‘Seeking permission’: an interviewing stance for finding connection with hard to reach families

‘Seeking permission’: an interviewing stance forfinding connection with hard to reach families

Percy Aggetta, Mary Swainsonb and Dave Tapsellb

The systemic therapy literature is dominated by clinic-based accountsof therapy. The work of an outreach, home-based therapy team isdescribed, in a tradition of systemic therapies which directly seek tochallenge service access constraints and social injustice. In payingcareful attention to the micro-interactions of initial contact, seeking per-mission is suggested as an interviewing stance for connecting with fami-lies who are not engaged with services, where there have been historiesof partner violence.

Keywords: hard-to-reach; home-based; social exclusion; social justice; permission.

Author voice/location

The authors are white, European and middle class; two men and onewoman. Two are in heterosexual partnerships, all have children andone is a grandparent (Rich, 1986). The interviewing stance describedin this article, seeking permission, was developed as a response to thedilemmas experienced by an outreach team, in working with themothers of children, mostly boys, defined as having severe conductdisorder; all of the mothers having experienced extensive partnerviolence.

Introduction

There has been a core concern of UK government policy in the last10 years that community mental health services in the UK have notbeen targeting those most in need. Both in adult and child mental

a Head of Family Therapy, Child and Family Consultation Service, East LondonNational Health Service Foundation Trust, York House, 411, Barking Road, E13 8AL.E-mail: [email protected].

b Family Therapist, Child and Family Consultation Service.

Journal of Family Therapy (2011) ••: ••–••doi: 10.1111/j.1467-6427.2011.00558.x

© 2011 The AuthorsJournal of Family Therapy © 2011 The Association for Family Therapy and Systemic Practice. Published byBlackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA02148, USA.

health services a number of central government papers, policies andfunding streams have sought to address this discrepancy (Depart-ment of Health, 2009). However, there are several meanings inher-ent in the ‘increasing access’ policies. One is shown in the UK’sNational Health Service initiative in which brief therapies, notablycognitive-behavioural therapy, are being made more widely availablefor the commonest presentations (National Mental Health Develop-ment Unit, 2010). One of the core assumptions in this project is thatthe patient is present and available, motivated to seek treatment,and has given full consent. This also applies to the many action-based parenting programmes on offer (Department for Education,2010).

A second stream of policy has been concerned with those familieswho are not accessing services generally and are not present andavailable (Cabinet Office, 2008). A core theme is that those most at riskfor poor life chances are suffering multiple disadvantages that areinteractive and cumulative. Connected in this loop are structuralpoverty, child and adult mental health, individual attainment, parent-ing, gender-based violence, patriarchy, felt powerlessness and stigma.In these papers, multi-agency working, information-sharing, risk andprotection are prioritized.

Just as cognitive-behavioural therapy, motivational interviewing(Miller and Rollnick, 1991) and the many parenting programmeshave come to dominate service provision where clients are present,available and consenting, the systemic therapies might be wellplaced to deliver effective mental health services to families embed-ded in complex, incoherent service matrices where the contrarymight be the case (Sundelin and Hansson, 1999; Waldegrave, 2009).In the former there might well be concordance, agreement andcommon ground (McGee et al., 2005) between therapists andclients, particularly in relation to the importance attached to talkingas a means to resolve problems; in the latter, there may be farless so. Clients in the former domain are seen as having the capa-city to perform effectively in the world and might accept an invita-tion to do so; in the latter, the world is acting on the clients, beatinga path to their door. Indeed, outreach therapy is coming underincreasing scrutiny from many quarters as community therapists,sometimes alone in clients’ homes, are working within a contextof competing governance frameworks, giving clients entitlementto information privacy and the need to share information acrossagencies.

2 Percy Aggett et al.

© 2011 The AuthorsJournal of Family Therapy © 2011 The Association for Family Therapy and Systemic Practice

The reframe team

The reframe team is a specialist child and adolescent mental healthoutreach team for children between the ages of 5 years and 13 yearsexhibiting severe conduct problems, based in a Child and Adoles-cent Mental Health Service (CAMHS) in the East End of London,UK. The local community is high on all indices of social and eco-nomic deprivation and a significant proportion of the clinic’s fami-lies have experienced partner violence, parental mental healthproblems, corporate care and educational exclusion. The team wasset up in 2003 to address the needs of a core group of conduct-disordered children who were known to education, social services,health agencies and the non-governmental sector but who weretreated in an uncoordinated way. These children tend to showpersistent patterns of aggression and antisocial behaviour and thefamilies themselves were deemed hard to reach and marginalized(Vetere and Cooper, 2001). Like outreach teams generally, theteam faced a dilemma around two contrary mandates: the require-ment to share information with other agencies in complex networks,a child safeguarding function, along with the need to deliver thera-pies for complex behavioural problems, while at the same timebeing clear that the family has given permission and consents totreatment.

Combating access problems, social justice and systemic therapy

In reviewing the literature we were struck by the paucity of articleslinking the nitty-gritty of family therapy practice with the broaderissues of social justice. In a review of the five journals in the USAKosutic and McDowell (2008) found that out of 1735 articles pub-lished between 1995 and 2005 about 20 per cent included a significantfocus on issues of social justice and the authors draw our attention tothe dearth of articles on social class (p.157). Indeed as Beitin and Allen(2005) and Waldegrave (2009) point out, research linking the practiceof family therapy with social justice is scant.

However, woven through systemic therapy writing in the last 30years has been a core concern with justice issues. Minuchin (1974)began his work with marginalized families and Hare-Mustin (1978),Goldner (1985), White and Epston (1990), Hardy and Laszloffy(1995), McGoldrick (1999), Falicov (2003), McCarthy (2001) andWaldegrave (2009) have all put issues of justice and equality in theforeground.

Home based family therapy 3


However, much of this groundbreaking work took place within theclinic office setting. Many therapy accounts in the literature describefemale clients, often following male violence, entering a closed spacein a clinic with a therapist who is often a man. With many services nowembracing work outside the clinic, in the home, for example, we wereinterested in how outreach systemic work is currently being theorized.Kosutic and McDowell (2008), for example, make a number of rec-ommendations about the practice of justice work but do not considerthe special challenges thrown up by off-clinic work.

Aponte et al. argued in 1991 that ‘Home-based services are aneffective tool for working with high-risk families who do not respondto traditional in-office services’ (p. 403). In the home therapyliterature early papers were written in the UK by Cottrell (1994)and Messent (1992). Cottrell looked at issues of seating, attendance,disruptions and timing. Research in the USA and Australia hasadvocated the home therapy approach (Cortes, 2004;Huston andArmstrong, 1999; Thompson et al., 2009; Woods, 1988; Woodford,1999) and particularly that services take account of the multiple socialpressures on single female carers (Wisdom et al., 2009). Fuller (2004)has argued that therapists in the home need to pay attention to therules of conduct:

Whereas in the clinic you want to engage the family so they will comeback, in home-based therapy it is necessary to engage the family so thatthey will let you back in! (Fuller, 2004, p. 179)

Christensen (1995) found mixed feelings about home visiting in astudy of therapists doing home-based therapy, though interestingly, itwas the trained family therapist who found the method most useful.Indeed, although marginalized families show high drop-out ratesfor all forms of therapy (Sundelin and Hansson, 1999), many of thebest validated multi-systemic approaches make extensive use of homevisiting (Carr, 2009; Henggeler and Borduin, 1990).

Another US family therapy tradition focusing on access, equalityand justice issues, often termed community family therapy, makesextensive use of home visiting and off-clinic work (Almeida et al.,2008; Carroll, 2007). In the UK there is a growing tradition of familytherapists working outside the clinic, in schools, general practicesand homes. In adult mental health, home visiting has been crucialin the work of the Somerset team (Burbach and Stanbridge, 2006);Peter Jakob’s team, following Omer, have developed strategies forde-escalating violence in the home ( Jakob, 2006; Omer, 2001, 2004;



Omer et al., 2008). Another research theme has focused on thesubjective experiences of clients entering the clinic setting and onthe fact that a number of clients favour a flexible approach to servicedelivery (Reimers et al., 1994; Van Lawick and Bom, 2008; VanOrman, 1996).

A core dilemma, amongst others, for these teams, is how therapistsfind ways to engage with families who are not present, available andconsenting, particular where there are ongoing issues of risk, and inhomes where there may have been histories of violence (McCarthy,2001;Weakland and Jordan, 1992; Waldegrave, 2009).

Performing permission-seeking

Permission-seeking is a response to the difficulty we experience inengaging and then working on an outreach basis with families withchildren and young people who exhibit extreme violence and disrup-tive behaviour. What became clear in our work is that these familieshad histories of disrupted and conflicted relationships with helpingagencies and were not accessing child mental health services. Theywould be referred repeatedly to specialist mental health services butwould either not attend or would attend for a single appointment andthen not return. Often, they were referred by the child safeguardingagencies.

We found that it was common both within our service and the widernetworks to describe these families as hard to engage, resistant orhighly dysfunctional. In persisting with making contact with referredfamilies and discussing with them their view of helping agencies webegan to develop the idea that it was not the families who were hardto engage, but that the families experienced the services as hard toengage with. What is more, families’ retreat into the margins mightalso be understood as a strategy to maintain safety in what theyperceive as a hostile environment.

Seeking permission grew out of the tension between being askedto do therapy in the home, given that this is also a context wherethere has been gross misuse of power and gender-based violence.Usually this misuse of power has been aimed at women, primarilymothers. So, seeking detailed permission of the mother presents anongoing challenge to an embedded discourse of powerlessness, andthis then begins the process of shifting authority back to the motherin relation to their children’s, usually their son’s or sons’ behaviour.This stance is also helpful in challenging power imbalances in



differences between the therapist and the family, such as gender,race and culture, thus opening a space where these issues can beopenly discussed.

Seeking permission, in practice, means asking the client’s permis-sion to proceed at all steps in the process of engagement. This is incontrast, perhaps, to one-off permission-seeking, a moment at theonset of therapy when permission is sought, for example for video-recording. So, from the very first phone call onwards the therapistasks tentatively for permission to proceed. As we began to work in thisway we found ourselves engaging with 95 per cent of the familiesreferred to the team, families who had been consistently described byservices, including ourselves, as hard to engage.

As we developed these conversations with clients and colleagues webegan to change from trying to find ways of fitting the family to theclinic and wider services, to finding ways of fitting the clinic or widerservices to the family. In essence we started to think about where thefamily would want to be seen, if given a choice. In a large number ofcases the family choose to be seen at their home; others choose theschool and in some cases, following discussion, others opt to be seen inthe clinic. We work where the family wants to work, which is mainly inthe home.

The context of violence is often the highest context marker for usin our work with isolated families; violence is an act that is embeddedin patterns, sequences of talk and relationships (Vetere and Cooper,2001). It therefore influences other relationships including thatbetween the family and the helper.

As our conversations with these families developed we becameaware of a bind that services and families become habitually caught upin: therapy is a conversation-based modality. We introduce the ideathat talk is a good thing and attempt to invite others to join a moreuseful conversation. Often we converse in English with families forwhom English is not the first language. For the isolated families withwhom we are working, for whom violence is so often entwined withdaily conversation, the idea of talking may often be seen not as asolution but as a potential area of difficulty. The invitation to talkabout something often precedes a violent act. It could be argued thatalmost all violence is preceded by some form of verbal exchange.Therefore, it is not unreasonable for families and individuals whohave experienced considerable violence to think that talking may be apart of the problem and not part of the solution. Thus we wonderedwhether a reluctance to engage in talking with therapists might be



explained by the context of risk in which the families had experiencedtalking. We therefore began to think carefully about how we negoti-ated our contact with the family.

Seeking permission as a stance became a shorthand for two relatedareas. Firstly there is our body posture; how we position ourselvesphysically in terms of approach behaviour, sitting and standing, headposition and use of gesture. Developing an awareness of bodilygesture is a major consideration for male therapists. Secondly, we takethe reflexive position that the client controls the context of therapy,the physical space in which therapy takes place. This includes adopt-ing a voice tone that is tentative, curious, extremely polite and neithercomplex nor ‘clever’. In this model we use questions as invitations(Cecchin, 1987) and search to open space to give power back to theclient by affirming the client’s control of the space in which theconversation is located.

From the permission-seeking stance we attempt to give the family avery different experience of external agencies entering their space.In this model we use every contact with the family as an opportunityto slow down the interaction and the conversation, to stay with a focuson permission and consent, before proceeding with talk about theproblem.

An important aspect of permission-seeking is using it to initiateconversations about potentially unsafe subjects. This micro-positioning allows invitations to be issued to talk about difficultthemes. Awareness of the influence of difference and power, and howthey interconnect, can often be overlooked when we are faced withextreme behaviour and challenging families. Utilising the permission-seeking stance, we have been privileged to talk about racism, violence,abuse, faith and beliefs, culture, sex and sexuality, gender and life-stage with parents and children, both together and separately. Wehave explored these in the context of the therapeutic relationship,family relationships and within extended personal and professionalnetworks. Permission-seeking allows families and therapists to decideon the content and pacing of any conversations and the level ofdisclosure or non-disclosure, along with the careful mapping of theprofessional and non-professional network available to the family.

Permission-seeking: a practice example

Permission-seeking is illustrated with brief examples from work withthe Armstrong family:



Alfie lives with his mother, Ms Armstrong. The family had had threeprevious referrals to CAMHS but had not attended. Alfie was referred atthe age of 10 due to aggression and violence towards his mother and toteachers at school. On one occasion when his mother had refused toallow him to play out it was reported that he had repeatedly hit her witha hammer. The case was picked up by the outreach team when we startedworking alongside the family and the very concerned professionalnetwork.Over a number of months the dialogue between Ms Armstrong and Alfieincreased. Sessions took place primarily at the family home although inthe latter stages Ms Armstrong occasionally asked to be, and was, seen atCAMHS. Ms Armstrong’s reasons for this choice had to do with wantingto talk about themes associated with her own upbringing and life. Alfie’sviolence, which at the outset was severe and repetitive, decreased sig-nificantly. Ms Armstrong’s experience of control increased, as did Alfie’sability to let his mother make decisions. They were more able to under-stand each other’s points of view. Balanced, more positive feedbackabout the family was communicated to the safeguarding agencies andover time the network was able to reduce its involvement, and Alfie wasable to be maintained in mainstream school.

The first contact with a family is usually by phone and is always startedby asking the parent or carer if this is a good time to speak. Almost allour work initially starts with a conversation with a mother. We seekpermission to have a conversation initially, not permission to talkabout the problem. So in these critical initial contacts the therapiststarts the process of handing over power, even if that is just the client’spower to say ‘Now is not a good time’. In fact, usually we found thatif the therapist seeks permission slowly and carefully, then the clientwill want to talk:

Therapist: Hello. Is that Ms Armstrong?Ms Armstrong: Yes, who am I speaking to?Therapist: I’m Dave – you don’t know me but I’m phoning fromCAMHS, is this a good time for us to talk?Ms Armstrong: Um maybe, what’s it about?Therapist: Well it’s about your son Alfie, but if this is not a good time I’mhappy to ring back at another?Ms Armstrong: No, it’s alright, I have a bit of time now.Therapist: Great, thanks, I’ll try to be brief. Let me know if you arerunning out of time.

If permission is not given we seek permission to explore if there is abetter time to talk or if we could talk to someone else who could be



helpful? If permission is given, following Tomm (1987) and Pearce(2007), the therapist pays careful attention to bifurcation points in theconversation when permission can be established to proceed further:

Therapist: Would you like to meet up and talk some more about Alfie?Ms Armstrong: I don’t know.Therapist: It’s your choice. It’s a chance for you to tell me about yourworries about him.Ms Armstrong: Alright.Therapist: So where is the best place to meet to talk?Ms Armstrong: What do you mean?Therapist: Well, I could come to you at your home, or you could cometo CAMHS if you prefer. We could meet at the school or somewhere youthink would be most helpful to you.Ms Armstrong: I don’t mind. Where do you think?Therapist: Well, I think it’s your choice really. I don’t know what’s goingto be the best place for you?Ms Armstrong: I’m OK if you want to come to my flat.

If permission is given on the phone to meet and this meeting takes placeat the home, we then seek permission at the door to proceed further.We do not assume that just because the parent agreed on the phone toour visit that that agreement is still valid. The family context, like ours,is always fluid. It may not be the right time to talk and giving the parentor carer the permission to turn us away, despite our status, power andauthority, is crucial both in engaging the family but also in avoiding theimplication that the parent is powerless. We take the theoretical posi-tion that to change, a client needs power, and that these isolated clientshave had abundant experience of being robbed of power throughviolence. However even at this point the therapist assumes nothing;agreeing to talk is not agreement for the therapist to enter the home.Entering someone’s home is very different from the client entering thephysical space of the clinic. Home is essentially a personal space and thehonour and privilege clients afford the therapist in allowing them toenter is uppermost in the therapist’s mind. ‘We ask if we can come in;we ask whether we should take our shoes off; we ask which room theywould like us to occupy and then we ask where to sit’. This closeattention to permission-seeking is crucial in continuing to build,through micro-steps, an account of the parent being in charge.

In this approach we do not hold on to the view that sessions last fora length of time stipulated by the therapist, though we are clear aboutthe time available. Therapists state that they will be present in thehome for no longer than is necessary:



Therapist: I won’t be here longer than an hour. If at any time you wantme to leave for whatever reason I’ll be happy to. I won’t think of it as anegative, I’ll think you’re just making a positive and active choice.

In fact, being asked to leave can be reframed as a positive request andestablishes the parent’s role as the boss of the house. Again, thesemicro-moves challenge the discourse of powerlessness that is so preva-lent in families in which violence and aggressive child behaviouroccur.

The ensuing session is punctuated by permission-seeking. Thecontent of the initial session often turns on themes connected withsafety, the expectations of the professional network, the family’s rela-tionships with external agencies and the family’s views of the differentbeliefs held about them within their neighbourhood and the profes-sional network. The therapist asks if there is agreement to talk abouta theme and as each theme develops permission is sought for furtherdiscussion. ‘I guess I just want to pause there and ask if it is OK withyou to carry on with this subject at this time’. ‘What would be theadvantages and disadvantages of continuing with the conversation?’‘What would need to happen for you to feel safe continuing with thisconversation?’ ‘Has this been discussed like this before?’ The explicitseeking of permission is crucial in enhancing the power and authorityof the parent. Through this continual invitation to assume authority,parents are more able to talk about what they could do differently.Children start to experience a sense that the available adult is incontrol, and begin to relinquish extreme behaviour, using other moreuseful ways of communicating.

We enter the family’s domain gradually, gently modellingpermission-seeking. We avoid a stance of automatically assuming thattalking is a good thing. In the sessions we explore the client’s viewsabout talking; our clients may have a number of reasons that maketalking difficult. ‘Can we talk about it? Are we able to explain it? Is itsafe to talk? Do we have the words? Will we look foolish?’ (Frosh et al.,1996; Reimers et al., 1994). Although there are constraints in workingin the home (Cottrell, 1994), one advantage of doing so is that wecan experience the challenges the family face in their lived context.Families don’t have to describe their interactional patterns or theirphysical environment; they show it to us. In homes where talking mayhave been a precursor to violence, permission-seeking detoxifies thetalking space. For families, this can reduce anxieties around havingto talk and can lead to a richer dialogue as the meeting unfolds. The



therapist pays close attention to the language used by the family,noting abusive or blaming patterns of speech, but models a non-reactive response where possible (Omer; 2001, 2004):

Alfie: [Addressing his mother]: Fuck, off you, cow, I’ll do what I fuckingwant. You can’t stop me!Ms Armstrong [shouting]: Alfie, please turn the TV off. You can have iton later.Alfie: Fuck off, I’m watching it now.Ms Armstrong: Alfie I’m turning it off now.Alfie: Go on then and I’ll fucking hit you.Therapist: Is this what normally happens when Alfie is asked to dosomething he does not want to do?Alfie: And you can fuck off as well.Ms Armstrong: See, this is what it’s like all the time.Therapist: Is it OK to ask a question about what’s happening?Ms Armstrong: Mmm, OK.Therapist: So if it could be different what would you and Alfie be doingdifferently?

Asking detailed permission-seeking questions of the parent, whilediscouraging the child from making decisions, from the outset, opensspace for the parent to re-claim authority, allowing a structural inter-vention (Minuchin, 1974; Minuchin et al., 1998). In this way the thera-pist expands the constrained personal authority that the parent hasaccrued. Meeting the family from the stance of permission-seekingallows the therapist to take an active stance in relation to the child’sbehaviour using humour, directness and transparency and ‘warms thecontext’ (Burnham, 2005, pp. 7–8) for ‘putting the parent in charge’:

Therapist: So, Ms Armstrong, you were telling me about how Alfie hadhit you with a hammer.Alfie: I didn’t hit her with a hammer.Therapist: How would you describe what happened, then?Alfie: Well, I did hit her with a hammer but it was the wooden end.Therapist [looking bemused]: The wooden end?Alfie: Yeah, so I did try not to hurt her bad.Therapist: Oh well, that’s alright then! So do you think your mumappreciated your thoughtfulness while on the floor bleeding?Alfie: No, but, I dunno, I did not really mean to hurt her.Ms Armstrong: He has never said that before.

This exchange opened up a theme around safety, play and nurturingwhich was developed gradually in the course of the session. Children,particularly boys, are encouraged to talk and listen appreciatively



and much time is spent developing time and space for positive activi-ties between parents and children. The parent in this case was helpedto find a balance between harsh and permissive parenting that was,with parental permission, used by the network of safeguarding agen-cies as a marker for progress. The therapist engages in detailedconversation with the client about the team’s attendance at, and pro-duction of written reports to, local statutory safeguarding meetings. Atthe end of each session the therapist checks out what was helpfulabout the session and whether and if the family would like to be seenagain. The therapist then negotiates the location of the next sessionand the client gets to choose where and when the meeting will takeplace.

Subsequent sessions are concerned with continuing to usepermission-seeking to re-establish the parent’s authority in relation tothe child or children and for the family to re-engage with the servicenetworks. It is important to establish with the family and professionalnetwork who has permission to talk to whom and the limits of confi-dentiality, particularly seeking clarity from the same groups about theissues around safety and protection; as the parent regains authoritytime is spent clarifying the different statutory roles of the agenciesinvolved with the family. Permission-seeking becomes a vehicle fordiscussing difficult areas and the differing positions around disclo-sure, confidentiality and who is responsible for knowing what. Thetherapist aims to reduce splitting processes, blame and the scape-goating of professionals in the network and to explore ways of bridg-ing broken links between network members. In the case of theArmstrong family, the theme of Ms Armstrong finding a balancebetween harsh and permissive parenting was developed in the net-works as a positive marker for success. Joint visits are often held withsafeguarding agencies with the aim of rebuilding links and redescrib-ing the family and its relationships with agencies.

We work to clarify who is in the network, what the different attribu-tions are, who can decide what with whom, and where and when thoseconversations will take place. The same respectful position taken withthe family is also taken with members of the network, beginning withthe assumption that everyone is doing their best in a difficult situation.There may be a series of separate meetings with different members ofthe network, including the parents or carers, and, where appropriate,the children. But the process of these meetings is set in the context ofpermission-seeking and a full discussion with the clients before anyfresh sequence unfolds. Often these families have experienced external



agencies as being aggressive and unhelpful (Kosutic and McDowell2008; Van Lawick and Bom, 2008; Vetere and Cooper, 2001). From apermission-seeking stance we will work with the family to redescribethe network, and with the network to redescribe the family, providingopportunities for positive relationships all round.

Discussion

Building bridges across models

McCarthy (2001), quoting from Ehrenhaus’ (1993) article, invites us‘to be vigilant so that the local narratives of a client’s lived experiencesare not ‘drowned out by the tyrannising power of the therapeuticmotif ’’ (p. 258). In our daily clinical experience these local narrativesconcern the overarching contexts of gender-based violence, poverty,abuse and social exclusion. We feel that as therapists we are accultur-ated to construct a space which privileges talking, while parentingprogrammes create a space which privilege action and didacticism.Clients are sensitive to national, cultural and local motifs about whatconstitutes therapy ‘space’ and many clients, particularly those whohave experienced gender-based violence, may fear or resent therapytalk or the didacticism of the parenting programmes. Although muchhas been written about the necessity for therapists to create andsustain dialogical spaces it has sometimes been difficult for us to callforth these ideas reflexively in the context of home visits in poorneighbourhoods and in homes that have witnessed extreme violence,usually male on female. From the stance outlined above, the therapistexplores the experience of entering the client’s space, as well asinviting the client to enter the therapist’s space. While we agree withFlaskas that the field of therapeutic engagement has been stunted bya narrow focus on the dynamics of initial contact and the first session(Flaskas, 1997), our focus on the initial session and conversations withclients leading up to it has been shaped by our trying to offer ourselvesricher discourses and effective therapy in working with highly mar-ginalized clients. We argue that permission-seeking should be woventhrough all phases and episodes of therapy, particularly home-basedtherapy.

Burnham (2005) has posited what he terms relational reflexivity,where he invites us to orientate to the frame of therapy by payingclose attention to the context and by asking questions about questions.Indeed, family therapy could be seen as having moved from a concernwith the family as the problem, to a focus on the context as the



problem and, for the families described in this article, the relationshipbetween the family and local services may be problemmatic. We arguethat permission-seeking questions can be helpful in ‘co-ordinating theresources’ (Burnham, 2005, p. 15) of the home-based clinician and theclient in what is often a complex and difficult context, saturated withnarratives of violence and disempowerment. The permission-seekingapproach encourages the clinician and client to keep the conversationmoving forward and assists with transparency, encouraging cliniciansto share their thinking more openly.

Bavelas (2005) has researched the effect of different kinds of ques-tions, particularly what she calls constructive questions. These arequestions that establish common ground between the therapist andthe client and invite further collaborative responses (McGee et al.,2005). She has made the point that many systemic theoreticians,particularly those outlined in our literature review, have not beeninclined to research the efficacy of the questions they advocate.Bavelas has exhaustively researched how therapist and client coordi-nate their responses and gestures to one another and how questionscan empower and lead to better outcomes.

From the clinic to the home

We agree with Van Lawick and Bom (2008) that the home offers anumber of rich contextual cues for therapeutic work. We have foundthat home-working is often seen by some colleagues as unusual anddifficult and in many ways its advantages are far fewer than office-based work. Our experience is that, while there are some disadvan-tages to working in it, the home environment is also rich in contextualclues to the family’s strengths. In addition, the home is full of oppor-tunities to do creative and useful work, some of which are not avail-able to the clinician based in the office. We notice that frequently, onfirst arriving in a family living room, one of the children, typically thereferred child, might invite the therapist to sit down. The therapistwarmly acknowledges this invitation but refers the decision to theparent. To accept the child’s invitation to sit down may reinforce theaccount of the child being in charge. The therapist searches reflex-ively for cues to model deference to the parent, and although thesemay be very short episodes within the space of a meeting, they func-tion as challenges to parental disempowerment, as well as allowing thechild to step back into being safely parented. As Vetere and Cooperpoint out, therapists, in the aftermath of partner violence need to



make the connection explicit between parenting and child behaviour(2001).

From the simple to complex

By developing the simplest of permission-seeking conversations thetherapist creates a conversational and interactive space where complexdiscourses that may be constraining change can be gently decon-structed. We would argue that by asking permission to talk, to enter, tosit, when to leave and what to discuss, we open space for the family toexperience a shift in relation to power. We commence this primarilythrough our behaviour and by modelling the simplest interactionsbased on permission-seeking, rather than starting with questions relat-ing to the problem. This initial approach can lead to questions aboutthe clients’ social contexts and the effects of multiple forms of oppres-sion on their lives’ (Kosutic and McDowell, 2008, p. 160).

From withdrawal to agency

Our hypothesis is that for many of these families the experience ofbeing invited into another space, particularly if that invitation is issuedby a person in authority, is particularly difficult. We would argue thatwhen parents are asked questions that seek permission in great detailthis constructs an account of them as having agency. In giving agencyback to the parent, a conversation may emerge that draws on how theclient constructs and holds on to hope. Delineating agency from thebriefest of episodes often leads to more hopeful conversations, that,for example, parents have good intentions, desires and motivationand that context, relationships and social disadvantage may constrictthe conversations, experiences and narratives they want to have. AsKosutic and McDowell (2008) point out, justice work involves thetherapist taking a stance that ‘Encourage(s) clients to resist oppressivenarratives by developing stories about coping strategies, managementof hardship and adversities, and strengths across generations of fami-lies, families of choice or kin networks’ (p. 160).

Transparency and reflexivity

Our clinical experience is that these families have experienced manyinterventions from many agencies over long periods of time, some-times intergenerationally. We have found permission-seeking conver-



sations open up possibilities for us to examine our own reasons for thequestions we are asking and to maintain curiosity in what may be aproblem-saturated context. Clients become curious about the inten-tions of the therapist and begin to ask why the therapist is asking thequestions. This opens the possibility for critical discussion about themultiple oppressions faced by women, particularly in relation to theirmale partners (Kosutic and McDowell, 2008); in turn leading togreater use of self-disclosure and more opportunities, particularly formale therapists, to explore their own positions and experience inrelation to gendered beliefs about power and authority in relation-ships. Therapists in home therapy contexts with marginalized clientsneed to pay close reflexive attention to levels of context unfolding inthe conversation. Cecchin’s (1987) distinction between protection andtreatment is useful but we have found that permission-seeking dia-logue has many levels of context and can act as a bridge between thetwo domains, opening up the possibility of reconnecting families andnetworks.

Home-visiting marginalized clients where there has been violencecan be very stressful for therapists. In difficult meetings, being awareof one’s own breathing can help therapist reflexivity (Hick, 2009). Welike to match our utterances to the rhythm of the client’s breathing. Sowe like to think of ourselves as connecting permission-seeking to therhythm of the conversation. We monitor our own breathing responseto the flow of talk, establishing a pace and depth that fits for the family.Breathing awareness can also assist the therapist in managing whatcan often be stressful encounters. At times we may try to slow or speedup the breath and the pace of the conversation but always through theseeking of permission, using this as a way to establish signposts orpunctuations in the course of the session.

Theorizing home-based therapy

We think that permission-seeking interviewing may have some utilityfor outreach therapists. Outreach therapy teams are caught in a deepethical dilemma; having the duty to work in a context where thefunction of the team is to engage reluctant, sometimes mandatedclients in a multi-agency context, while having the responsibility topay attention to clients’ rights to confidentiality, the permission toshare information and the need to act in coordination with childsafeguarding agencies. The kind of therapeutic space constructed inthe permission-seeking model allows outreach clinicians, in our view,



to draw on both modern, action-based traditions and postmodern,language-based traditions to give them the tools to act both effectivelyand reflexively.

Thus, therapists aim to create a dialogical space where, usingpermission-seeking, they shed power and the parent regains authorityand, using structural techniques, parents are encouraged to regainauthority in relation to their children.

Conclusion

An interviewing stance for outreach therapists connecting to margin-alized families, particularly where there has been violence, has beensuggested in this article, based on the work of a team in EastLondon, UK. This methodology might assist outreach therapists inmanaging the competing demands of treatment, protection, consentand information-sharing and can be theorized as deriving from twotraditions, a social constructionist position that pays careful attentionto language and social inequality issues and a structural positionhighlighting the recovery of parental authority. Richer discourses arenecessary for the outreach clinician who may be working in thehomes of highly marginalized families without the benefit of office-based professional conversation. How permission-seeking questionsare used, phrased and sequenced, and whether they do in factenhance collaboration and outcome, may be a fruitful area of furtherresearch.

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‘Seeking permission’: an interviewing stance for finding connection with hard to reach families