Model for Integrating
an Implicit Assessment with an Explicit

Spiritual Assessment

Caring, respeclfiil, spiritually empathetic environment

themselves as spiritual or secular. For example, in
the latter case, a spiritual life map might be used to
diagram clients’ primary sources of meaning and
hope over the course of their lives (Hodge, 2005).
The life map can be assigned as homework, saving
valuable therapeutic time, and discussed in the
next session. The physical depiction of clients’
sources of strength can elicit fresh therapeutic
insights, uncover unoperadonalized assets, and sug-
gest new strategies to ameliorate problems.

Central to the assessment process, however, is the
creation of a caring, respectful, spiritually empathetic
environment (see Figure 1). Indeed, the success of
the therapeutic enterprise itself rests upon the crea-
tion of such an atmosphere. Toward this end, it is
critical to obtain clients’ consent before moving to a
comprehensive assessment. Because of the pro-
foundly personal nature of spirituality, practitioners
should carefully monitor clients’ verbal and non-
verbal responses to ensure they consent to the assess-
ment process from start to finish.

In light of the sensitive nature of spirituality and
the attendant potential for hann, the choice to
address spirituality in a more in-depth manner calls
for careful consideration. For example, practition-
ers might assess their level of competence regarding
clients’ spiritual beliefs and values (NASW, 2001).
Similarly, practitioners should possess sufficient
training to ensure any spiritual strategies used in
therapeutic settings can be implemented in a pro-
fessional manner (Hodge, 2011). In certain situa-
tions, the results of the initial assessment may
suggest that referral to other practitioners with
more expertise with a given population (or inter-
vention) is in clients’ best interests.

The discussion of cultural competency high-
lights the issue of practitioners’ level of personal

comfort with spirituality. For a variety of reasons,
some social workers believe that spirituality should
not be addressed in clinical settings (Canda &
Furman, 2010). An implicit assessment offers
such individuals a vehicle for discussing spirituahty
in a more oblique manner. While practitioners
must ensure they possess sufficient levels of
cultural competency to provide effective services,
an implicit assessment provides therapists who are
uncomfortable with traditional spiritual language a
way to discuss clinically salient transcendent
dimensions.

Another option that covers terrain similar to that
of an implicit spiritual assessment is an explicit exis-
tential assessment. Readers interested in this
approach might consult the work of Yalom (1980).
Although all therapists can likely benefit from
Yalom’s work, practitioners who are uncomfort-
able with traditional spiritual language might find
it especially helpful.

CONCLUSION

Traditional spiritual assessment approaches repre-
sent a good fit for many clients (Canda & Furman,
2010; Hodge & Limb, 2010). For some, however,
these methods may not represent valid approaches.
Such clients may be better served by an implicit
spiritual assessment.

For example, when working w t h clients who
believe spiritual language is irrelevant to their lived
experience, an implicit spiritual assessment pro-
vides a means to explore the transcendent dimen-
sion. Similarly, an implicit assessment offers
practitioners a way to build trust and rapport when
clients are hesitant to trust practitioners with a
highly sensitive subject. In short, an implicit assess-
ment helps practitioners identify and operationalize
dimensions of clients’ experience that might other-
wise be overlooked in a traditional assessment.
Consequently, it is an approach that essentially all
practitioners can benefit fiom incorporating into
their “assessment toolbox.”

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Arizona State University, and senior nonresident fellow. Program

for Research on Religion and Urhan Civil Society, University of

Pennsylvania. Address correspondence to the author at Mail Code

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Original manuscript received February 4, 2012
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Accepted July 31, 2012
Advance Access Publication June 13, 2013

230 Social Work VOLUME 58, NUMBER 3 JULY 2013

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C H A P T E R 5

Collaborative Inquiry
An Anthropological Approach

to “Intervening” with Families

The first four chapters examined conceptual models or ways of thinking
about families that position helpers as appreciative allies in the process
of engagement, assessment, and contracting. These next five chapters
examine clinical practices or ways of interacting with families that invite
respect, connection, curiosity, and hope. This chapter begins with a brief
reconsideration of the process of “intervening” and then offers an orga-
nizational framework for collaborative inquiry that positions therapists
as co-researchers who are working with families rather than acting on
them. An extended clinical consultation illustrates this framework. Sub-
sequent chapters take up different elements of this framework in more
detail.

WHAT DOES IT MEAN TO “INTERVENE”?

Family therapy has historically had a strong emphasis on intervention.
Within the mental health field, family therapy represented not only a dif-
ferent way of thinking about clients and problems but also a significant
shift in ways of interacting with clients. It began as a radical move away
from the orthodoxy of psychoanalysis and contained a shift from under-
standing problems as the goal of treatment to doing something about
problems in a short time (Ravella, 1994). In this way, family therapy

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became quite interventionist. Cecchin, Lane, and Ray (1994) have
described an interventionist model as one in which a “therapist orga-
nizes an action, suggestion or prescription for the purpose of having a
predictable result” (p. 13). Many techniques in the mental health field
are grounded in an assumption that we can have predictable results and
get clients to see or do things in particular ways at particular times. For
example, we offer an insight that we hope will have particular effects,
we teach skills that we hope clients will use in particular ways, we set up
enactments to achieve a particular outcome, we reframe behavior to pro-
mote a particular perspective. In each of these situations, we enter with
a predictable result in mind. Often, that hoped for result is informed
by an implicit model of how families should function (e.g., what consti-
tutes “appropriate” generational boundaries, or “differentiated” func-
tioning, or “healthy” negotiation of life cycle transitions), and our
efforts attempt to bring family functioning in line with normative
standards.

Unfortunately, our focus on rectifying family dysfunction can pull
us into an instrumental orientation in which we engage with certainty
and a sense of mission. When we begin specifying how things should be
in clients’ lives, we risk losing sight of client preferences. We can get out
ahead of clients and end up blocking their view of desired futures. When
clients lose sight of their preferred directions in life, they may submit to
professional preferences and end up following someone else’s agenda,
which doesn’t support long-lasting change. Alternatively, they may
actively resist our efforts or become pseudo-compliant, pretending to
comply and hoping we’ll go away. Hence, our attempts to achieve a pre-
dictable result without explicitly negotiating it with a family may end up
making our work harder.

The belief that we can get a family to see something in a particular
way or bring about a particular outcome has been referred to as a belief
in “instructive interaction.” A number of writers have suggested that
instructive interaction is impossible and that we cannot get a family to
respond to interventions in a predetermined fashion. Although we enter
interactions with particular hopes and intentions, we cannot determine
the specific effects of our actions on others. Our interventions may trig-
ger responses, but they do not determine them. We cannot get clients to
do or see things that we want when we want. The idea that instructive
interaction is impossible may or may not be “true.” However, it can be a
very useful idea in helping us step back from nonproductive struggles
with clients and opening possibilities for alternative interactions. At the
same time, it is impossible to avoid influencing others. As Cecchin et al.
(1994) state:

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When people interact, they inevitably influence each other, but not always
with predictable results. Intervention, when thought about in this way, is
unavoidable, because to interact means to intervene in the private space of
the other. No matter how much we try, influence is unavoidable. . . .
Although it seems true that we do, in fact, influence one another, we cannot
predict the outcomes of our efforts. (p. 15)

If we acknowledge that interventions do not have predictable results,
then every interaction with clients is an intervention. Everything we say
and do has an effect on clients. It is impossible to be noninterventionist.
The issue is not whether we are interventionist or noninterventionist, but
what stance we hold as we intervene.

Harlene Anderson and Harry Goolishian (1988, 1992) have coined
the phrase “not-knowing” to suggest a particular stance in collaborative
conversations. A not-knowing stance refers to an attitude and belief that
a “therapist does not have access to privileged information, can never
fully understand another person, always needs to be in a state of being
informed by the other, and always needs to learn more about what has
been said or may not have been said” (Anderson, 1997, p. 134). As
Anderson (1995, pp. 34–36) emphasizes:

A not-knowing position does not mean the therapist does not know any-
thing or that the therapist throws away or does not use what she or he
already knows. It does not mean the therapist just sits back and does noth-
ing or cannot offer an opinion. It does mean, however, that the therapist’s
contributions, whether they are questions, opinions, speculations, or sug-
gestions, are presented in a manner that conveys a tentative posture and
portrays respect for and openness to the other and to newness.

Despite Anderson’s (1995, 1997, 2005) repeated attempts to clarify a
not-knowing stance, it has often been misinterpreted as dismissing
professional knowledge (perhaps an ironic example of the myth of
instructive interaction). Another framing of this juxtaposition of know-
ing and not-knowing that may trigger fewer misperceptions would be a
juxtaposition of certainty and curiosity (Amundson, Stewart, & Valen-
tine, 1993). For this discussion, I draw on the phrase “cultural curios-
ity,” as introduced in Chapter 1, to refer to a continuing attempt to
actively elicit a client’s particular meaning rather than assume we
already know it or that it is the same as ours.

A striving for cultural curiosity begins with a conviction that clients
are the experts on their experience and an attempt to fully enter into and
honor that experience. It includes a willingness to question what we
think we know and a commitment to continually learn more about what

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clients have to say about their experience. This attitude is reflected in a
Robert Louis Stevenson quote, “To travel hopefully is a better thing than
to arrive.” Although we cannot arrive at a complete grasp of another
culture, we can always travel hopefully toward a better understanding.
Kaethe Weingarten (1995, 1997, 1998) has discussed a similar process
that she refers to as “radical listening.” She characterizes radical listen-
ing as the “shifting of my attention from what I think about what my cli-
ents are telling me to trying to understand what my clients think about
what they are telling me” (Weingarten, 1998, p. 5). This shift could also
be summarized as a movement from assigning our meaning to clients’
actions to eliciting their meaning. In this regard, I have often referred to
it as listening on client turf rather than on professional turf. Each of
these phrases (“not-knowing,” “cultural curiosity,” “radical listening,”
“listening on client turf”) captures a shared position from which to
engage clients. This position does not disavow therapist knowledge or
influence, but draws on it in a different way. In this position, there is an
acknowledgement that it is impossible to impose meaning or get people
to do or see particular things at particular times, along with a commit-
ment to engaging clients in ways that enable them to generate alternative
meanings through invitational interaction.

MOVING TOWARD INVITATIONAL INTERACTION

The following story sets a context for discussing the power of invita-
tional interaction. A number of years ago I conducted a study on the
interaction of beliefs held by patients, spouses, and physicians in situa-
tions of chronic medical noncompliance (Madsen, 1992). One of the
couples I interviewed consisted of Pat, a 40-year-old white woman
whose hypertension escalated out of control when she drank, and Jack,
her 35-year-old white boyfriend with a long history of alcohol misuse. I
met with them in their home. About 5 minutes into the interview, Jack
excused himself and went into the kitchen. He returned with two cans of
beer, offered one to me, and when I declined, shrugged, drained the first,
and started on the second. I had a number of reactions. I was shocked
and angry that he was drinking. I worried that it would “bias” the
results of the interview and wondered whether I would be able to use
this interview in my study. At the same time, I didn’t feel comfortable
asking Jack not to drink during the interview. This was the couple’s
home, and they had graciously let me into it. They were not being paid
for the study, and I did not have a relationship with them in which I had
an authorization to instruct them on what I might consider “proper eti-
quette.” I sat there in my discomfort, unsure of what to say. I decided to

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say nothing and continued the interview. Jack drank throughout the
interview, polishing off a six-pack by the time we finished. In the inter-
view, we focused on (among other things) the potential consequences of
various decisions they might make about alcohol use (e.g., If Pat kept
drinking and Jack stopped what would happen to her health and their
relationship? If Jack kept drinking and Pat stopped, what would happen
to her health and their relationship? What would happen if they both
kept drinking? What would happen if they both stopped drinking?).

In the course of the interview, the following story emerged. Pat’s
original husband had abandoned the family (for which she blamed her-
self), and she was committed to establishing a two-parent family for her
daughter. She believed that if she kept drinking, hypertension would end
her life and her daughter would lose a mother. She also believed that if
she quit drinking, it would end her relationship with Jack (whose previ-
ous marriage had ended when his wife quit drinking) and her daughter
would lose a father. Pat felt caught between two pulls. If she didn’t stop
drinking, her daughter would lose a mother, and if she did stop drinking,
her daughter would lose a father. As I asked about the effects of this
dilemma on Pat, she disclosed that it made her feel like a bad mother
and left her terribly depressed. She felt that she was caught in a bind that
she couldn’t escape and would subsequently become hopeless and end
up drinking to numb the pain. As we talked about the effects of this
dilemma on their relationship and their future together, the couple
became reflective and slightly sad. I left the interview feeling appreciative
of the power of this dilemma and its effects on Pat and Jack.

Interestingly, in a 6-month follow-up with their physician, I found
out that the couple had quit drinking the day after the interview and had
maintained sobriety since. In fact, seven of the nine patients interviewed
in the study were now managing their chronic medical conditions for the
first time in 2 years. A number of patients and physicians attributed that
change to the development of different perspectives that came out of the
interview process. One informant from the study put it this way:

“I’m thinking about the difficulty I’ve had managing my medical con-
dition in a whole different way. It makes sense to me now that I’ve
had difficulty managing it and I’m not blaming myself for it. This
shift has given me some room to go about dealing with my medical
condition in a completely different way.”

Although the changes in Pat’s and Jack’s lives were dramatic, I had
not been attempting to disrupt their drinking or to get Pat to better man-
age her hypertension. The interview with Pat and Jack occurred in the
context of a research study rather than a clinical intervention, and yet it

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had had a profound impact on the couple. Although my intention had
been to gather information for a research study, I had assumed that the
process of gathering that information might open new possibilities for
Pat and Jack. My experience in this study was very much in line with the
efforts of Lorraine Wright (1990), who developed a research interven-
tion for families in which traditional family therapy had proved unsuc-
cessful. In this approach, the therapist would explain that she had no
further ideas for how to be helpful to the family and then offer the fam-
ily an opportunity to participate in a research project that focused on
helping professionals learn how families coped with chronic illnesses.
Wright found that this shift was not simply an attempt to redefine family
therapy, but rather one that changed the context of her clinical work
from therapy to research. She explained that this shift in context had a
profound effect on therapists. It reduced their usual therapeutic impulse
to inform, instruct, direct, or advise family members and contributed to
the development of an investment in learning from the family rather
than changing the family. Families responded positively, and Wright
(1990) concluded, “We facilitate the greatest change in our clinical work
when we focus on learning from our clients rather than believing that
they are learning from us” (p. 484).

THERAPY AS CULTURAL ANTHROPOLOGY

The shift in emphasis described by Wright (1990) fits with an anthropo-
logical metaphor for the process of interacting with clients and families.
In this metaphor, we can think of clients and their families as foreign cul-
tures. We can think of ourselves as cultural anthropologists or ethno-
graphic researchers who have been given the opportunity to enter into
the life space of clients and learn all that we can about the particularities
of their culture. An example of this metaphor in action comes from the
work of Marilyn O’Neill and Gaye Stockell (1991). They worked in an
Australian day treatment center in which eight male consumers were dis-
satisfied with the system and expressed that dissatisfaction through a
variety of destructive behaviors that included abusive language, property
destruction, ongoing substance abuse, and a disregard for others at the
center. These behaviors had managed to alienate many of the staff, who
saw excluding the men from the center as the only viable course of
action. O’Neill and Stockell proposed instead to run a group for the
men. They decided to view the men as experts in dealing with chronic
mental illness and invited them to a group that explored the men’s
expertise in managing mental illness. Drawing on an anthropological
stance, they elicited the men’s experience of mental illness, the effects it
had on their lives, and the ways in which they coped with it. As they

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listened to the men’s experiences of the disempowering effects of mental
illness, they resisted the temptation to give advice, offer ideas, or make
judgments about their situations. The aim of the group consisted of elic-
iting and documenting the expertise the men had in managing chronic
mental illness. The therapists’ roles consisted of asking questions to
guide the process. When asked to provide a name for the group, the
men initially decided to call it “The Losers’ Group.” However, halfway
through the group, as the participants’ expertise in managing mental
illness became more solidified, the men petitioned to change the group’s
name to “The Worthy of Discussion Group.” By the end of the
group, the men viewed themselves differently and had made significant
improvements in their lives (including improvements in daily living skills
that were never directly addressed in the group). O’Neill and Stockell
(1991) summarized their learning:

We observed that changes were occurring for the men. We were also aware
that these changes were not due to any teachings about problems and solu-
tions but from the discovery that their special knowledge, skills, and quali-
ties had enabled them to choose a preferred outcome for themselves. The
men became responsible for choosing the directions that their lives should
take. Our role in these groups was described succinctly by one of the partic-
ipants: “You [therapists] have been asking us instead of telling us.” (p. 205)

This example characterizes a directional shift in information flow. Infor-
mation is not coming from the therapist to the client. Instead, it is being
jointly developed in the space between client and therapist though a
questioning process. This shift could be described as a collaborative co-
research project.

David Epston (1999) is perhaps the person most widely associated
with the term “co-research.” He initially developed co-research as an
approach to situations in which children and adolescents with life-
threatening chronic illnesses were not responding to more conventional
treatments. Epston became convinced that clients held alternative bodies
of knowledge (consisting of abilities, skills, and wisdom) that could be
profoundly useful if tapped. These varieties of knowledge were often
obscured, and David engaged families in a co-research project to resur-
rect them and make them more available for client use. This was not a
process of going out and discovering preexisting knowledge, but rather a
process of eliciting, elaborating, and bearing witness to abilities, skills,
and types of knowledge that are jointly developed in the context
of the interview. For example, in the Worthy of Discussion groups run
by O’Neill and Stockell (1991), the wisdom offered by the men in
the group was wisdom that was developed in the context of the group
interviews. This idea of jointly developing shared knowledge rather

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than discovering preexisting knowledge is at the heart of collaborative
inquiry. Epston began eliciting and elaborating client knowledge in inter-
views and subsequently developed written collections or archives of that
knowledge that could be made available to other clients. One example of
this is his efforts to develop anti-anorexia archives that contain client
wisdom about the ways in which anorexia as a problem has affected cli-
ents and their families along with accounts of how clients and families
have coped with and resisted the effects of anorexia (Maisel, Epston, &
Borden, 2004). The process of making this knowledge available to oth-
ers is both a gift to others and a profoundly empowering repositioning
of clients from being objects on the receiving end of services to consul-
tants who have something to offer others. The purpose of generating
knowledge in co-research is different from the usual purpose of generat-
ing research-based knowledge. Co-research makes no claim to be an
objective or neutral process. It has the explicit purpose of supporting cli-
ents in reflecting on their current relationship with a problem and, if that
relationship does not fit with client preferences, inciting and sustaining
resistance to the problem. This is activist knowledge with the explicit
purpose of helping people change their lives. The different stories high-
lighted here illustrate the power and possibilities of invitational interac-
tion and co-research. The next section examines in more detail the pro-
cess of what I’ve come to call “collaborative inquiry.”

ENGAGING IN COLLABORATIVE INQUIRY

Collaborative inquiry can be a co-research project in which therapists
engage clients in a joint exploration of preferred directions in life, with
an attempt to identify elements that constrain and/or sustain their pur-
suit of desired lives and an examination of ways in which clients address
constraining elements and draw on sustaining ones. In this process, we
can view professional expertise as the ability to ask questions that elicit,
elaborate, and acknowledge family abilities, skills, and know-how that
have been previously obscured. I refer to this as collaborative inquiry to
suggest a partnership in which we tap the resourcefulness of both clients
and clinicians. The process is not a simple conveyance of professional
expertise to clients, nor a simple eliciting of client ideas. Rather, it
acknowledges the shared knowledge that can be developed in the con-
text of therapeutic relationships.

The purpose of collaborative inquiry is to make space for the emer-
gence of alternative stories that will support people in moving forward
in their lives and facilitate their accessing important abilities, skills,
and knowledge. Clients are offered an opportunity to reflect on the

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dominant stories that have organized their lives, the degree to which
those stories fit or do not fit for them. If the stories do not fit, collabora-
tive inquiry provides opportunities for people to develop and enact
richer stories that open possibilities and have the potential to carry them
forward in their lives. This is not a process of substituting “old, bad”
stories for “new, improved” ones, but rather expanding from sparse sto-
ries that are often constraining and pathologizing to broader, richer sto-
ries that acknowledge difficulties and also open new possibilities.

In the process of collaborative inquiry, our questions become vitally
important. Although questions are often used to gather information for
our benefit as clinicians, they can also be designed for the benefit of cli-
ents. As clients contemplate the questions we ask and undertake a men-
tal search in responding to them, they have particular experiences of self.
When such experience is different and powerful, this process can have
transformative effects. Although I view this as a collaborative process, I
am not suggesting that it is an egalitarian partnership. Clients are in a
much more vulnerable position in this relationship, and it is important
to acknowledge and be mindful of the power differential that exists. In
this process, clinicians have a particular expertise in inquiry and take on
a leadership role in the organization of questions, but remain account-
able to clients for both the direction of the inquiry and the effects of the
questioning process on clients.

There are a number of benefits to framing our work as a collabora-
tive co-research project. The process holds the potential to engage clients
as active agents in their lives rather than as passive objects of our efforts.
This engagement has empowering effects on clients by amplifying their
influence and participation in the process. And collaborative inquiry
enhances therapeutic relationships. Ryan and Carr (2001) summarize a
variety of family therapy process research studies suggesting that when
clients perceive therapists to be collaborating and empathizing with
them in addressing the difficulties in their lives, they feel a stronger ther-
apeutic alliance, cooperate more, and engage in less “resistance.”

THE PLACE OF PROFESSIONAL VALUES AND KNOWLEDGE
IN COLLABORATIVE INQUIRY

Engaging in the process of collaborative inquiry does not mean that we,
as therapists, abdicate our own values or knowledge. I am not advocat-
ing a kind of moral relativism in which we enter into family cultures
uncritically and simply accept all aspects of how they operate. It is
important to critically examine both our own and our clients’ beliefs,
practices, and values as well as the effects they have. In this process,

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there is a focus on the particular real effects of actions on others and on
fostering accountability for those effects. For example, we can shift from
thinking about substance use as something that is universally evil or bad
to examining the real effects of the use of particular substances at a par-
ticular time in a particular situation. It would be important to examine
the effects of substance use on the person, important others, and the
relationships between them. Although I might not tell a mother who is
using substances that she should just stop, I would engage her in a dis-
cussion about her hopes for herself and her children and how she prefers
to be as a person and a mother. I would then explore with her how sub-
stance use supports or constrains those hopes and preferred ways of
being. I would also engage her in an extended discussion of the effects of
substance use on her children, with an effort to elicit her thoughts before
offering my own. A preference for an invitational approach is a prag-
matic as well as aesthetic decision. Simply telling people to do something
often does not work, and as we’ve seen in several examples in this chap-
ter, inviting people to reflect on the consequences of their actions can
yield powerful results.

At the same time, it is important to keep concerns about the abuse
and neglect of children at the center of our practice at all times. If, in this
instance, I had a concern that a mother’s substance use put her children
at risk, I would not hesitate to raise that concern with her and to notify
protective services. In this response, I am aware that I may not be able to
“get her to see” that this is a problem (despite my hopes). I think of my
job here as not necessarily getting her to see that her actions are prob-
lematic, but as taking responsibility for my response to her actions. If I
hear about a child who is at risk, I have a legal obligation and ethical
responsibility to respond in ways that seek to ensure the child’s safety.
This is where I do adhere to a normative standard.

The values we hold profoundly influence the ways in which we
interact with families, and it is important that we openly and respectfully
acknowledge this with them. Rather than pretend that we come to our
work value free, we can identify our values and be open about them.
Values and the way in which they inform our actions can be an impor-
tant topic of discussion in our work with families. Within a cross-
cultural metaphor, it is important to recognize and honor the assump-
tions that we bring from our own cultures into the negotiation. There
are particular values that I hold strongly (e.g., anti-violence, pro-respect)
that I communicate to families. However, it is important for me to
acknowledge these as my values. They may or may not fit for particular
families. If I try to force a fit, my attempts usually backfire. If I offer par-
ticular ideas or values as a piece of my culture that clients might find

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helpful, they are more likely to consider such ideas than if I try to “con-
vert” them. At the same time, I strive to consistently act in accordance
with my values. For example, in a heterosexual couple in which a man is
speaking abusively toward a woman, I would raise my concerns that this
way of speaking could feel abusive and demeaning and ask each about
their experience of it. I would attempt to focus on the way of speaking
rather than the speaker as a possible problem and inquire about effects
of that way of speaking on the woman, on the man, and on their rela-
tionship. I might examine how those effects fit with the kind of relation-
ship they would prefer to have. In asking them questions, I’d want to
keep in mind the power dynamics in the room (e.g., I’d want to be mind-
ful of the gender politics in the room and be sensitive not to put the
woman in an overly vulnerable position nor speak on her behalf in a
way that she might experience as patronizing; I’d also want to be aware
of my own power position in the interaction and raise these concerns as
questions rather than declarations, and try to do so in a way that the
man experiences them as connected rather than judgmental). I might
also ask them about their reactions to my questions and concerns. As a
bottom line, I might ask the man to not speak that way while in my
office, but would own that as my desire and need (e.g., “I find it too dis-
tressing and distracting when you speak to her in those ways and I’d like
to ask you to refrain so that I can be more helpful to the two of you”).
However, it is important to acknowledge that this response comes from
my values and may or may not fit with their values. The practice of
transparency (described in the first chapter), through which we make
visible the values, thoughts, and assumptions that organize our work,
helps to build relationships in which we can discuss and negotiate differ-
ent perspectives in ways that do not impose our values on families and
yet does not ignore them either. Chapter 1 offered a set of guidelines that
can be useful in organizing difficult conversations across value differ-
ences (Roth, 1999, 2006a).

Collaborative inquiry also does not entail an abandonment of pro-
fessional knowledge. Our professional experiences have exposed us to
multiple ways in which other families have coped with particular prob-
lems, and there may be some valuable wisdom in those experiences. For
example, the distinction between intent and effect, demonstrating that
our actions may have negative effects even though our intentions are
positive, is one that many couples have found helpful. The distinction
between “parenting to protect” and “parenting to prepare” is another
useful idea (Parry & Doan, 1994). In parenting to protect, a parent’s job
is to protect a child from bad things happening to him or her, whereas in
parenting to prepare, a parent’s job is to prepare a child for living in a

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difficult world. Often (though not always), there is a developmental
point at which parenting to prepare may be a more useful model for
parenting. I have found this distinction very useful and have offered it to
parents at times. However, my intention in sharing either of these dis-
tinctions with clients is to offer them ideas that might be useful rather
than attempt to get clients to embrace the ideas. In a sense, I’m offering a
piece of my professional cultural knowledge and heritage that might
enrich their lives.

I want to emphasize that I am not suggesting we avoid offering useful
thoughts to families. The timing of when we offer ideas to families is
crucial. My preference is to first elicit client knowledge and bring forth
ideas that are jointly developed in the session. Following that, I might offer
additional supplemental knowledge that comes from my own professional
or personal experiences if it seems appropriate and useful. However, it is
crucial that we have an invitation for such an offering and that our ideas
are conveyed in ways that acknowledge the family’s idiosyncratic assump-
tions and values. Families can experience the offering of our knowledge as
supporting and enriching their wisdom or as invalidating and supplanting
it. It is important to offer our ideas in ways that clients experience as
empowering rather than inadvertently disempowering. One way to do this
is to make sure that the process by which we offer our knowledge is
accountable to clients for its effects on them. We can consistently and
repeatedly check with clients about how the process of therapy is going for
them and adjust our efforts accordingly.

DEVELOPING A CONTAINING ENVIRONMENT
FOR COLLABORATIVE INQUIRY

Collaborative inquiry requires an interpersonal atmosphere contained
enough to successfully invite clients into a reflective stance (i.e., being
willing and able to consider questions and respond to them thoughtfully
and honestly). For many clinicians working with difficult families, such
containment may seem more often the exception than the rule.1 Family
members can present as out of control, continually interrupting each
other, and extremely reactive to each other. It can be useful for clinicians
to observe the ways in which family members interact as a way to gain
valuable information, but it is notably less helpful for family members to
repeatedly experience themselves as out of control. The process of col-
laborative inquiry both requires and contributes to a safe, contained
environment.

James and Melissa Elliot Griffith (1992, 1994) have distinguished
emotional postures of tranquility and mobilization and examined the

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ways in which each opens or closes possibilities for therapeutic dialogue.
Postures of tranquility include states of listening, wondering, reflecting,
affirming, understanding, and trusting. In emotional postures of tran-
quility, attention is focused inward, vigilance to threat is low, and
there is openness to new information. Emotional postures of mobiliza-
tion, however, involve the physiological “fight or flight” response and
include states of guardedness, hyperarousal, shaming, blaming, attack-
ing, defending, justifying, controlling, distancing, and ignoring. Vigi-
lance is high and attention is focused outward in an effort to predict and
control others’ behavior. When people are primed to fight or flee, they
are not well positioned to take in information or engage in creative
problem solving.

Inviting multi-stressed families into an emotional posture of tran-
quility may strike many clinicians as a kind of oxymoron. These fami-
lies are often seen as crisis prone, and their suspiciousness and reactiv-
ity are viewed as a family characteristic rather than an interactional
process between families and helpers. Many families who have had
multiple pathologizing encounters with helpers are justifiably vigilant
as they interact with therapists. A clinician’s role in collaborative
inquiry requires active leadership. This is not a process of just listening
to people’s stories. It requires an active presence, setting a tone of
respectful curiosity and providing a leadership role in how the conver-
sation unfolds. The process of continually pulling for threads of com-
petence, connection, and hope requires focus and agility. If our job is
to open space for people to have a different experience, then our work
must begin with a belief that families can have different conversations.
There are a number of distinct ways in which we can structure thera-
peutic meetings that contribute to a containing environment. I have
often conceptualized our role as “conversational architects,” in which
we collaborate with families to design conversational structures that
will hold a different conversation and yield a preferred experience of
self and others. I want to highlight three particular ways in which
we can develop conversational structures that support collaborative
inquiry. These include efforts to help clients become more deliberate in
their responses, the use of communication agreements, and the devel-
opment of conversational structures.2 I discuss work with a couple to
highlight each of these.

Tom and Beth were a working-class Jewish couple with a long his-
tory of screaming matches in which they would talk past each other, cut
each other off, and continually go off on attacking tangents. These fights
traumatized their 11-year-old son, who increasingly refused to come out
of his room at home. Their first two therapy meetings were character-
ized by the same interactions, and I found myself feeling dizzy, frus-

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trated, and lost. Before the third session, I held individual meetings with
each member of the couple to gather information that would help me
design and propose a structure to hold a different type of conversation.

In the individual meetings, I made a point of building a connection
with each member, examined the toll the fights had taken on their rela-
tionship, and elicited their hopes for a better relationship. I proposed a
context shift in our work together, suggesting several sessions in which
they would each agree to momentarily step away from attempts to win
the argument in order to preserve their relationship from the costs of
waging those arguments. In this shift, there is a movement from a “reso-
lution conversation” aimed at solving the arguments or fixing the prob-
lem, to a “learning conversation” aimed at developing a better under-
standing of the other’s experience of the fights, with the objective of
preserving their relationship and building a foundation for subsequent
resolution conversations. In many ways, this is similar to the context
shift previously discussed in Wright’s (1990) research intervention. Each
member of the couple agreed to several meetings for this purpose and
agreed to the structures and processes that were developed in collabora-
tion with them, as described in the following paragraphs.

Moving to Planful Responsiveness

In the individual meetings, I asked both Tom and Beth to think about
what they hoped to accomplish in learning more about the other’s per-
spective and why that would be important to each of them. At the
beginning of the joint meeting, I reminded them of that request and
asked them each to pause for a minute and silently think about the
purpose that brought them to this meeting. I then asked each to imag-
ine that they were now at the end of the meeting and that purpose had
been fully realized. I posed some questions for silent reflection to
ground them in that experience and then asked each of them to think
about how they wanted to relate to the other in this meeting (e.g.,
“What tendencies, ways of relating, or ways of being would you each
like to bring forward and hold back in order to support the purpose
that brings you here?”). They thought about this for a bit and then
were asked to say a word or phrase that would capture how they each
wanted to be in the meeting. Tom replied, “Standing in her shoes,”
and Beth responded, “Open and curious.” I asked each of them why
these ways of being would be important to them and what would help
them to keep to such ways of relating in the meeting. This invitation
to focus on how they each wanted to be in the meeting, rather than
how they wanted the other to be in the meeting, helped them move
from reactivity and attempts to change the other to reflection and

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planned responsiveness. Asking them to pause and reflect for a full
minute before responding to my questions also slowed the pace of the
meeting and encouraged a more reflective space.

Communication Agreements

Communication agreements, in which participants develop a set of
ground rules, agreements, expectations, or shared promises to guide
their speaking and listening in a session, can be extremely useful
(Chasin, Roth, & Bograd, 1989; Roth & Chasin, 1994). In my individ-
ual conversations with Tom and Beth, I asked a number of questions to
learn how the upcoming meeting might go well or poorly for them. We
discussed a number of possible communication agreements that could
support a more constructive conversation, and I proposed a number of
communication agreements that could help them have a constructive
“learning conversation.” These were framed as agreements or shared
promises that the couple were making to each other to support the kind
of conversation they wanted to have and promote the kind of relation-
ship they wanted to develop. I proposed several agreements, and we then
together worked out a final list. The agreements, framed as shared
promises in the service of their relationship, included:

“We promise to share speaking time and respond to any time limits
set.”

“We promise to suspend efforts to persuade in order to seek mutual
understanding.”

“We promise to speak from our own experience and not attribute
intentions or motives to the other.”

“We promise to listen carefully when what is said is hard to hear
and hang in and not interrupt the other.”

“We respect each other’s right to pass in response to any questions
asked.”

“We authorize Bill to help hold us to these agreements.”

This last agreement is an important one. It is important that a therapist
have clients’ authorization to help hold them to communication agree-
ments. Having the agreements in place ahead of time and an authoriza-
tion to help people hold to them allows the creation of a structure that
will contain the meeting, rather than relying solely on a therapist’s facili-
tation skills to contain the meeting. Having that authorization allows the
clinician to remind people of the promises they’ve made in support of
their purpose rather than trying to impose the clinician’s rules and get
them to comply in a heated moment.

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Conversational Structures

The final element needed for developing a containing environment for a
learning conversation is the use of conversational structures that sepa-
rate out and clearly demarcate time and space for speaking and listening.
The purpose of these structures is to support a learning conversation
that will serve the purposes that bring each member to the meeting. This
is not an attempt to provide a normative model of functioning for their
lives, but to offer them a structure that will support the kind of learning
conversation they’ve said they would like to have. This kind of structure
often involves having one member speak while another listens. It is
important to put clearly defined time parameters on this structure (e.g.,
“Tom, I’d like to ask you to speak about your concerns about X for 2
minutes while Beth listens. I’m going to hold you to 2 minutes and ask
Beth to simply listen, then we’ll shift and I’ll ask Beth to speak about X
for 2 minutes and ask you to listen”). Short time frames make it easier to
listen (e.g., most people can listen to just about anything if it is only for
2 minutes). The time limits often feel strained and unnatural, but the
point is to build a structure that will contribute to a different conversa-
tion in that particular meeting. If clients find the structure useful, we can
engage them in reflection on what they find useful and whether and how
they would like to bring that more into their daily life.

One conversational structure involves giving each member set times
to speak, and alternating speaking and listening. In another structure,
one member is interviewed; the others observe and are subsequently
interviewed about their reflections. As we interview one individual, it is
important to pay close attention to the others’ reactions during that
interview, anticipating their responses and engaging them before they
become reactive. We can also repeatedly compliment other family mem-
bers for continuing to listen in the face of what may be provocative
statements. When people are assured of shared speaking time, it allows
them to more fully listen and reflect rather than simply prepare their
rebuttals. Similarly it can be useful to actively interview a listener about
his or her experience in order to highlight particular aspects of that
experience.

This is a brief explanation of some of the ways in which we can
actively contribute to the development of a containing environment.
Again, I want to emphasize that collaborative inquiry is an active pro-
cess that consists of collaboratively structuring a constructive conversa-
tion rather than just passively listening to a family’s story. In the next
section, I highlight an organizational framework that can ground collab-
orative inquiry in the four conceptual developments that form the foun-
dation of this book.

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SUSAN DISABLES THE BAD-PARENT BUTTON:
AN ORGANIZATIONAL FRAMEWORK

FOR COLLABORATIVE INQUIRY

We can productively organize our efforts to help clients and families
around the following five broad steps:

1. Getting to know clients outside the problem’s influence.
2. Helping clients envision preferred directions in life.
3. Helping clients identify elements that may constrain and/or sus-

tain their development of preferred directions in life.
4. Helping clients address constraining elements and/or enhance

sustaining elements.
5. Helping clients develop communities to support the enactment of

preferred lives.

This section draws on an extended clinical consultation to illustrate this
organizational framework. Although the example is a one-time consulta-
tion, this framework also can serve as a map for our overall work with
families and is applicable across many contexts. After a description of
the family, I highlight each step in some detail with reference to the con-
sultation interview.

Description of the Family

Susan was a poor, white, working, single mother with two children,
Carol (7) and Frankie (5). Her family was referred to a home-based team
to help Carol, who struggled with repeated explosive temper outbursts.
These explosions had taken a significant toll on both Carol and Susan as
well as on their relationship. The family was involved with protective
services because of repeated physical fights between Carol and Susan.
They had a long history of unsuccessful encounters with numerous help-
ers. However, over the past 5 months of working with a home-based
family therapist and a new after-school program, things had begun to
change. Carol was more able to control the temper outbursts and Susan
was more confident as a parent. However, the family therapist was con-
cerned that these changes rested on a shaky foundation. Susan had an
extensive history of abuse herself and little community to support her.
The family therapist requested a consultation to help solidify changes in
the family and support Susan in becoming a more effective parent.

The consultation interview included Susan, her home-based family
therapist, a clinician from the after-school program, and me as the con-
sultant. The consultation was scheduled to include Susan’s daughter, but

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she had been sick earlier in the week and Susan decided it was more
important that she attend school than yet another therapy meeting. In
the spirit of collaborative inquiry, this consultation was framed for
Susan as a consultation we were seeking from her, rather than an inter-
vention we were providing for her. We wanted to elicit, elaborate, and
acknowledge her wisdom accrued from coping with a difficult situation.
We thought that we as helpers could learn a lot from the consultation
and also hoped that the questions in the consultation would have benefi-
cial effects on Susan and her family. Susan felt touched and validated by
this request and was very interested in participating.

The initial consultation included an interview with Susan and her
helpers in one room with a number of team members in another room
observing behind a one-way mirror (with Susan’s consent). At some
point, three members of the team came into our room and offered reflec-
tions that acknowledged the ways in which they had been moved by
Susan’s story. Susan and the helpers sat off to the side listening and then
Susan had an opportunity to respond to the reflections. The consultation
was videotaped, and Susan later viewed the videotape with her therapist
to further reflect on it. In addition, I sent her a follow-up letter that doc-
umented her abilities, skills, and wisdom that emerged in the meeting
and posed additional questions to invite further reflection on her part.
Therapeutic letters can be a powerful adjunct to clinical meetings and
will be examined in more detail shortly and again in Chapter 9. Finally,
the videotape of the consultation was shown to other witnessing groups
(again with Susan’s permission) and their reflections were captured and
shared with Susan and her therapist.

Getting to Know Clients Outside the Problem’s Influence

If we view people as being in a relationship with a problem (rather than
having or being a problem), we can begin our work by getting to know
clients outside the problem’s influence. Getting to know people as three-
dimensional human beings with multiple aspects of experience that we
can respect and appreciate builds a strong foundation for a therapeutic
relationship. Marcia Sheinberg (1992) points out the usefulness of elicit-
ing stories of pride before stories of shame. Inquiry into what clients
appreciate and value about their lives facilitates engagement and makes
it easier to subsequently examine difficulties. The process of getting to
know clients outside the problem’s influence was previously examined in
Chapter 3.

In this clinical example, Susan arrived late for the consultation and
entered angry, exasperated, and embarrassed. I asked about her morning
and heard a wrenching story of Susan getting her daughter on the school
bus and then noticing some forgotten homework. Susan drove to her

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daughter’s school to deliver the homework, and her daughter greeted
Susan with outrage for embarrassing her rather than gratitude for the
extra effort. Susan then drove to the consultation in heavy traffic, know-
ing she was going to be late, anticipating criticism and judgment, and
both preparing her defense and preemptively castigating herself. As she
told this story, I marveled that she would put all this extra, unrewarded
effort into helping her daughter out. Susan replied, “That’s what moth-
erhood is all about. You don’t always get the recognition you deserve.”
That reflection provided an important opening, and we moved into a
conversation about her commitment to her daughter and how parenting
for her was, in her words, “not just a job, but a calling.” The transition
from a not uncommon story of parental frustration to an examination of
Susan’s commitment to “Parenting as a Calling” carried her out of the
harried pace of being late for a meeting and into a more reflective space
that provided a stronger foundation for moving forward.

Helping Clients Envision Preferred Directions in Life

The process of getting to know clients outside the problem’s influence
and eliciting stories of pride as a foundation for subsequent inquiry
often leads naturally into the second step of developing a vision of future
possibilities or preferred ways of being in the present that can serve as an
agreed-upon focus for helping efforts. Chapter 4 examined the useful-
ness of a proactive focus and offered a number of questions for jointly
developing collaborative goals. As clients begin to concretize preferred
directions in life, we can help them build a foundation of motivation,
resourcefulness, and community that will more solidly anchor this
vision. We can ask family members why the direction they’re describing
is important to them (enhancing motivation), inquire about when they
see threads of it emerging and steps they are taking to live into that
vision (elaborating resourcefulness), and seek to learn about who in their
lives might appreciate and stand behind their efforts to develop that life
(developing a community).

In this clinical example, Susan found our initial conversation
about Parenting as a Calling to be useful, and I asked a series of ques-
tions to take the idea further. I asked what that phrase meant for her
and how her parenting was different when she experienced it as a call-
ing rather than a job. The questions tapped into her pride and passion
about her parenting. She described moments of a loving, thoughtful,
and connected relationship with her daughter, and I asked a number of
questions to concretize that description. In an effort to build a more
solid foundation for Parenting as a Calling, I asked Susan a series of
questions about why this was important to her, how it was currently
showing up in her life, and who in her life might appreciate it. The

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phrase “Parenting as a Calling” became an organizing focus for
the consultation and allowed us to move into jointly learning more
about her efforts to more consistently ground her parenting in that
commitment.

Identifying Constraining and Sustaining Elements

Once we have helped clients envision preferred directions in life and
learned a bit about why those directions are important to them, we can
work with clients to identify elements, factors, or forces that might con-
strain or sustain the development of desired lives. Chapter 2 outlined a
number of examples of constraints at different levels (biological, individ-
ual, familial, social network, and sociocultural) and in different realms
(action and meaning). We can also identify elements, factors, or forces in
life that sustain, support, or enhance the pursuit of preferred lives. These
may include sustaining beliefs, actions, and interactions at various levels,
as well as the intentions and purposes, values and beliefs, hopes and
dreams, and commitments people bring to their lives. We can think
about people as being in a relationship with constraining and sustaining
elements, as shown in the figure below.

In considering this figure, we can think about the relationship
between a person and constraining and/or sustaining elements as both
ongoing and modifiable. Constraining and sustaining elements can be
seen as having significant influence in the life of the person and the per-
son can be seen as having significant influence in the life of those ele-
ments. The process of addressing the relationship between people and
constraining and sustaining elements is examined in significant detail in
Chapters 6 and 7. Although there has typically been more focus on
problems and constraining elements, we can also focus our efforts on
helping people draw on and enhance their relationship with sustaining

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elements. For example, Susan’s commitment to Parenting as a Calling is
sustained by her hopes for her daughter’s future. As she holds a picture
of her daughter as a newborn and remembers the hopes with which she
brought Carol into the world, her commitment to Parenting as a Calling
becomes more tangible and real to her. In this way, helping clients
enhance their relationships with sustaining elements in their lives can
support their preferred direction in life.

With a map of constraining and sustaining elements in mind, we
can ask clients whether they would prefer to begin by focusing on things
that support their efforts to build desired lives or by focusing on the
obstacles on the road to preferred futures. If clients are primarily inter-
ested in sustaining elements, we can build on emerging possibilities to
develop richer life stories and may not need to directly attend to the
problems that initially brought them to therapy. At other times, it may
be important to more directly address problems or constraining ele-
ments. If so, we can work with people to anticipate potholes on the road
to preferred living and help them draw on abilities, skills, and knowl-
edge to address the potholes they experience in their lives. (Conceptual
maps for this process are discussed in depth in Chapter 7.) The option of
focusing on constraining or sustaining elements offers the flexibility to
fit our efforts to client preferences along with our own judgment about
directions that might prove most fruitful.

The clinical consultation with Susan focused on supporting her
commitment to Parenting as a Calling. When offered a choice of focus-
ing on what sustained that commitment or what pulled her away from
Parenting as a Calling, she chose the latter and began talking about the
many ways in which her daughter would “push her buttons.” She
described her parenting at those times as “going right down the toilet.” I
asked Susan if it would be okay if we shifted our focus from Carol’s
pushing of buttons to the buttons that got pushed and how Susan would
rather respond to “pushed buttons.” She agreed, and we talked about
pushed buttons as an externalized problem, then moved into a discus-
sion about what Susan called the “bad-parent button.” We explored the
influence of the Bad-Parent Button on Susan’s parenting, her sense of
self, and her relationship with her daughter. The following dialogue
highlights some of the effects of the Bad-Parent Button on Susan’s inter-
actions with her daughter, Carol.

BILL: So, this idea that it was your fault that Carol was struggling with
her temper, what effect did that idea have on you?

SUSAN: It actually made me a whole lot less patient with her ’cause I’m
trying to make her perfect because that means I’m perfect if she’s
perfect. It just changed my whole attitude with her.

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BILL: So, when her not being perfect becomes a comment on you, would
that then steal away any patience you have for her?

SUSAN: Yeah.

BILL: So, it’s not just her that you’re concerned about, but her and also
what it says about you?

SUSAN: Yeah.

BILL: It’s really unfortunate, I think, the ways in which moms get blamed
in that way.

SUSAN: I’d have to agree.

In examining the effects of the Bad-Parent Button, it’s important to
note that this button does not stand alone in isolation. Susan is among
many mothers who have been pulled into blaming themselves for their
children’s misfortunes. The Bad-Parent Button in Susan’s case (and in the
case of many mothers) is embedded in a broader cultural context and
receives significant support from the prevalence of mother-blame in our
culture. In examining the effects of particular problems on people, it is use-
ful to place those effects in the context of broader taken-for-granted cul-
tural assumptions and practices that contribute to those effects. Exposing
and critically examining cultural assumptions and practices that support a
problem helps to undermine the influence of that problem and minimize
self-blame. The goal here is not to replace one set of prescriptions of how
to be in life with another, but rather to make visible the taken-for-granted
assumptions that organize our lives so that clients can examine those
assumptions and decide how they actually fit for their lives. The rest of the
consultation focused on the Bad-Parent Button as a constraint to Parenting
as a Calling and helped Susan to shift her relationship to that constraint.
As a result, the rest of this section focuses on constraining rather than sus-
taining elements. We return to and examine the usefulness of building on
sustaining elements in more depth in the next chapter.

Helping Clients Address Constraints

Once clients have identified particular constraints, we can help them
reflect on their current relationship with these constraints as well as the
relationship they would prefer to have. Then we can draw on our expertise
in inquiry to pose questions that elicit client knowledge, abilities, and skills
that can help them shift their current relationship to constraints and more
deliberately develop the kinds of lives they would prefer. Again, the focus
here is on eliciting client abilities, skills, and knowledge, rather than con-
veying professionally derived strategies for preferred living.

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As the clinical consultation with Susan continued, she mentioned
that there were times when she was able to disable the Bad-Parent But-
ton. I asked a number of questions about how she did that and whether
she preferred times when the Bad-Parent Button got pushed or times
when she was able to disable that button. The following dialogue high-
lights her response.

BILL: So, I’m sort of sitting here thinking about these times you’ve
described where on the one hand (right), the Bad-Parent Button gets
pushed and you’re at the end of your rope and feeling like “I just
don’t want her in my life,” and on the other hand (left), you’re able
to disable that button and remember that “she’s the most important
thing in my life.” Does that capture the difference for you?

SUSAN: Yes.

BILL: This may seem like an odd question, but I want to make sure I’m
clear about it. Which do you prefer?

SUSAN: Times when I disable the button and remember that she’s the
most important thing in my life.

BILL: Why is that? It’s clear to me that this is really important to you.
Why is that important to you?

SUSAN: Because she has been through so much already. I just, I don’t
know, it’s . . . she’s been my world since day one and will never stop
being my world, no matter how angry she makes me, how frus-
trated, how sad, how happy, no matter what. She is my world.

BILL: So, no matter what buttons get pushed, she will still be your
world?

SUSAN: Yeah, the fact that she is my world is why she is still with me. I
have fought for my daughter from day one, very literally.

Although questions about people’s preferences may seem like rather
obvious questions, they are actually very important. Questions about
people’s preferences provide an occasion for them to make their values
and intentions known. To voice a preference out loud is to commit one-
self to a direction in life. Preference questions create a context to make
such commitments. These questions invite people to clarify and elabo-
rate their values. In this way, preference questions are helpful in mobiliz-
ing and aligning a person’s emotional responses behind his or her pre-
ferred direction in life (Tomm, 1989). As Susan talked about her
daughter’s importance to her, she was stepping into a commitment to
disabling buttons. The process enhanced motivation. It also provided a

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basis for further inquiry into Susan’s intentions, values, hopes, and com-
mitments and made the process more meaningful and personally salient.

As Susan continued speaking about her commitment to disabling
the Bad-Parent Button, her physical demeanor in the meeting shifted.
She sat up and became more of a presence in the room. I asked her
about the steps she took to disable buttons, and she had little to say
initially. This is not unusual. When asking about events that fall out-
side the dominant stories in people’s lives, it is entirely expectable that
those events don’t come to mind immediately. Collaborative inquiry
involves a joint search for events that fall outside the dominant story.
After several forays into the search for exceptions, the following con-
versation ensued.

BILL: How did you start to disable that button? What were some of the
first steps you took to disable it?

SUSAN: The biggest step was to stop letting everybody else rule the way I
parent my child. A lot of the times the way I reacted to Carol had
nothing to do with Carol and it had nothing to do with me. It had
to do with everybody else. The fears of how I was going to look to
everybody else if she didn’t behave.

BILL: So, back to that thing about mothers and fear and judgment?

SUSAN: Yes! I was petrified of protective services, which played a big
part in how I handled her. My fear would take over and then the
anger would take over as well.

BILL: From what you’ve been saying, it sounds as though what would
happen with your parenting was that there were lots of voices in
your head, saying do this, do that. Would that describe it?

SUSAN: Absolutely! I had to stop and think of what every single person
in my life was going to say if I didn’t do this, this, this, and this.
And, I had to stop that. It didn’t matter what everybody else
thought, it mattered what I think and my child thinks, and the rest
of the world can just disappear.

From this exchange, we expanded the frame to examine steps that
Susan took away from Pushed Buttons and Parenting out of Fear and
Judgment and toward Disabled Buttons and Parenting out of Love and
Commitment. Alternating between questions to develop this richer story
and questions to solidify its meaning, I sought to elaborate this develop-
ing story of Susan’s parenting and invite her reflection on her emerging
identity within it. Susan continued speaking more confidently, and we

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moved into an examination of future possibilities that might emerge
from these developments.

BILL: So, this change in your parenting, who else should get caught up
on these changes? Who would be important to have learn about
these changes?

SUSAN: I don’t know. The one who sees it is the only one that matters to
me anyway, and that’s my daughter.

BILL: And what has she seen?

SUSAN: Mommy’s a whole lot more fun. Mommy’s not saying, “Carol,
you’re wrong. Carol, go to your room.” Mommy’s not crying for
hours on end because Mommy doesn’t know what to do. Mommy’s
able to just sit down and read a book with Carol. Just in the past
week alone, I’ve actually found enjoyment in doing homework with
Carol, which is a miracle.

BILL: So, she sees this different story about your parenting. What effect
do you think it has on her?

SUSAN: I think it has an awesome effect on her.

BILL: And as you continue to keep these buttons disabled, as you con-
tinue to have your parenting anchored in your love and commit-
ment for her, how do you think it will affect her life?

SUSAN: She’ll continue to grow, she’ll continue to see the right way to
handle things, and, hopefully, eventually she will continue to see dif-
ferent ways to handle her anger.

Finally, in an attempt to further ground Susan in this developing
story of Disabled Buttons and Parenting out of Love and Commitment, I
asked Susan what thoughts she would have for other parents looking to
disable Bad-Parent Buttons. She outlined three pieces of wisdom:

• Be open to what your children have to teach you.
• Let your children know they matter and are important.
• Don’t let others rule your parenting and don’t parent out of fear.

We talked about how she had arrived at these realizations and how she
managed to hang onto them in difficult times. Finally, by way of con-
cluding the consultation, I asked her what ideas she would have for pro-
fessionals trying to help parents disable Bad-Parent Buttons. Her sugges-
tions for helpers were simple:

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“Don’t sit in judgment. When helpers don’t sit in judgment, the
defensiveness goes away. Clients don’t feel the need to sit there and
defend every little thing they just said or did. When I talk to these
guys [the two helpers in the interview], I can say anything and not
think, ‘Oh my God, I can’t believe I just said this to them. What’s
gonna happen now? What are they gonna think or do?’ When I’m
not caught up by that, I can be more open and they can be more
helpful. That’s my only suggestion, but it’s a big one.”

Although the solicitation of her wisdom for helpers fit the frame of the
consultation (to help the helpers), it was also done with the intention of
repositioning Susan from being the object of professional efforts to being
a more active agent in her own life.

Building a Community to Support Preferred Living

Susan was moved by this consultation and seemed to be in a different
place at its end. At the same time, the interview itself was quite ephem-
eral in the grand scheme of her life. To slightly alter an old African
phrase, it takes a village to raise a new story. It is important to help peo-
ple develop communities of support that will stand with them as an
appreciative audience for the enactment of new lives.

Problems exist within networks of support (e.g., the Bad-Parent But-
ton receives significant support in our culture through mother-blame).
Helping clients shift their relationships to problems is significantly en-
hanced through the development of a community that can support them in
that process. We all live out the stories of our lives in our interactions with
others, and those interactions solidify our narratives and further shape our
lives. As we begin to enact a richer story, the community that witnesses that
enactment takes on great significance. The development of a community
to witness and support the performance of emerging stories can be a cru-
cial piece of our work. There are a number of ways to support clients in
further elaborating and solidifying new lives. This consultation highlights
several that are further examined in subsequent chapters.

Immediately following the interview, the three members of the wit-
nessing team came in and shared their reflections while Susan and the
two helpers observed. Following guidelines for outsider witness groups
developed by Michael White (1995, 2000), their reflections were primar-
ily organized by three questions:

• What did you hear in this conversation that captured your atten-
tion?

• How does that connect to events in your own life or work?

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• How have you been moved by hearing this conversation, and
what from this conversation do you want to carry back into your
own life or work?

The purpose of the reflections was to acknowledge the ripple effects of
hearing Susan’s story rather than to offer advice or suggestions for
Susan’s benefit. Reflecting practices and the use of witnessing teams are
further examined in Chapter 8. Following their comments, Susan and
the two helpers were asked about their responses to the team’s com-
ments. Susan was visibly affected by the witnessing team and offered the
following response:

“It’s amazing. I’m not alone. Someone sees the life that everyone
keeps telling me I’m making up. They get it and see me as having
made some progress and having something to offer others. I’m glad
that what I’ve been through is useful to others. I will carry these
voices around with me for some time, and my hope is they can con-
tinue to grow and crowd out all those critical voices in my head.”

The next week, in a continued effort to help Susan keep alive this
alternative story, her family therapist met with her to watch the video-
tape of the consultation and elicit her reflections on watching it a week
later. In addition, I sent a therapeutic letter to Susan with my reflections
on the session. Therapeutic letters are powerful devices for sustaining
emerging alternative stories and are further examined in Chapter 9.
Although the experience of a particular meeting can fade with time, ther-
apeutic letters help to keep that experience alive and concrete. The letter
below alternates between documenting what Susan said in the meeting
and raising questions to continue an internal conversation and invite fur-
ther reflection on developments from the meeting.

Dear Susan,

I appreciated the opportunity to meet with you this week and learn
about your commitment to “Parenting as a Calling.” In the spirit of
supporting that commitment, I wanted to share back with you some
of the many things that I found moving and offer some reflections.

I appreciated your obvious concern for your daughter, Carol. Her
explosions sound as though they have taken quite a toll on her, on
you, and on your relationship. At the same time, I was profoundly
struck by your commitment to maintain your connection to her
despite those explosions.

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You described some remarkable changes in Carol over the last 5
months. When I inquired about how these changes had occurred, you
shared the credit among many sources and also included yourself. As
you said, “A child learns what the child lives.” I was moved to hear
you claim some credit for the changes in Carol’s life. It seems so often
the case that mothers receive way too much blame and far too little
credit. As you continue to give yourself the credit you are due, what
other changes do you think will occur?

You talked about the ways in which the Bad-Parent Button could get
pushed for you and how you have worked to disable that button and
increasingly ground your parenting in love for and commitment to
your daughter. You provided a very moving account of some of the
steps you took to disable that button, which included:

• Taking ownership of your parenting and realizing that you are
the primary caretaker and need to go with your gut rather
than be preoccupied about others’ criticism.

• Focusing on your daughter’s importance to you and remember-
ing your hopes for a different life for her.

• Taking time out and stepping out of interactions with Carol to
ensure that your parenting stays anchored in the love you have
for her rather than reacting to particular situations.

I would imagine these steps took a lot of hard work. I asked you
how Carol might describe your parenting now, and you thought she’d
say, “Mommy is more fun and not crying now.” You described that
change as an awesome one. As your parenting is increasingly
anchored in these important steps, how do you think your relation-
ship with your children will continue to unfold?

I also asked you what of your hard-won wisdom might be useful for
other parents who get pushed by the Bad-Parent Button. You men-
tioned three things:

• Being open to what your children have to teach you.
• Letting your children know they matter and are important.
• Working to not parent out of fear.

This wisdom rings true for me, both as a father and as a helper, and I
appreciate your permission to share those thoughts with other parents
who I think will benefit from them. As you read these ideas, how do
you think they might be useful for you?

After the three team members spoke at the end of our meeting, you
said you wanted to hold their voices in your head as you continue to
parent your children. I hope that appreciative voices come to crowd

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out the critical voices and that your parenting is increasingly
grounded in the wisdom you’ve described. Who else might appreciate
your efforts to disable the Bad-Parent Button? What do you think
your efforts would tell them about you? Again, I appreciated meeting
with you and wanted to thank you for the wisdom you shared.

In appreciation of all that you have to offer,

Bill Madsen

This letter had a profound effect on Susan. She read it over with
her family therapist and they discussed it in great detail, further solidi-
fying her emerging story in the process. In an attempt to continue to
keep the appreciative voices alive and assist them in crowding out crit-
ical ones, I began to use the videotape of this consultation in various
training and consultation groups (with Susan’s permission). I would
show participants the tape, and then have them offer reflections fol-
lowing the same three questions that guided the original witnessing
team immediately after the consultation. As participants spoke, I took
notes and then included them in several follow-up letters to Susan.
Here is a composite letter that contains some of the many things
people said:

Dear Susan,

As you know, I have been using the videotape of our meeting to help
mental health and social service workers draw on your wisdom in
their efforts to become more helpful to other parents attempting to
disable “Bad-Parent Buttons.” I recently showed the videotape of our
meeting to a group of professionals and then asked for their reflec-
tions, which I want to share with you. They were asked three ques-
tions: What stood out for you? Why is that important to you? What
do you want to take away from this?

Here are some of the things they said:

“I was really touched by Susan’s ability to find and hang onto her
own voice. It is hard to step away from others’ voices when you’re
dependent on professionals, when your life hangs in the balance. We
get so organized by what you should and shouldn’t do, and I really
appreciated her strength and resolve to listen to her own voice. It
solidifies for me the importance of going with my own inner voice.
Recently I made a decision, and fear gets me to not trust my decision.
I can lose sight of who I am and what I know and end up running to
others and bouncing off them. Watching this interview helps me get
back to my commitment to trusting myself.”

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“It’s hard to hear your own voice, especially when the system is not
kind to the fact that people sometimes fall down. For me, the chal-
lenge is to look past the sheet of paper that is supposed to tell us
about clients and to move beyond our fixed ideas about where we
think people should be in their lives or what they should be doing, to
where they actually are in their lives. It made me more conscious of
how many people are moving through their lives chained down by
fear. I think fear shuts people down, and watching this interview gives
me ideas about how to be more understanding about that.”

“I was moved by Susan’s determination to not repeat abandonment. I
have a connection with that. As a man who grew up without a father
and is now a father, I really connect with her determination to be a
different parent with her children. My fathering is sometimes criti-
cized, and it was very helpful to watch Susan’s determination to hold
onto her own voice. I was very moved by that. It confirms for me
that it is entirely possible for human beings to turn things around and
not be subject to fate or what is written on their assessment sheets.
As I watched this, I became more convinced that parents have
answers and abilities that we as professionals often miss. Watching
this confirms that I need to look for and believe in the inner strength
that parents have.”

Those are their responses. I’d be interested in whatever thoughts and
reflections you might have, and I appreciate your willingness to help
others learn from your experience and wisdom. As you think about
the effects you are having on an ever-widening circle of helpers, what
is that like for you?

With continued appreciation,

Bill Madsen

Susan was very moved by this series of letters. She often carried
them with her and would make a point of rereading them when she
anticipated difficult situations. As she put it, “These letters keep my
head filled with the voices I want in it.” Susan felt wonderful in reading
these letters. But this process is not simply about helping people feel
good, it is about helping them build better lives.

Comments on This Consultation

Susan moved out of state and I no longer have contact with her. At the
last report, she and her daughter were both doing better in their lives,
though still encountering a number of everyday challenges. Susan had
practically no community at the time of this consultation, and the letters

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  • WilliamCMadsen_2007_Chapter5Collaborative_CollaborativeTherapyW
  • DOC102921

70

Families in society: the Journal of contemporary social services
©2013 alliance for children and Families
issn: Print 1044-3894; electronic 1945-1350

2013, 94(2), 70–78
Doi: 10.1606/1044-3894.4282

Evidence-guided practice: Integrating the Science and
Art of Social work
alex Gitterman & carolyn Knight

social work educators and practitioners have had an ongoing debate whether the profession is primarily a science or

an art. the pendulum has swung back and forth, with the current tilt toward scientific explanations and formulations.

evidence-based practice is the most symbolic manifestation of this tilt. the authors propose an alternative approach

to practice that integrates, rather than separates, the art and science traditions. evidence-guided practice incorporates

research findings, theoretical constructs, and a repertoire of professional competencies and skills consistent with the

profession’s values and ethics and the individual social worker’s distinctive style. major assumptions, as well as challenges,

associated with the model are identified. a case example illustrates major concepts of the model.

impliCations For praCtiCe

• social workers are encouraged not only to engage in

theoretically informed and evidence-based practice

but also to maintain their creativity, authenticity,

and flexibility.

From their very beginning in the settlement and char-
ity organization society movements, and throughout
the evolution of the profession, social work educa-

tors and practitioners have had an intense and ongoing
internal debate: Is social work primarily a science or an
art? The pendulum has swung back and forth. Its current
tilt is toward scientific explanations and formulations, as
reflected in the evidence-based approach to practice. We
argue that the science of evidence-based practice versus
the art of spontaneous practice is an artificial dichotomy.

in this article, the major tenets of evidence-based
practice are first summarized, as are its advantages
and limitations. We then describe an approach to prac-
tice that integrates rather than separates the science
and art traditions, an approach we intentionally term
evidence-guided practice (egP). We use evidenced-
guided rather than evidenced-informed because the
term guided suggests that evidence is used to facili-
tate professional action. ample opportunities also are
available for social workers to use theory, professional
experiences, and practice wisdom. We believe that the
concept of guided has more of an action orientation
than informed.

Evidence-based practice: major Assumptions

The concept of evidence-based practice actually origi-
nated in the medical profession (sackett, rosenberg,
gray, haynes, & richardson, 1996). The major prem-
ise of evidence-based medicine has been that decisions
for promoting health and treating illness should be
based on the best available medical evidence (borry,

schotsmans, & dierickx, 2006; Cochrane Collabora-
tion, 2010; gupta, 2009; taylor, 2012). evidence-based
medicine has been defined as “the conscientious, ex-
plicit, and judicious use of the current best evidence in
making decisions about the care of individuals” (sack-
ett, richardson, rosenberg, & haynes, 1997).

influenced by these developments in medicine, so-
cial work scholars have advocated an evidence-based
approach to social work practice (Corcoran, 2000;
gambrill, 1999; gibbs, 2003; gibbs & gambrill, 2002;
gossett & Weinman, 2007; Macgowan, 2008; rubin,
2007). evidence-based social work practice has been
defined as the “mindful and systematic identification,
analysis, evaluation, and synthesis of evidence of prac-
tice effectiveness, as a primary part of an integrative
and collaborative process concerning the selection
of application of service to members of target client
groups” (Cournoyer, 2004, p. 4).

evidence-based proponents argue that social work-
ers should base their practice decisions on a critical re-
view of available intervention strategies for a particu-
lar client’s challenges and difficulties. The intent is to
identify and employ those techniques that have been
found to help an individual, family, or group with a
specified problem. The social worker selects the most
relevant, empirically verified approach. evidence-
based practice also includes clinicians’ efforts to evalu-
ate their intervention efforts (baker & ritchey, 2009).

advocates of evidence-based practice justify the ap-
proach on ethical grounds, asserting that it encourages
professional accountability to clients, as well as reflects
the professional’s commitment to lifelong learning
and competent practice (gambrill, 2007; hudson,
2009; Zlotnik, 2007). further, advocates argue that it
encourages clients to be informed consumers of the
services they receive, in contrast to traditional ap-
proaches to practice that are viewed as “authority-
based” (gambrill, 1999).

Gitterman & Knight | Evidence-Guided Practice: Integrating the Science and Art of Social Work

71

Drawbacks
The simultaneous focus on the individual, family,
and/or group and wider social environment has come
to define social work as a profession and distinguishes
it from other helping professions. The early, diagnos-
tic model of social work practice has been supplanted
in social work education by an ecological approach
that takes into account the myriad forces that shape
human behavior. The worker considers forces within
and outside of the client as sources of problems and
targets for intervention.

since the professions of social work and medicine
have different functions, social work’s renewed reliance
on medical tenets is puzzling. The current evidence-
based emphasis in social work is all the more perplexing
since the medical profession has begun to rethink and
refine its own evidence-based approach (avis & fresh-
water, 2006; devisch & Murray, 2009; sestini, 2011).
Critics note that evidence-based medicine ignores the
needs of the individual patient (gupta, 2011; tannahill,
2008). Practicing physicians criticize evidence-based
medicine’s narrow focus and its lack of attention to the
range of variables that contribute to health and illness
(Kumar, grimmer-sommers, & hughes, 2010). a more
comprehensive definition of evidence-based medicine,
promulgated by its earliest proponents, reflects this
broader perspective: “evidence-based medicine is the
integration of the best research evidence with clinical
expertise and patient values” (emphasis added; sackett,
richardson, rosenberg, straus, & haynes, 2010, as cited
in oancea, 2010, p. 160).

The social work profession’s purpose is by definition
especially broad: to improve clients’ social and psy-
chological functioning; to enhance the transactions
between people and their environments; and to influ-
ence communities, organizations, and legislation to be
more socially just (gitterman & germain, 2008). so-
cial work takes place in a social context, embedded in,
among other things, poverty, unemployment, oppres-
sion, racism, homelessness, and community violence.
Complex social problems do not lend themselves to
narrow and discrete interventions that are the foun-
dation of evidence-based practice (Walker, Koroloff,
briggs, & friesen, 2007). The medical profession has
begun to rethink its evidence-based orientation. We
believe that social work, with its broader ecological fo-
cus, must do the same.

Limitations of research. evidence-based practice
proposes that specific interventions exist to solve most
types of problems, and social workers can find and
then use the most effective—the “best”—intervention.
These two premises have a seductive appeal. in the real
world of people with messy and overwhelming life
stressors, a logical, orderly, and sequential formula-

tion is reassuring. it is understandable that one would
be drawn to the idea that using technique X with
Client Y with Problem Z will lead to the intended out-
come. evidence-based practice assumes a linear rela-
tionship between research and practice, when in ac-
tuality the connections between theory, research, and
practice are complex and often elusive.

evidence-based social work practice emphasizes
studies that typically involve brief, cognitive, and
skill-focused interventions (reid, Kenaley, & Colvin
2004). typically, these studies focus on intervention
that affects individual change—whether the change is
in thinking processes, emotional responses, or specific
behaviors. The narrow focus of these interventions
readily lends itself to testing and replication. but this
does not mean that they truly reflect “best” practices,
since less straightforward, harder-to-measure prob-
lems and interventions are excluded (otto, Polutta, &
Ziegler, 2009; Wampold & bhati, 2004). reid (2002,
p. 277) captured the potential consequences of nar-
rowing our professional perspective:

an intervention may be effective in reducing a
problem of classroom behavior of a child in an
inner-city school, but this kind of effective practice
could be challenged on the grounds that social
work resources might be better spent involving
community members in changing a school that
is chaotically managed and under-funded. such
a school might not only produce an unending
stream of classroom behavior problems but might
be making a mockery of the very idea of providing
decent education for the children attending.

focusing exclusively on discrete, measurable indi-
vidual behavioral changes ignores the struggle people
experience in dealing with and surviving day-to-day
life challenges, struggles to which the social work pro-
fession is committed to addressing. “[Clients] thrash or
float through interventions without significant, lasting
impact because they fail to engage the core of people’s
lives—the chronic obstacles that bind one crisis to the
next, the extreme experiences…that have become cus-
tomary, the human relationships that may be as toxic
as they are supportive, the unique context in which
each person struggles to survive” (smyth & schorr,
2009, p. 5). Thus, evidence-based practice tends to be
overly reductionistic and simplistic (Cnaan & dichter,
2008; steiker et al., 2008).

a separate body of research suggests that whatever
model or intervention is used, the quality of the thera-
peutic relationship is mostly responsible for positive
or negative outcomes (smyth & schorr, 2009). for ex-
ample, Castonguay, goldfried, Wiser raue, and hayes

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72

(1996) compared the impact of cognitive behavioral
techniques on changing the distorted cognitions of
depressed clients. The cognitive behavioral interven-
tions were compared with two less clearly defined vari-
ables: the quality of the therapeutic alliance and the
clients’ emotional involvement with the therapist. The
researchers found that these last two variables actually
were more highly related with clients’ progress than
the cognitive behavioral techniques under study.

There are more than 100 studies that support these
findings (andrews, 2000). essentially, these studies
indicate that effective therapeutic outcomes are more
related to the quality of the relationship established
between the worker and client, as well as the ability of
a worker to be attuned and responsive to client com-
munications; outcomes are much less related to spe-
cific techniques, models, and protocols (duncan 2001;
smyth & schorr, 2009).

further, the client is a partner in the therapeutic
enterprise (duncan & Miller, 2000; smyth & schorr,
2009). by focusing solely on what the worker does and
ignoring the client’s contributions, evaluation research
designs lead to questionable findings that are of limit-
ed utility. duncan (2001, p. 33) described the relevance
of the client’s contributions:

Why should it be a surprise that the very factors
that were operating in a client’s life before
counseling also have crucial effect on the helping
process? Clients, who are, for example, persistent,
open, and optimistic, who, for that matter, have
a supportive grandmother or are members of a
religious community, are more likely to make gains
in counseling.

finally, outcome studies are not neutral endeavors.
Many are designed and implemented by proponents of
the very approaches being evaluated. essentially, these
studies may be affected by “investigator allegiance”
(betts-adams, leCroy, & Matto, 2009, p. 171). fund-
ing initiatives and availability, primarily defined by
the federal government, as well as managed care re-
strictions by and large determine what type of research
will be valued and carried out. organizational, com-
munity, and collegial pressures also significantly influ-
ence design, measurement, and interpretation of data.

in addition, when practitioners undertake litera-
ture searches to find relevant empirical data, they
have no way of knowing whether a study’s findings
are reliable, valid, and generalizable to their settings
and their clients (tarrier, 2010). The fact that a jour-
nal publishes a study is not sufficient evidence of va-
lidity or reliability. Peer reviewers typically only re-
view researchers’ summary presentation of data and
rarely examine the raw data.

in a postreview of articles published in medical
journals, altman (2002, p. 12) found “considerable
evidence that many statistical and methodological
errors were common in published papers and that au-
thors failed to discuss the limitations of their findings
and that the importance of findings were consistently
exaggerated.” even if peer reviewers successfully re-
jected invalid studies, altman (2002) further discov-
ered that most papers ultimately found acceptance in
other medical and scientific journals. evidence-based
social work practices “can only be as good as the re-
search on which decisions are to be made” (Margi-
son, 2001, p. 174). The question remains, therefore,
how much confidence can social work practitioners
have in the validity and reliability of findings avail-
able from outcome studies?

Inconsistency with contemporary practice. Per-
haps most fundamentally, the realities of contempo-
rary social work practice work against a purely evi-
dence-based orientation. Most social workers simply
do not have access to bibliographic databases and the
peer-reviewed literature, both of which are required to
practice from an evidence-based foundation (Knight,
in press; gira, Kessler, & Poertner, 2004; ruffolo, sa-
vas, neal, Capobianco, & reynolds, 2008). even if they
did have such access, most practitioners lack the time
to read and review such resources, given more im-
mediate and pressing demands associated with their
practice (osterling & austin, 2008).

despite the increased emphasis on teaching social
work students about research, evidence continues to
suggest that practicing social workers lack the skills
and expertise necessary to operate from an evidence-
based foundation (Knight, in press; lord & iudice,
2011; Mullen, bledsoe, & bellamy, 2008; staudt, 2007).
finally, evidence-based practice does not take into ac-
count the team-oriented, multidisciplinary nature of
much of social work practice. Clients often simultane-
ously receive multiple services, making it difficult to
discern cause-and-effect relationships (bledsoe et al.,
2007; soydan, 2007).

Evidenced-guided practice:
major Assumptions

Various scholars have been actively seeking to build
bridges between the art and science traditions, prefer-
ring to use terms such as evidence-guided or evidence-
informed practice (betts-adams et al., 2009; Klein &
bloom, 1995; letendre & Wayne, 2008; Macgowan,
2003; nevo & slonim-nevo, 2011; Zayas, gonza-
lez, & hanson, 2003). We intentionally use the term
evidence-guided to refer to an approach to practice
in which interventions are suggested, rather than
prescribed, by research findings. This is more than a

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73

semantic distinction. evidence-guided practice pos-
sesses the same ethical advantages associated with ev-
idence-based practice. however, it also recognizes the
uniqueness of the individual and the inherent dignity
and worth of the person. evidence-guided practice
reinforces client empowerment and clients’ right to
self-determination. finally, egP is consistent with the
profession’s commitment to vulnerable populations
and social justice, since it adopts an ecological view of
client problems and worker interventions.

Attention to Range of Variables That Affect
Intervention Outcome
evidence-guided practice encourages practitioners to
be consumers of research and to rely upon best prac-
tices. but it also requires practitioners to attend to the
subtle, harder-to-measure variables that also influence
intervention efficacy. as noted, these include, among
others, the worker–client relationship, client and
worker characteristics, worker skill, and practice and
cultural context (Palinkas et al., 2009; Whaley & da-
vis, 2007). Thyer (2010) argued, for example,

there are no such things as evidence-based
interventions. there are research supported
interventions…the phrase evidence-based practice
refers to a ProCess of choosing one’s course of
action, based upon an integration of many different
factors, research evidence being one, but client
preferences and values being another, professional
ethics being a third, one’s own practice skills being
a 4th, environmental resources being a 5th, etc. no
one of these factors has primacy over the others,
even the research evidence.

Thus, egP is inclusive, and it recognizes the range
of variables that come into play in the effective help-
ing relationship. evidence-guided practice means that
social workers should attend to findings from outcome
studies that have been validated and sufficiently rep-
licated. Where egP parts ways with evidence-based
practice is the recognition that the particular choice
of technique to address client difficulties will hinge on
the unique needs and desires of the individual client.
The worker has to be prepared to be creative and come
up with other strategies if those that have been found
to be effective do not work with the particular client.
tarrier (2010, p. 134) summed up the balance of at-
tending to the individual and to the research base:

as a clinician i have to deal with patients as i find
them with all the idiosyncrasies and heterogeneity
that it involves.…to discharge [this responsibility]
i need to be able to derive from the evidence base
the best treatment for that patient as dictated by the

empirical research.…the researcher has established
that a particular treatment works (or not) in
general; the clinician is responsible for application of
evidence to individual patients. (emphasis added)

unlike evidence-based practice, egP explicitly rec-
ognizes relevant theory. Theories, as well as research,
provide significant guidelines for practice. Theories
about phases of individual, family, and group devel-
opment; about ethnic/racial, religious, spiritual, and
sexual identity development; about individual, family,
and group behavior; and about how people change the
structure of social workers’ assessments and suggest
the direction that intervention may take (gray & Mc-
donald, 2006; shdaimah, 2009).

While both theory and research findings about a
broad range of variables are essential to social work
practice, they are not sufficient. The application of
theory and research to practice requires critical think-
ing (gambrill, 2006). This is defined as the ability to
define an issue/stressor/problem; to “distinguish, ap-
praise, and integrate multiple sources of knowledge:”
to formulate a tentative practice direction(s); to self-
monitor, to self-reflect, and to “attend to professional
roles and boundaries” (Council on social Work educa-
tion, 2008, p. 3).

Attention to Artistry
Theory and research evidence provide a base for a dis-
ciplined, scientific approach to engaging and helping
clients. but social workers must also possess the au-
tonomy and flexibility to improvise and to be sponta-
neous. The worlds of theory and research are logical,
orderly, and sequential. in contrast, the lives of people
are confusing, disorderly, and contemporaneous. The
very act of finding the connections among theory, re-
search, and practice often requires a great deal of curi-
osity and creativity (gitterman, 1991).

our needs for certainty and constancy can com-
promise our natural curiosity and ability to tolerate
ambiguity. Prescriptive theoretical frameworks and
evidenced-based protocols may have the unintended
consequence of rendering professional practice more
rigid, devoid of spontaneity and authenticity, and less
responsive to the “messiness” of clients’ lives.

in a particularly telling study, henry, strupp, butler,
schacht, and binder (1993) examined clinicians’ behav-
iors before and after they were trained in using manu-
als to guide their interventions. The researchers found
that those who followed these prescribed interventions
demonstrated “unexpected deterioration in certain in-
terpersonal and interactional aspects of therapy” (p.
438). The therapists reported that their spontaneity and
intuition were curtailed, and clients felt “subjected” to
treatment rather than engaged in treatment. The re-

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74

searchers further observed that “after training, thera-
pists were judged by their clients to be less approving
and supportive, less optimistic, and more authoritative
and defensive” (henry et al., p. 439).

natural curiosity, a willingness to take a risk and
follow hunches, and the ability to learn from mistakes
and make more sophisticated mistakes are the sine quo
non of artistry, as are the ability to “go with the flow,”
to follow client cues, and to be transparent and genu-
ine in our relationships with our clients. informality,
spontaneity, and humor, when appropriate, provide a
significant base for an artistic approach to engaging
and helping clients.

social workers must each integrate professional
methods, knowledge, and skills with their distinctive
style and unique persona (Cnaan & dichter, 2008).
Without this integration, clients often perceive social
workers as mechanical and rote. When social work-
ers rigidly adhere to prescribed interventions, they are
unable to be authentically present or actively listen to
clients’ verbal and nonverbal responses. Professionals
must have the flexibility to follow clients’ messages
and their own professional judgments. in fact, compe-
tence, the capacity to self-monitor, and autonomy are
precisely what makes a social worker a professional.

Practice Illustration
to illustrate an evidence-guided approach to practice,
the authors drew on the group work modality, where
the debate regarding the artistry and science of group
work has been especially intense. group work is in-
creasingly reliant on evidence-based manuals (Caplan
& Thomas, 2003). Critics of the “manualization” of
group work argue that control of the group rests sole-
ly in the hands of the worker, which undermines the
empowerment of members. further, the fixed agenda
found in a manual artificially defines members’ needs
as well as indicators of success. Perhaps most funda-
mentally, the emphasis is on content—that is, what is
in the manual—rather than on the process and mem-
bers’ here-and-now interactions with one another and
with the worker (gitterman, 2011).

Consistent with an evidence-guided orientation,
however, group workers are beginning to recognize the
benefits of evidence-based manuals (galinsky, 2003).
a manual has the potential to sensitize the worker to
the issues that may surface in the group and provide
both the leader and members with a direction for work
(galinsky, terzian, & fraser, 2006). further, clear ob-
jectives and outcomes have the potential to enhance
the overall effectiveness of the group intervention.

from an evidence-guided perspective, the group
worker must be well versed in group work research,
theory, and process in addition to the contents of the
manual. for example, the social worker facilitating a

group must know that much of the driving force of the
group experience is provided by the interplay of mem-
bers’ feelings about the worker’s authority and feelings
about becoming close to each other. in most instances,
the preoccupation with the worker’s authority either
precedes or occurs simultaneously with group mem-
bers learning to trust and become close with each oth-
er (bartolomeo, 2010; schiller, 2010). if the worker ex-
pects to have her or his trustworthiness, authority, and
competence tested in advance, the worker will have an
easier time depersonalizing the testing and developing
appropriate interventions.

to specifically illustrate this concept, consider the
following scenario. Marcus is a social worker facili-
tating an anger management group for adolescents
who are required to attend because of their involve-
ment with the juvenile justice system. Most have been
charged with drug-related offenses and/or assault.
Marcus is using an evidence-based manual that relies
primarily on cognitive behavioral strategies. The man-
ual includes 10 weekly lessons that teach members,
among other things, possible sources of their anger,
how to identify triggers, and techniques to manage
their anger. each session of the group emphasizes a
different lesson and builds upon the previous session.
The manual is prescriptive in that each lesson is laid
out in great detail, including suggested worker com-
ments and required member activities. spontaneous
exchanges between members and between the mem-
bers and the leader are not addressed, implying that
the leader should provide structure for each minute of
the hourlong sessions.

in the first session, the six members of the group—
all young men ages 15 to 17—are silent and appear to
be hostile and disinterested. Marcus astutely recogniz-
es that he cannot immediately jump into the manual’s
“lesson” for the first session, which includes defini-
tions of anger and what triggers angry responses in in-
dividuals. if not addressed, members’ resentment and
anger would lead only to an “illusion of work” (shul-
man, 2009), in which they might go through the mo-
tions of listening to Marcus’s “lectures” and engaging
in the required activities without any real change in
their thinking or behavior taking place. The challenge
for Marcus is that his agency requires him to follow the
manual, so he has to find a way to integrate the lessons
included in the first session with what he sees right in
front of him.

after explaining his role and the purpose of the
group (evidence-based practice that enhances mem-
ber commitment to the group), Marcus directly ac-
knowledges members’ apparent anger about being in
the group rather than starting with the lesson for the
session. he makes this observation: “today we are sup-
posed to talk about what anger is and what causes us

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75

to get angry. given how you all are feeling about being
here, i suspect you can tell me a thing or two about
both of these issues!” This comment initially is met
with hostile silence, but Marcus persists and observes,
“i am wondering whether the group’s silence is a sign
of members being pissed off about being here?” one
of the members, Jonah, responds, “Yeah, man, this is
bull—t. i don’t need no group. i just need to be left
alone!” Marcus then observes, “Jonah is upset, and i
bet he’s not the only one.” other members nod their
heads in agreement. Marcus then says, “Perhaps we
can start there, with you guys talking about the fact
that you are angry that you have been made to come to
this group when you don’t think you need it.” at this
point, samuel, another member, volunteers, “i smoke a
little dope some of the time. so what? it ain’t bothering
nobody, so i don’t see why i have to be here!”

This group is well on its way to being a meaningful
experience for the members, despite their initial un-
willingness to participate. Marcus demonstrates that
one need not choose artistry over evidence or vice ver-
sa. Marcus’s skill as a group worker is apparent as is his
understanding of group dynamics, individual member
behavior, and the group worker’s role. he does not
lose sight of the fact that he is operating from an ev-
idence-based manual that depends upon a particular
sequencing of content. Marcus is skillfully able to link
the two—the process that is occurring in the here and
now with the content that is outlined in the manual.
Marcus reveals his critical thinking ability when he as-
sesses what members’ behavior means and links their
reactions to the intent of the session and purpose of the
group in a meaningful and genuine way.

Marcus quickly realizes that he does not need to
talk hypothetically about members’ anger and what
causes it, as the emotion is right there, staring him
(and others in the group) in the face. had Marcus ig-
nored members’ actual feelings in favor of an academic
discussion of anger and its causes, as dictated by the
manual, he would have lost the group before it even
started. as he acknowledges the young men’s feelings
about the group, Marcus is following the lesson plan
for the first session. but he is doing it in a way that has
meaning for the members and capitalizes on their im-
mediate, here-and-now reactions.

Implications for Social work Education
and practice

evidence-guided practice requires that students be
taught to think critically and to be self-aware. They also
must be encouraged to employ the science of social work
in a way that is genuine and reflects their uniqueness
as individuals. social work education also must teach
students to not just tolerate ambiguity, but embrace it.

social work education must do a better job of prepar-
ing students to value research findings and use them in
their practice. The solution to this problem lies not in
simply throwing more research terms and statistics at
social work students. evidence-guided practice should
be presented and modeled in the practice courses.
staudt, bates, blake, and shoffner (2003–2004), for ex-
ample, have developed the systematic planned practice
model (sPP). Consistent with egP, the emphasis in this
model is on multiple sources of knowledge and critical
thinking. “sPP is not an evaluation design, but rather a
way of thinking about and conceptualizing practice so
that evaluation becomes an integral part of practice….
Within the sPP framework, practitioners must make
explicit their practice decisions, provide rationales for
these decisions, and specify the practice implications
of the decisions” (staudt et al., p. 71).

students themselves have recognized the value of
learning about research concepts in practice courses
(staudt, 2007). Presenting research material in meth-
ods courses legitimizes its importance for practice and
demystifies it for students. Yet, egP is more than the
application of research concepts, as we have discussed.
evidence-guided practice reflects an ecological per-
spective and depends upon worker self-awareness, use
of self, critical thinking, and a solid grounding in the-
ory, each of which should already be an integral part of
any practice/methods course.

in a different vein, egP requires support from em-
ploying organizations and academic institutions in the
form of access and time for social workers to consult
the literature, particularly bibliographic databases. in
addition, the professional literature needs to be pre-
sented in a way that allows practitioners to easily and
quickly grasp essential information (osterling & aus-
tin, 2008; staudt, dulmus, & bennett, 2003). several
recent developments in the field are promising. gary
holden’s information for Practice website (http://ifp.
nyu.edu/) is easy to use and practitioner friendly. it
contains recent research relevant to contemporary
social work practice and is available free of charge to
anyone who logs on to the site. similarly, the Min-
nesota Center for social Work research (http://www.
cehd.umn.edu/ssw/research) regularly publishes a free
newsletter that summarizes recent research and pres-
ents it in a way that is accessible to practicing social
workers. unfortunately, it is unlikely that most social
workers practicing today are aware of these and other
such resources that support egP (lord & iudice, 2011).

social workers are caught between agency mandates
for documenting positive outcomes and what they
have been taught about an ecological, client-centered
approach in social work. The challenge is to encour-
age agencies and funding sources to adopt this more
ecologically focused approach to practice. evidence-

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76

guided practice provides practitioners with the tools
necessary to employ research findings, and it has
the added advantage of encouraging workers to take
into account the range of variables that inevitably af-
fect practice outcomes. borrowing from smyth and
schorr’s (2009) discussion of what it takes to provide
effective interventions, particularly to marginalized
populations, the authors propose that egP adhere to
the following principles:
1. trusting relationships—between worker and client,

between client and significant others—are central to
effective outcomes.

2. Clients must be active and informed partners in the
social work endeavor.

3. Clear standards for practice must be balanced
against flexibility in the face of client needs
and circumstances.

4. The agency and worker must take into account and
be prepared to intervene in the wider
social environment.

5. Workers must be accountable for their actions
and must continuously use research to guide their
practice and refine and improve program design and
delivery of services.

conclusion

We conclude with the suggestion that efforts to identify
best practices must continue, but must be expanded to
include the more subtle, hard-to-measure variables that
we have identified. such research is not impossible to
conduct, as the results of studies cited in this article in-
dicate. What is required, however, is greater advocacy
on the part of social work practitioners, educators, and
researchers for financial and organizational support for
a broader, ecologically based approach to research.

increased attention also needs to be devoted to iden-
tifying how to get information to practitioners in a
way that makes it easy for them to use. as noted, there
are forums that already provide valuable information
to guide clinicians in their practice, and more such
sources are appearing all the time. however, these in-
formation clearinghouses are only as good as the con-
sumers who use them.

social workers must embrace scientific methods to
guide their practice. They also must uphold their pro-
fessional responsibilities and commitment to social
justice and to a multidimensional view of clients and
the challenges they face. and finally, they must hold
on to their humanity, spontaneity, and passion for
making a difference in people’s lives. evidence-guid-
ed practice, as described in this article, allows social
workers to do just that.

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Alex gitterman, edD, Zachs professor of social Work, University
of Connecticut. carolyn knight, msW, phD, lGsW, professor, Uni-
versity of maryland. Correspondence: [email protected];
University of Connecticut, school of social Work, 1798 asylm ave.,
West Hartford, Ct 06117.

Authors’ note. We express our appreciation to professors Heller and
Klein for providing suggestions to an early draft of the manuscript.

manuscript received: June 18, 2012
revised: september 18, 2012
accepted: october 2, 2012
Disposition editor: Jessica strolin-Goltzman

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