Using the Precursors Model of Change to Facilitate Engagement Practices in Family Counseling

Precursor 1: Sense of Necessity for Change

A sense of necessity is present when one experiences an urgency toward, need for, or some recognition of, a change of circumstances through which positive change can occur (Hanna & Ritchie, 1995). This precursor has long been noted as an important characteristic of change in the counseling literature (McMullin, 1999; Power, 1981; Whitaker, 1989). Epictetus (c. 130/1944), the second century philosopher often noted for his cognitive view of the interpretation of events, recognized necessity as a fundamental aspect of freedom. For families that actively seek therapeutic support, it seems natural to believe that such intentionality denotes a sense of necessity for change (Lynch, 2014). However, many families display strong intentions for change without ever grasping the volitional aspect of necessity. In some cases, this sense may be directed at the wrong problem altogether, as when an identified patient serves the role of scapegoat amid serious systemic issues (Rasheed, Rasheed, & Marley, 2011).

It is the combination of intention and volition that represents the key difference between giving mere lip service to change and sensing that something must change immediately (Hanna, 1996). A genuine sense of necessity often results in a strikingly different level of therapeutic involvement than seen otherwise (Hanna, 2002). Attending to this precursor requires that counselors recognize the degree of necessity for change across the family system and grow necessity for each family member. Insofar as the grounds for establishing a sense of necessity may reveal different motivations among individuals (Haine-Schlagel & Walsh, 2015), it is important to be aware of motivating factors at play for each member of the system. In other words, matching the motivational impetuses among family members may at times be less effective than establishing a uniquely inspired sense of necessity for individuals.

The precursors model highlights a number of techniques and strategies designed to establish a sense of necessity for change. In all cases, counselors are directed to assist the family in discovering the benefits of change and overcoming barriers that hinder necessity (Hanna, 2002). Some of these interventions include aligning therapy with something of value to the family, creating cognitive dissonance, discussing the level of importance the family assigns to change, acknowledging ambivalence, clarifying secondary gains, identifying core beliefs, reviewing the consequences of not changing, and addressing subpersonalities that are interested in change (Hanna, 2002). These are well-established interventions in counseling and psychotherapy, which reflects the overarching value of the model as a means to match each precursor with a variety of potentially appropriate techniques.

In terms of the vignette, a sense of necessity is clearly present for Sue and Mike but not for John. Creating cognitive dissonance using a three-stage reality therapy technique (Glasser, 1965) can increase John’s sense of necessity. The first question would be “What do each of you want for the family?” If John says that he wants to improve his relationship with Mike, the next question would be “What have you done to improve that relationship?” John may provide examples of past efforts, lament Mike’s lack of responsiveness, or perhaps note his uncertainty about what to do. Reflecting that despite John’s desire to improve the relationship it remains abrasive and argumentative, the counselor would ask, “Is your current approach to the problem working?” From here, a discussion as to how counseling might be useful to explore new approaches to the problem can facilitate buy-in and establish John’s sense of necessity for change, thereby further engaging the family system.

Precursor 2: Willingness or Readiness to Experience Anxiety or Difficulty

This precursor relates to the degree to which one is willing to experience the persistent anxiety, discomfort, difficulty, or hassle that so often accompanies the change process (Hanna, 2002). Altering habitual patterns of thinking and behaving can be an uncomfortable experience, and many clients balk at the prospect of such a challenge (Sexton et al., 2003). Nonetheless, this precursor, in various formulations, has long been cited as an important client change variable (Hanna, Giordano, Dupuy, & Puhakka, 1995; Mahoney, 1991; Mahrer, 1989). Even when a family system recognizes a necessity for change, the anxiety or daunting challenge that arises as part of the change process may seem too much to endure. This precursor draws attention to this challenge, highlighting the importance of confronting affective difficulties that may arise in response to the idea of change (Scheel, 2011).

When families seek therapeutic support, detrimental patterns of avoidance within the system are often the culprit (Carr, 2012; Henggeler & Sheidow, 2012; Rasheed et al., 2011). The most obvious example may be found in terms of communication styles, such as handling conflict by blaming others, enacting punishments, or clearly avoiding important issues in order to reduce anxiety. Such avoidance techniques are effective short-term solutions that often lead to ineffectual, long-term problems (Ryan, Lynch, Vansteenkiste, & Deci, 2011). Working together as a family unit to deal with such systemic communication issues takes a willingness to experience the difficulties that come with resolving interpersonal differences (Hanna, 2002). Problem-solving can be anxiety provoking when viewpoints on the source of the problem differ among family members. Effectively changing such entrenched patterns may require helping the family overcome specific blocks to experiencing anxiety or difficulty, so that systemic transformations become possible.

The interventions for overcoming such difficulties are numerous and, as in all of the precursors, quite well established. These include methods for confronting responsibility, eliminating the tendency to blame others, self-monitoring the ebbs and flows of anxiety, using paradox, pinpointing internal dialogues of avoidance, supporting experimentation, identifying core beliefs, and applying metaphors (Hanna, 2002). In terms of metaphors, family counselors can reframe an unwillingness to experience anxiety by discussing the inherent challenge posed by the process of change. For example, metaphors such as “no pain, no gain” can be as easily applied to mental challenges as to physical ones. The “old pipes, dirty water” metaphor parallels such challenges with the notion that old, rusty pipes emit dirty water until the water runs long enough to become clean, or for the problem to run clear (Hanna, 2002).

In terms of the vignette, Sue and John tend to blame Mike for current problems without taking responsibility for their contributions. To confront the tendency to blame others, counselors can clarify how assigning blame is a method to avoid the anxiety of responsibility (Yalom, 1980). Challenging Sue and John with questions such as “Has blaming Mike actually reduced the difficulty of this problem?” “Is having someone to blame important in your family?” or “How is this problem controlling your family?” can be a catalyst for discussing how the family system views responsibility (Hanna, 2002, p. 220). Exploring the precursors is often a direct rather than a passive process. While these questions are confrontational in nature, the timing and genuine curiosity of the counselor are required in order to open an effective dialogue on the topic of systemic patterns of blame and responsibility (Hanna, 2002).

Precursor 3: Awareness of the Problem

This precursor has been widely identified as an important change variable (Hanna & Puhakka, 1991; Hanna & Ritchie, 1995) and is directly related to the idea of consciousness-raising (Prochaska et al., 1992). While families may seek counseling because they recognize a problem exists, most are unaware of the systemic nature of the problem. Sometimes this results in misidentifying the problem, as in scapegoating (Rasheed et al., 2011). In other cases, there may be a familial recognition of general systemic problem while the complexity of its subcomponents is overlooked. For example, a family may agree that blame and arguing are serious family problems but remain unaware of how contributing factors such as secondary gains at both the systemic and the individual level maintain the problem. In other cases, parents may recognize that a particular method of discipline is ineffective but remain unaware of how that form of discipline both stems from and actively contributes to systemic conflict and interpersonal communication problems.

If therapeutic change is to occur within a family system, an awareness of the problem itself can be of considerable value (Hanna, 2002). This is a primary purpose of clinical assessment in evidence-based family approaches, as it becomes a role of the counselor both to identify patterns that contribute to family dysfunction and to address those issues using interventions (Henggeler & Sheidow, 2012). While the precursors model supports systemic pattern identification and intervention, it further asserts that an awareness of the problem should also include an understanding of factors that contribute to the problem. In this respect, it requires a degree of perceptual clarity related both to the problem itself and to the inadvertent role of the family system in its maintenance. It becomes the responsibility of the counselor to help the family increase their clarity of perception, as it can be hard to recognize the complex motivational dynamics of a system from within the system itself (Hanna, 2002).

Interventions for building awareness from the precursors model may include direct or active confrontation, the empty chair technique, identifying automatic thoughts or core beliefs, using paradox, enhancing tolerance for ambiguity and confusion, applying metaphors, role-playing, implementing awareness-building reframes, and helping clients locate feelings as bodily sensations (Hanna, 2002). Established methods such as family sculpting can be used to encourage empathic awareness by having family members act out a scene as if they were another family member, thus granting the portrayed individual an alternative view of how they are perceived (Satir, Banmen, Gerber, & Gomori, 1991). Effective variations on family sculpting may include the use of acting-out-theater from psychodrama therapy (Hanna, 2002). In all such interventions, the focus is on growing awareness and insight.

In terms of the vignette, there is a general lack of consensus on the source of the problem. While the family agrees that something needs to change, both the parents and the son identify one another as the source of family distress. Some clarity might be brought to this situation using family sculpting. If Mike were to portray his mother and father as standing over him while he huddles low to the ground with his back turned to them, the potential to grow Sue and John’s empathic understanding of Mike’s sense of his place in the family system could dramatically influence their awareness of the problem. At the same time, if Sue portrays herself as crying with her hands over her face while John turns away and Mike yells, both father and son might grasp their own impact on Sue’s experience. Such symbolic representations can grow awareness of the problem from multiple perspectives, providing a unique opportunity to evaluate and empathically address role perceptions across the family system.

Precursor 4: Confronting the Problem

Without awareness, there is no established problem to confront, but without confrontation, there is little chance that awareness alone will lead to change (Hanna, 2002). There is a considerable difference between admitting to the existence of a problem and examining it in detail since the latter requires sustained attention, or an active desire to directly face the very problem of which one is aware. Additionally, confronting a problem can be an anxiety provoking process that requires a willingness to experience difficulty as well. Yet, despite the close relationship between confronting the problem and both awareness of the problem and a willingness to experience anxiety, it remains distinct insofar as it is an observational process involving sustained attention to the identified problem.

Confronting the problem is a powerful force for positive change (Hanna & Puhakka, 1991; Hanna & Ritchie, 1995; Pennebaker & Beall, 1986; see also James, 1981). It appears that the processes of exposure and systematic desensitization associated with behavior therapy may derive their power from this precursor (Hanna, 2002; Hanna & Puhakka, 1991). Confronting can be understood in the context of mindfulness as well and indeed is understood that way in Buddhism (Pandita, 1991) which serves as the source of mindfulness techniques. It should be kept in mind, however, that a family’s ability to confront a specific problem is not a global condition, as each individual must often come to such a recognition on their own terms (Carr, 2012). Counselors must be prepared to implement relevant techniques that can help both individual family members and the family system as a whole confront problems in a meaningful and sustained manner.

While the interventions related to this precursor are quite varied, each serves to increase one’s direct, focused, sustained attention toward a specific problem; even when it is confusing or stultifying. Interventions for confronting the problem include applying the miracle question, discussing how the problem could be worse, using a mirror to enhance self-consciousness or self-confrontational dialogue, confronting hesitancy about change itself, or implementing strength-oriented metaphors (Hanna, 2002). For maintaining the ability to confront a given problem, interventions include concentration training, distinguishing between immersion in observation of thoughts, concretizing the problem by acting as though an object is a physical representation of the issue, or the use of in vivo confronting as a variation and expansion of the systematic desensitization technique (see Hanna, Hanna, & Keys, 1999).

In the vignette, the onion peeler technique (Perls, Hefferline, & Goodman, 1951) helps clients examine thoughts, feelings, and interactions beyond the behavioral or observable level. For example, the counselor might repeatedly asking Sue the question “How does Mike’s behavior look to you at this point?” in order to dissolve her sense that Mike is the problem (Hanna, 2002). If Sue defends her position with statements such as “He looks angry and resentful” or “It looks selfish,” the counselor would continue with the basic question, “How does Mike’s behavior look to you now?” Following multiple repetitions, Sue will begin to make more personal statements such as “It looks like he doesn’t love me” or “He looks like he’s trying to hurt my feelings.” Her statements may come to reflect her own contribution to the issue, such as “He looks defeated and withdrawn” or “He looks hurt and confused.” Through a process of sustained attention, the problem has been confronted in a way that can enhance individual awareness of the problem and grow insight into systemic patterns.

Precursor 5: Increasing Effort or Will Toward Change

This precursor clearly highlights the importance of action, and research has long pointed to the exertion of effort as an important aspect of therapeutic change (Axsom, 1989; Omer & London, 1989; Strupp, 1996; Yalom, 1980). Like its fellow precursors, effort is a common factor of change that Axsom (1989) called a “central feature of therapies” (p. 234). A. A. Lazarus (1989a) noted that the success of therapy largely depends upon how much effort is expended by a client. Even if a family has established every other precursor, lack of action can still prevent positive progress. While this seems an obvious requirement for therapeutic engagement, monitoring the degree of effort exerted by clients outside of counseling itself can be a challenge (Mahoney, 1991). By attending to this precursor, counselors are prepared to monitor a family’s degree of effort and address specific barriers such as time constraints, self-efficacy issues, and general uncertainties about how to enact newly introduced strategies.

Families tend to recognize the challenge of acting on new insights, ideas, and interventions. Changing entrenched habits and patterns is a difficult process, even when it comes to seeming simple behavioral tasks. Whether it be paying bills, doing dishes, completing school assignments, or following household rules, families can struggle when it comes to converting their plans into relevant actions (Rasheed et al., 2011). A lack of impetus to follow through with more dynamic, complex strategies—such as altering specific communication patterns during an argument—can quickly derail the change process. Since the barriers to exerting effort or will toward change appear in many forms, counselors must take on the challenge of identifying and then assisting family members in the process of overcoming such barriers (Sexton et al., 2003).

Some of the interventions set forth by the precursors model to increase effort or will include the use of immediacy, disputing core beliefs, identifying negative self-talk, applying metaphors, using graduated tasks, providing goal clarification, tasking the client with self-observation practices, and gauging client desire for change by mapping intentions and counterintentions which enact and block action, respectively (Hanna, 2002). In terms of the vignette, using a self-observation task may be useful for this family. For example, instead of assigning a new intervention for homework, the counselor can ask all family members to make no changes at all. Rather, they are assigned the task of observing family interactions and then writing these observations down before the next session. This should include notes on their own contributions to a conflict, which can be identified and discussed in session. By highlighting their own behaviors, the family is better prepared to exert effort toward change before a new strategy is initiated by grasping how current behaviors contribute to the problem.

Precursor 6: Hope for Change

Hope can be simply defined as the realistic vision or expectation that positive change can occur (Hanna, 2002). Hope plays an important role in the change process, with evidence from the coping literature highlighting its influence on our ability to handle difficult situations (Korner, 1970; R. S. Lazarus, Kanner, & Folkman, 1980; Snyder, 1994). Interestingly, hope is also closely related to Bandura’s (1977) formulation of self-efficacy, and J. Frank (1968, see also J. D. Frank & Frank, 1993) identified hope as the vital operating factor in the placebo effect. Evidence-based family approaches articulate the value and importance of instilling hope in the therapeutic process (Carr, 2012; Henggeler & Sheidow, 2012; Sexton et al., 2003). Whether by focusing on family strengths or enhancing confidence in the treatment approach and counselor competency, hope is clearly an invaluable aspect of therapeutic change (Hanna, 2002; Sexton et al., 2003).

The instillation of hope is not simply a matter of wishing or longing. It involves the ability to solve problems and overcome obstacles to goal attainment (Hanna, 2002). This can be quite challenging for families that have been unable to achieve positive change despite best efforts. However, instilling hope can produce an upswing in a family’s mood and general outlook (Snyder, 1994). The hope-building methods set forth by the precursors model are meant to create a sense of empowerment. Some interventions include telling stories of people who have successfully enacted change, identifying core beliefs about future outcomes, reframing negative behaviors as skills, converting a threat into an opportunity, identifying courses of action and testing them through role plays, and maintaining a high level of hopefulness such that the client is inspired by means of contagion (Hanna, 2002).

It should be noted that counselor creativity and outlook are important factors in the process of instilling hope (Hanna, 2002). In many families, the basic desire for cohesion and loving support can inspire profound visions of hope toward creating change (Rasheed et al., 2011). When such inspiration is paired with appropriate and realistic interventions, the possibilities can unfold in profound and inspiring ways. In terms of the vignette, the counselor might choose to reframe certain negative behaviors as skills. If Mike has been manipulative, the counselor might admire the skillfulness with which Mike gets his way and then highlight how his ability to get what he wants could be put to other, more positive uses. His tenacity may reflect leadership or even entrepreneurial skills, and related opportunities might be further explored. Such a discussion can help the family build hope toward change by seeing how problems can be transformed into unique growth opportunities (Hanna, 2002).

Precursor 7: Social Support for Change

Of all the precursors, social support is the most self-explanatory. Families require social support from both within and outside the family unit in order to enact change (Carr, 2012; Rasheed et al., 2011). Research has long supported the idea that social support is a factor in therapeutic change (Beutler & Clarkin, 1990), and it has been identified as a source of spontaneous improvement in some cases (Lambert, 1992). For example, depression is occasionally alleviated through the establishment of social support alone (Sarason, Sarason, & Pierce, 1990). Within the family, it is important to develop a sense of collaboration toward intended therapeutic goals. Of equal importance is the elimination of contact with others who act to harm the family or impede positive therapeutic change (Hanna, 2002). Counselors can also help establish wraparound services that prevent family isolation once counseling has been terminated (Sexton et al., 2003).

The precursor interventions for social support may include teaching social skills, exploring issues of trust, entry into group therapy, identifying social supports, identifying parties who interfere with change, reestablishing contact with supportive parties, using A. A. Lazarus’s (1989b) concentric circles technique, and empathy training (Hanna, 2002). Support-oriented training via role-plays, rehearsals, and graduated tasks may help clients overcome barriers to the establishment and maintenance of social supports (Hanna, 2002). In terms of the vignette, the concentric circles technique could be used to help the family identify various sources of support, both within and beyond of the family. Conducting this technique at the beginning and end of the treatment can serve to highlight changes that have taken place through treatment. By having an open discussion on how the family perceives their support system, specific interventions can be delivered in order to fill gaps or confront issues of isolation.