As we note elsewhere, the structured assessment process we describe does not have the formality of a pre-ordained structure, but without doubt ‘orientation’ – its first step – should never be omitted or skipped through as if it simply were a polite and warm introduction. It lays the foundation stone of any collaborative approach.
As we later describe, it is re-visited whenever things later get stuck.
After initial introductions, undertaken to ensure the presence of all feels valued, the orientation begins with an enquiry to establish what each present brought as expectations brought to session, including those of the therapist/s. No misunderstandings or doubts can be skated over, not just because unresolved these would impede engagement, but also because the care and means taken to address these sets the tone for the whole session.
In particular, respectful curiosity, all contributions listened to and, as the orientation proceeds, the beginning of asking relational questions:
Did you know that Helen was worried about coming/anxious that she’d miss a whole block of work/wouldn’t mind if she got upset because at last the family was talking about what upsets everybody/do other people feel the same/what about Gran at home – did she say what she thought about this meeting, what she was hoping from it/anybody else rather they could speak for a few minutes on their own?’ …
Confidentiality concerns often proves less of an issue than textbooks from other psychotherapeutic modalities state, as most family members bring an awareness of how much is already known within the family, by observation/overhearing if not directly informed about it, etc. Most are also glad that the perspective of each can be available and each present usually wish to be helpful even if they don’t initially see how. Once initial data-gathering becomes established, just how much people know and what they’ve tried to do to help of course becomes clearer.
Confidentiality concerns can’t be skated over and are among the most frequent reasons for agreeing to meet one or more family members separately. However, we propose starting therapy by remaining together for the first part of the appointment because, as often as not, the family member who wished to have time on their own finds the means to raise what they had wanted to talk about whilst others were still present (in systemic terms, their contribution is then all the more effective).
The orientation is completed by outlining the assessment process, what will happen and how long it will take. This will include:
- how questions will be asked
- about what (the possible scope of enquiry as well as of immediate concerns)
- the importance of listening to what each other say
- the need for follow-up questions (to clarify/better understand what has been said), so may sometimes interrupt (to check a developing understanding, or to see what other people think/remember, etc.)
- that the therapist(s) hope to summarise as they go along
- the therapists talking to one-another (reflection-in-action) whilst the family listens. The family’s thoughts about what is then said are also privileged
- the assessment will conclude with a shared understanding of how to make sense of the problems that brought the family to the service; and if that proves not possible, what else might be needed and how to go about that
- the meeting will conclude with the broad outline of a formulation-driven treatment plan
The orientation is not complete without eliciting the family’s understanding and approval of it. Again, it is important to address any misunderstandings or residual doubts. Most therapists’ disposition is polite and respectful, so might not proceed with pressing on in any enquiry that seems ‘off limits’. If a family member’s doubts can’t be fully resolved, an open acceptance of these is essential (including the proposal to re-visit these later) and might still allow an engagement sufficient to proceed with the assessment.
Re-orientation: when therapy seems ‘stuck’, re-visiting the orientation is the first step in taking stock of the situation. Scott Miller’s Session Rating Scales (SRS) emphasise the importance of constantly eliciting feedback and evaluating with the family the engagement and orientation to therapy.
Most if not all ‘therapy problems’ are due to unresolved problems in how family issues had been formulated and how ‘listened to’ family members perceive they have been. This could have arisen from inadequate reflection on ‘what is known’, but much more often is because the difficulty in understanding is due to significantly incomplete knowledge of all issues salient to the formulation (so the formulation could never have been sufficient to guide intervention-planning in the first place).
That in turn is an unarguable indication of an incomplete assessment, sometimes too quickly entered before orientation was completed (under pressure of time, wish to quickly help to begin solving the family’s problems) or – as we describe elsewhere – because an emergent issue had seemed compelling and mistaken as a sufficient reason for the problems.
Completion of this first phase of the initial consultation may take only 5-6 minutes but if it takes 50 minutes none of that time has been wasted. The care taken becomes amply rewarded by the trust and relationship that has built up, and the resulting greater openness often leads to a far from slow unfolding of the family systemic issues salient to referred problem.