ORI GIN AL PA PER

Establishing Therapeutic Dialogue with Refugee Families

Suzanne Guregard • Jaakko Seikkula

Published online: 2 April 2013� Springer Science+Business Media New York 2013

Abstract The article describes an investigation into dialogues between native Swedish

psychotherapists and refugee families. Dialogue is needed to establish the therapeutic

alliance, which is ultimately important for healing, whether of individual sickness or

family crisis. However the development of dialogue is hindered by cross-cultural and

language barriers. We concentrate on one aspect of research originally presented in a

Doctoral Thesis by the first author, asking how culture and power differences, together

with their resettlement in a strange country, affected meetings with refugee families, and

how these problems were overcome; language and the presence of an interpreter are not

discussed. A multi-perspective methodology was used in the original research, combining

text analysis, review of video-recordings by the participating therapists, and interviews

with the families. All these forms of investigation are drawn on here, but particularly text

analysis. Significant hindrances to dialogue turn out to be differences in cultural values

between refugee and therapist, their different power positions, and the refugee’s weariness

and distrust of meetings. Strategies to minimise power differences are an essential aspect of

the Finnish open dialogue approach, which turns out to be particularly relevant to such

refugee meetings.

Keywords Refugee � Dialogue � Therapeutic alliance

Background

This article derives from doctoral research (Guregard 2009), where the second author was one

of her supervisors. At the time of this research, Suzanne Guregard (SG) had recently been

appointed head of the Child and Adolescent Psychiatric Clinic (here abbreviated to CAP)

S. Guregard (&)South Alvsborg Hospital, Bramhultsvagen 53, 50182 Boras, Swedene-mail: suzanne.guregard@vgregion.se

J. SeikkulaDepartment of Psychotherapy, University of Jyvaskyla, P.O. Box 35, 40014 Jyvaskyla, Finlande-mail: jaakko.seikkula@jyu.fi

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Contemp Fam Ther (2014) 36:41–57DOI 10.1007/s10591-013-9263-5

in Boras, an area containing many refugees to Sweden. The thesis was concerned with the

development of therapeutic dialogue between Swedish therapists and refugee families

seeking treatment for themselves or their children. Most refugee families have suffered severe

trauma in their home countries. Many have also had difficulty with authority after reaching

Sweden, making them circumspect when making contact with Swedish officialdom, a cat-

egory in which social workers and psychotherapists become included. They have no natural

basis to trust—the staff are foreign, the circumstances are alien, and ‘‘talking’’ methods of

treatment may be unfamiliar. Moreover, for refugees, the inner basis for security may have

been torn away by trauma. Hence establishment of trust is the first priority. This trust must be

established across cultural barriers. This establishes the research questions for this article:

What form do these barriers take, and how are they overcome? The research was undertaken

by examining material from meetings between five Swedish therapists and six refugee

families, recorded by video-camera. To investigate what happens in the everyday situation,

the recorded meetings took place in the everyday working situation of two psychiatric clinics.

This article presents some of the thesis material. However most discussion concerning the

language barrier and the presence of an interpreter is omitted, while a minimum number of

families and meetings are used to address the research questions.

Our title refers to ‘‘therapeutic dialogue’’. Unlike ‘‘therapeutic alliance’’, discussed

below, dialogue is not a technical term but an ordinary word in the English language. The

Oxford English dictionary definition (Oxford 2006) is ‘‘discussion directed towards

exploration of a subject or resolution of a problem.’’ Wierzbicka (2006) argues that the

practice of dialogue opens up understanding in areas such as religion and politics, but also

between cultures and generations. Linnel (2009) writes that dialogical interaction is the

principle mechanism through which individuals and society makes sense of the world they

live in, and find a language through which to express this understanding. Hence dialogue

arises naturally in most situations where there is a problem to be resolved, and there is a

peer relationship between the participants. In therapeutic meetings, the unequal positions

of client and therapist mean that care may be needed for dialogue to develop. Our article

concerns the particular kind of care needed with a refugee family. Every participant in an

external dialogue engages in at least two different conversations—one outer and one inner

(Andersen 1997; Rober 2008). With trauma victims, this capacity for inner dialogue and

reflection is reduced (Blackwell 1997), so external dialogue can be hard to promote.

The concept of the therapeutic alliance is introduced here because of the evidence that a

strong alliance between client and therapist increases the prognosis for a good outcome

(Lambert and Barley 2001; Wampold 2001; Horvath and Bedi 2002; Elvins and Green 2008),

while the relationship between dialogue and outcome has attracted less attention. One

comparatively succinct definition of ‘‘therapeutic alliance’’ is given in Pinsoff and Catherall

(1986, p. 199): ‘‘We define the therapeutic alliance as that aspect of the relationship between

the therapist system and the patient system that pertains to their capacity to mutually invest in,

and collaborate on, the therapy’’ (our italics). Dialogue is needed to collaborate, and hence a

necessary condition for a therapeutic alliance—the personal bond is also important, and with

many refugees, this capacity to make attachments is reduced (Woodcock 2000). It is therefore

reasonable to claim that dialogue in therapeutic meetings is important for good outcome. The

strength of an alliance is usually measured by subsequent questioning of therapists and/or

clients following the meetings. With dialogue, it is possible to observe its development or

otherwise during the meeting itself, as this article shows.

The ‘not-knowing position’ presented in Anderson and Goolishian (1992) addresses the

unequal power positions of client and therapist. However the term ‘‘not-knowing’’ implies

that the expert knowledge of the therapist is discounted, so has been replaced by

42 Contemp Fam Ther (2014) 36:41–57

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‘‘collaborative therapy’’ (Anderson 2001). In collaborative therapy, there is a great

emphasis on language and the way new understanding emerges from the dialogue between

therapist and client. Sutherland (2007, p. 199) writes: ‘‘As families, jointly with therapists,

come to make sense of their living systems differently, the problems dissolve or new

possibilities for living and relating emerge, rendering the initial problem irrelevant’’.

Making sense of one’s living system implies reflection, so reflection in an utterance is also

considered in our text analysis.

Open dialogue (OD) is a collaborative therapeutic approach developed in Finland,

which has been used successfully with patients suffering from severe psychiatric illness

(Seikkula 2002; Seikkula et al. 2011). It is distinguished by its use of the network of family

and work-colleagues to support the patient and enrich the dialogue. New understanding

emerges from the polyphony of voices. The treatment meeting is the main forum for

therapeutic interaction, and occurs regularly during the whole treatment period. All

treatment decisions are made openly in these meetings. The task for the professional team

member is to identify as nearly as possible with the suffering of the patient and family.

Compare Lantz and Gyamerah (2002, p. 248), ‘‘Empathic availability is a committed

presence to the client family, and an openness to their pain…’’ Careful following and

responding by therapists are essential characteristics of dialogue (Seikkula and Trimble

2005). However responding is not merely linguistic, but requires engagement and empathy.

It also requires therapeutic discernment to identify ‘‘hidden voices’’ in the talk, i.e. feelings

that are suggested but not made explicit. In OD, the lay members of the network are

encouraged to take the lead and set the agenda. This can be particularly important with

refugee couples; Reichelt and Sveaass (1994) found that, for ‘‘good conversation’’, the

couple’s urgent need for practical help and advice had to come before any therapeutic

agenda. In order to investigate the dialogical quality of a meeting in detail, a text analysis

method is needed. Here dialogue sequence analysis (DSA) is used, outlined in Seikkula

(2002) and elaborated in Seikkula et al. (2011). This introduces a number of OD concepts,

so our article can be said to have an OD perspective.

When considering the cross-cultural problems to be overcome in meetings between

refugees and native therapists, many readers will think first of the language barrier. The

literature concerning the influence of the interpreter in meetings with immigrants or

refugees (e.g. Brune et al. 2011; Raval 2005) emphasises that the interpreter is much more

than a translator. Wadensjo (1992) describes the interpreter as a ‘‘broker’’, reconciling the

standpoints of the participants. The interpreter can be someone from the home country

providing a role model of survival in the new country. Alternatively the interpreter can be

seen as a threat (Fatahi et al. 2010). The presence of an interpreter certainly influences the

development of the therapeutic alliance (Miller et al. 2005). However Guregard (2009) was

also concerned with specific language limitations—loss of spontaneity, problems of

translating humour and metaphor, failure to translate asides that contribute to informality.

These topics deserve a separate article.

A survey of trauma experienced by refugees is given in Papadopoulos (2007). Even if

torture is not involved, separation from homeland, home, social structure, and employment

are traumatic enough. There is also the psychic stress endured by many asylum seekers

entering the host country (Heeren et al. 2012). At the time of the doctoral research, waiting

times for a residence permit in Sweden could extend to several years, placing severe stress

on families (they have now become shorter). Two of the six families participating in the

research experienced great difficulty with Swedish Immigration. They refused to accept

one mother’s statement that the police had abducted her own mother, even though this was

witnessed by the grandchildren. With another family, they refused to accept that the

Contemp Fam Ther (2014) 36:41–57 43

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parents were living together and with their children, and interrogated them in separate

rooms about family meals. Such experience can make asylum seekers deeply mistrustful, a

distrust latent in every therapeutic meeting.

Methodology

Overview

The research covers two or three early meetings between native-born Swedish therapists

and six refugee families. They were recorded by video camera and subsequently tran-

scribed for text analysis. Extracts from each therapy meeting were selected for replay to a

team consisting mainly of the participating therapists plus the first author, here termed the

‘‘reflecting team’’.1 These discussions are here termed ‘‘video-reflections’’. Each extract

was first commented in writing by the individual team members, and then discussed

between them. These team discussions were also videotaped, and a selection transcribed.

To obtain the families’ own perspective, the first author interviewed them after their

second therapeutic meeting. These interviews were audio-recorded and transcribed for

analysis. Thus the research material consists of four datasets:

• transcriptions of each therapy meeting

• written comments by the therapists.

• transcriptions of selected video-reflections

• transcriptions of each family interview

The amount of material is considerable, so only a selection is used here to illustrate the

problems and solutions that emerged.

The research was carried out in the naturalistic setting of two clinics. Neither therapists

nor interpreters were given special training for the research. Apart from the presence of a

video camera to record the therapy meetings, they were carried out under routine condi-

tions for each clinic. This method was adopted in order to draw lessons for clinical

practice. There can be a great gap between theory and everyday practise, so from a patient/

client perspective the identification of both good practice and shortcomings is very

important.

Participants

One therapist from the Gothenburg Crisis and Trauma Centre working with families, both

adults and children, and four therapists from CAP volunteered to participate. Since CAP

therapists normally work in pairs, this gave three sets of therapists. Each agreed to meet

two families under research conditions previously discussed. It was proposed to record two

or three early meetings with each of the six families. Early meetings were chosen because

it is then that the therapeutic alliance should be established. In fact 15 meetings were

recorded. Two of the five therapists were psychologists, the others social workers. Only

one psychologist and one social worker were accredited as therapists at the time, which is

not untypical for Swedish psychiatric clinics. For each set of therapists, the first two

refugee families who agreed to participate in the research were accepted. There were no

other selection criteria. These families had fled from Afghanistan, Azerbaijan, Bosnia, Iraq

1 Not to be confused with the term as used by Tom Andersen (Andersen 1997)

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and Iran, all countries with an Islamic culture, as with most recent refugees to Sweden,

although not all were practising Moslems. Family members were very different in edu-

cation, homeland environment and traumatic experience. Nevertheless many had experi-

enced an unwelcoming reception in Sweden, accompanied by an enduring fear of

expulsion, so there are important commonalities. Ongoing stress before and after the flight

can lead to physiological and psychological problems (Roth 2006), and also affect family

relationships (Woodcock 2000). Only one ‘‘family’’ consisted of children living together

with both parents. The term means only that biological parents attended meetings,

sometimes with their children. Of the 15 meetings, the 10 early meetings at CAP were

primarily exploratory. Hartzell et al. (2010) discuss such meetings and writes (pp. 274,

275) ‘‘When the families come they are in a difficult situation and are vulnerable… It is not

intended to be a therapeutic meeting, but it could be therapeutic and helpful if conducted in

a sensitive and open way…’’

Multiple Perspectives

Text analysis of the transcribed therapy meetings gives the most detailed information on

what was actually spoken, and could be said to provide the authors’ perspective on the

material. The video-reflections provide a great deal of information concerning unspoken

aspects of the therapy meetings, atmosphere, body language, and the inner voices of the

therapists involved (Rober 2005). These provide the therapists’ perspective. The interviews

provide the families’ perspective.

The chosen method of text analysis should be appropriate to the aspects of the meeting

under investigation. Dialogue Sequence Analysis (Leiman 2004; Seikkula 2002; Seikkula

et al. 2012) was used here because it is concerned with the dialogical aspects of the

meeting. Text analysis was carried out in Swedish, using the translated words of family

members, and further translated into English for presentation here.

Dialogue Sequence Analysis

Dialogue sequence analysis begins by dividing the transcribed text into ‘‘topic sequen-

ces’’—episodes concerning the same subject, and then assesses the dialogical properties of

each sequence—dialogue/monologue, symbolic/indicative, and dominance. ‘‘Dialogue’’

means that the speakers listen to each other and respond. ‘‘Monologue’’ includes talking

non-stop without listening, but also situations where people ‘‘talk past each other’’. As can

happen in clinical meetings, it includes sequences where the professionals pose closed

questions, and then tick off the answers as if completing a form. According to Linnel

(2009) dialogical utterances are links in a chain of meaning that points both forward and

backward. A sequence of unmotivated questions points neither forwards nor backwards,

and therefore fails as dialogue. In our text analysis, ‘‘question-and-answer sequences’’

occurred where therapists asked a series of questions in order to establish facts. This is an

example of the ‘‘medical model’’ (Hartzell et al. 2010) where therapists are mainly

expected to collect data at the first meeting.

The next classification is symbolic/indicative. ‘‘Symbolic’’ describes utterances that

evoke more feelings than are expressed in the actual words. Such utterances can be said to

be ‘‘multifaceted’’. We also consider whether an utterance is reflective or non-reflective.

Between them, these two classifications correspond approximately to internal/external

narrative in the Narrative Process Coding System (NPCS), (Laitila et al. 2001 E). The

capacity for reflective and complex thinking is diminished by trauma (Woodcock 2000).

Contemp Fam Ther (2014) 36:41–57 45

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Nevertheless many utterances in this research were still symbolic, reflecting the refugees’

ambivalent situation. They have left their homeland, but still not made their home in the

new country (Papadopoulos 2002). Response to symbolic utterances forms an important

aspect of this text analysis. Finally our text analysis asks whether ‘‘hidden voices’’ (Leiman

1998; Seikkula et al. 2012) find a response. There are more aspects to DSA than out-

lined above—for example quantitative, semantic, or interactive domination by one

participant,—but these are not shown here.

Video-Reflections

The first author has used video-recordings for many years to help train medical students in

consultation skills (Kurtz and Grumman 1972; Kagan et al. 1975; Holm 1987; Arborelius

and Bremberg 1992). Our research method was a combination of the Holm approach and

the Kagan Interpersonal Process Recall (IPR) approach. The reflecting team met for

several hours as soon as possible after each therapy meeting. It was impractical to replay

each hour-long meeting and invite participants to freeze the recording, so review was not

interactive. Instead SG chose three extracts, one from the beginning, one from towards the

end, and one from the middle of the meeting which she judged to be significant (Guregard

2009). The review of each extract began with each participant writing down individual

reflections concerning how the family was met and understood, whether there was dialogue

or not, and any supplementary comments. Then the team discussed the extract together

with a similar focus, although often extending beyond the material shown. The video-

reflections revealed different aspects of the meeting from text analysis, for example the felt

quality of the meeting, body language of the participants, and the inner voices (Rober

2005) of the therapists involved.

Interviews

SG conducted a semi-structured interview with five2 of the six families after Meeting 2,

asking:

1. How did you experience today’s meeting?

2. How was it to meet a Swedish therapist? Use of interpreters?

3. What difference do you feel between your first and second meetings?

4. Do you think you participated in the different decision taken about treatment?

5. Do you think you received help?

6. How do you find the Swedish Health service?

Their answers to these questions reveal some expectations of family members, and how

they felt these expectations were fulfilled.

Approval

Ethical committees in Sweden and England approved the research project. Each adult

family member gave written agreement to participate. Care to preserve anonymity has been

observed in this article, so all family names are pseudonyms.

2 The father in the sixth family attended Meeting 2 unaccompanied. The therapist told him gently that theymust work on his trauma before seeking employment. This invitation to reflect on his situation was too muchfor him and he broke off the meeting and left the therapy.

46 Contemp Fam Ther (2014) 36:41–57

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Family 1: The Problem Boy

Two meetings with this family are examined in some detail, since they illustrate both promotion of

dialogue and obstacles to dialogue. They also illustrate our methodology. This family had bad

experiences from the civil war. Their hometown was often bombed, and the mother’s sister was

killed in front ofher. The family fled toacamp, where theywere politicallyactiveagainst the regime.

Like many refugees, this family has multiple problems, and the social services are

involved. The father is sick and unemployed, and the parents divorced. The two sons live

with their father, the three daughters with their mother. Now Ben’s, the elder son’s, school

has asked for a psychiatric investigation because they say Ben is very aggressive towards

his classmates, and has concentration difficulties.

Meeting1: therapists, Ben, father, mother, one daughter, interpreter.

The meeting starts with the therapists introducing themselves. They are surprised to find

mother and small daughter present. This was unplanned, but the family had just left another

meeting at the boy’s school, attended by his mother. Asked about the school meeting, the

father sounds weary and says: ‘‘Nothing important was decided, at least so far as what will

happen with Ben.’’ Here are two comments on the father from the video-reflections:

Passive, what will happen? My fantasy—as immigrants and refugees they have been

through so many official meetings that it’s only to sit and wait.

It feels a decisive phase of the meeting when we ask father whether he understands how

an investigation could help his son. Nobody seems to have explained. In that moment I

got a strong feeling that many meetings and discussions had gone over his head.

The room is squashed with two extra people, and very unsettled. The young girl bounces

up and down on the beanbag provided by the therapists. There is factory noise outside,

which makes it difficult to hear. Also the boy reacts anxiously to the sudden noises. In the

video-reflections, the therapists say that they have become used to the noise, so ignore it.

Ben’s parents say that his biggest problem is forgetfulness. One therapist begins to discuss

this directly with Ben, but continues with what he likes at school. This leads into a dialogue

about football, at which point both parents become involved.

Topic Sequence 3: Forgetting, maths, football, reflective dialogue

T1: Do you find you easily forget what you’ve learned? Ben: Um

T1: Is it.. is it getting difficult with lessons, then? Ben: A bit

T1: What do you like best at school? Ben: Maths

T1: What else do you like? Ben: (thinks)

Mother: Playing football (everyone laughs)

T1: Have you just been playing football now?

Mother: He’s always on the way to playing football.

Man: He loves it day and night, just kicking a ball about.

T1: Do you play in a team, then? Ben: Yes

T1: So what are you, where do you play on the pitch? Ben: Forward

T1: So you’re good at scoring goals? Ben: (nods)

Father: Only football, nothing else.

T1: But it isn’t just kicking a ball. You need to fit into the team and follow the rules.

Father: There he fits in very well. During the years he played there, they’ve been pleased with him, andwhen he thought it was boring, he moved up to the next team.

Contemp Fam Ther (2014) 36:41–57 47

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The therapist brings out that the boy is not merely good at football, but also a good team

player and popular with his team-mates. Finding positive sides to survival in the host

country is important for therapy with refugees (Papadopoulos 2007). The picture of an

aggressive boy becomes modified. When many become involved in the dialogue, more

aspects than problems are revealed. The parents are also proud of their son, and the

atmosphere lightens considerably.

Later in the session, there is the following exchange:

Topic sequence 8: Ben’s war experience monologue

T1: How old was Ben when you came to Sweden?

Couple: 4 years

T1: Were the last years in your homeland difficult?

Father: Not so bad economically, but all the time there was this fear of being killed. So Bensuffered from the war.

T1: Was he living with you?

Father: All the time. And it was during the civil war when first one side captured the city andthen the other. There were shells falling around us all the time.

T1: So it was hard for you. Do you remember whether Ben also suffered?

Father: Certainly. We had to keep telling him not to play in the street, and go down to theshelter.

This is an example of a ‘‘Question-and-Answer’’ sequence where the therapists want to

be absolutely sure of the facts. The ‘‘medical model’’ certainly applied to this Outpatient

Department where the responsible psychiatrist expected treatment decisions to be made by

the psychiatric team with himself in the chair. The mother misses Meeting 2, but reappears

without the daughter for Meeting 3. One therapist takes the opportunity to ask her about

Ben’s birth and growing up.

Meeting 3: therapists, social worker, father, mother, new interpreter

Topic Sequence 7: The son’s birth dialogue

T1: How was it when Ben was little—how was it for the family when he was born,and the whole way up till today?

open question

Mother: It was like this…we got help from our neighbour to drive me to hospital. Ithappened on the way, and I felt totally alone. The father was in the front with thedriver, and I was utterly ashamed. You can’t allow men to see these things.

reflection

T1: It must have been a terrible experience. dialogue

T2: May I ask how you were living at the time? Was it some kind of refugee camp? interruption,monologue

Couple: Yes, we were there on the party’s location. Everyone belonging to the partywas there.

T2’s reflections on her interruption:

‘‘Annoying but I really felt the mother’s shame. I don’t know the culture. How is that

for a woman—to lie in the back of some kind of van alone, completely abandoned and so

48 Contemp Fam Ther (2014) 36:41–57

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bloody? When I look at the extract, first I thought ‘How the Hell could I be so stupid. But I

believe I felt that I must get her out of this situation’’.

The re-enactment of the trauma and the need to ‘‘bear witness’’ to the mother’s pain

(Blackwell 1997) are too overwhelming for T2. Cultural insecurity compounds these

feelings, and reinforces her need to change the subject. Gunaratnam (2003) terms this

‘‘Cultural Avoidance’’. The interruption could have been avoided, had the therapists been

trained to reflect with each other openly before the family (Seikkula and Olson 2003;

Seikkula and Trimble 2005). A therapeutic alliance between co-therapists cannot be taken

for granted. Open reflection also reassures the clients that the professionals have no secret

agenda.

T1: But we interrupted you, you were in the middle of telling how it was to have Ben… Didyou get to the hospital after Ben was born in the truck?

reconnection

Mother: We were nearly there when the baby came.

T1: What do you remember from that moment? Did he cry; was he an active baby when hecame, or…?

dialogue

Interpreter: Please understand, it’s she who is describing this. It’s not the same as here, theculture is different.

interruption

Mother: This driver was from the same district, and we were ashamed in the truck, when Ilay on my side with my towel, (Interpreter–excuse me) and there was the baby lyingbetween my feet. I took the towel and wrapped it round him. Oh we couldn’t clip the navel,and you know he was white as snow until a nurse came and clipped the navel, and took usinside the hospital.

symbolic

T1 persists with her topic and new understanding emerges. As she remarked in the

video-reflection: ‘‘After putting so many questions to the parents, we now get the

beginning of the story for the first time’’. This meeting shows how hard it can be to

anticipate the agenda. A routine question led to a story that was both unexpected and

shocking.

The father’s weariness with meetings to discuss his son has already been mentioned. In

the interview, he said: ‘‘For 2 years they just talk and talk, but still with no result. We want

a solution quickly.’’ In their reflections, the therapists say that the family ‘‘answer ques-

tions but add nothing’’. Dialogue was hard to establish, particularly because the family did

not properly understand why they were there, however hard the therapists tried to explain.

The whole family ‘‘came as hostages’’ (Escudero et al. 2010, p. 257) to a meeting set up by

the school psychologist. Without an agreed purpose, dialogue is less likely. Nevertheless in

Meeting 1, one therapist promoted dialogue by opening a discussion with the boy, not

about his problems, but about his achievements. This non-threatening conversation light-

ened the atmosphere and involved both parents. We will see how such a strategy also

functioned with other families.

Family 2: The Abused Children

The third meeting with Family 1 illustrated how dialogue was interrupted by the therapist’s

embarrassment and concern. Cultural insecurity also played a part. Now we consider

meetings with another family where culture differences seem important. The patient is the

Contemp Fam Ther (2014) 36:41–57 49

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12 years old daughter. Nina’s problems are insomnia, nightmares, no appetite, and

incontinence. Her father, who had been involved in political opposition, divorced his wife

to marry a woman from his own country living in Sweden. He brought his children to

Sweden, but they were abused and neglected by their stepmother, who also hit the father.

According to him, she had criminal associates and was addicted to gambling and narcotics.

The children’s biological mother became extremely worried for them, especially Nina, and

came to Sweden at great personal and financial cost to try to help. The father’s living

arrangements with his new wife broke down, but he could not return to his homeland,

besides which his children had come to prefer Sweden.

In Meeting 1, the therapists ask how the father came to have custody of such young

children after the divorce. The mother replies that this is the practice in their homeland, and

the therapists move on to their next question without pursuing the subject. To Swedish

eyes, it was very risky to wrench his children from home, homeland, and mother to put

them in the care of an unknown woman. This issue, which seems directly relevant to

Nina’s sickness, was never explored—a case of cultural avoidance. There was dialogue

between therapists and mother when they sympathise with her coming to Sweden. How-

ever they ask the father many questions with little apparent empathy. For example:

T1 So there was no adult who could protect Nina because she was even hitting you?

Father Except I did try to protect her

T1 I understand, but we are simply trying to capture Nina’s feelings of being

unprotected

Father Nina’s problems began when we were living in my stepson’s little flat and my

wife shut off the electricity. We had to get help from neighbours who brought

electric torches and heated our food

T1 It sounds as if your wife influenced you and your children a great deal

The father claims that he tried to do his best for his children, and he was certainly

resourceful in extricating them from the impossible situation he had created. The therapists

sympathise with the mother’s big step in leaving her homeland for Sweden, but do not

acknowledge the father’s ‘‘adversity-activated development’’ (Papadopoulos 2007). We

labelled this lack of response ‘‘monologue’’.

Nina still does not attend Meeting 2, ‘‘because of fever’’. Her mother tells the therapists

how Nina takes a baby bottle when she feels miserable and cries. One therapist reflects:

‘‘So one could think that when she feels upset, she tries to find something she used to like a

lot, as a kind of protection’’. However the mother now starts laughing, almost certainly

with embarrassment, and everyone agrees that the whole situation is a joke. They forget the

pain with which the subject was introduced and the therapists choose not to ‘‘bear witness’’

to Nina’s trauma. This passage was also scored as monologue because of the missed voice.

The therapists ask the parents how they plan to make a home for their children, perhaps

by living together again as mentioned in Meeting 1, but now they are reticent. The parents

tell the therapists their view that only a revisit to her homeland will cure Nina, and the

therapists offer help to obtain the necessary visas. Following this home visit, Nina comes to

Meeting 3. The parents claim that her symptoms have gone and further therapy is

unnecessary, to which the therapists agree. Dialogue seldom developed with this family,

mainly because of avoidance on both sides; nevertheless the therapists followed the par-

ents’ agenda and supported their treatment proposals. In their interview, both parents

declare themselves very satisfied ‘‘because the therapists asked the right questions about

Nina’’. Presumably also because of the practical help they received.

50 Contemp Fam Ther (2014) 36:41–57

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Family 3: Their Home Attacked

There are certainly differences of cultural value with this family, but they are not avoided.

This family is in crisis therapy after a criminal attack on their flat—gunshots through their

front door. The local authority suspects the family of criminal association and decides to

expel them from the city, from which they are only saved by the intervention of their GP.

Although the children are also traumatised by the experience, they do not attend the

meetings.

In spite of the cause of the crisis, much of the first meeting is taken up with the father’s

complaints about the Swedish Health Service, who mistakenly diagnosed his son as having

a brain tumour. The therapist listens patiently, but finally points out that she had no

qualifications in physiological medicine. She then brings in the hitherto silent mother by

asking the meaning of her name and those of her children, and develops a dialogue around

a common interest in mathematics. This also establishes that the woman is a skilled

professional in her own right. In the interview after their second meeting, the father is full

of praise:

The meeting was very good. When we came here our hearts were full. It was like

lifting a lid and it all poured out. We understood the questions very well, because the

interpreter was excellent. This second meeting was better than the first—because my

wife is very sensitive and easily bursts into tears. By this meeting, I believe she

understood that the staff were there to reach out a helping hand. The feeling of

participating in the decisions and planning was very good. Otherwise we would have

found some way to pull out.

He says that previous experiences with the Health Service were lessons in waiting. ‘‘I

think I must have visited almost every single authority and office. They have certain

suspicions, and these suspicions go hand in hand with the way of dealing with you—wait

and wait.’’ In spite of these discouraging experiences, and his initial misconceptions

concerning the purpose of the meetings, the father appears to have established a therapeutic

alliance with the therapist. However the mother remained silent in the interview. By the

last meeting, the concern about the criminal attack itself has subsided, and the mother is

most concerned about gossip in their immigrant community. The therapist tells them ‘‘This

is Sweden: you needn’t worry about malicious gossip if it’s unfounded’’. The man

immediately accepts the therapist’s argument, but his wife persists that the family’s rep-

utation is important for their children’s marriage prospects. In the video-reflections, the

therapist remarks that the mother ‘‘has a worm’s-eye view’’. She seems to ignore the

realities of life for a refugee living between two societies, and the fact that unfounded

suspicion by a Swedish authority nearly lost the refugees their home. Nevertheless the

topic sequence was scored as dialogue because the therapist confronts the value difference

and opens up discussion with both parents—dialogue is not necessarily agreement.

Discussion

Obstacles to Dialogue

Before summarising conclusions from meetings with the three families, it is important to

recognize that the obstacles are just aspects of a complex interaction. They often occur

together, and can be difficult to distinguish. For example mistrust and misunderstanding

Contemp Fam Ther (2014) 36:41–57 51

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occurred together in Family 1. The father said he had attended innumerable meetings

concerning his son without result, while the therapists said that many meetings had gone

over the father’s head. The overlap in responsibility between social services, primal care,

and hospital care is difficult for a native Swede to negotiate, almost impossible for a recent

arrival Misunderstanding and mistrust reinforce each other. The therapists in Family 1 had

difficulty in following the father’s life situation, leading both to monological sequences of

factual questions and the noted lack of empathy.

‘‘Dissonances’’ (Falicov 1988) in cultural values between Sweden and the refugee’s

homeland played a part in inhibiting dialogue with all three families. With Family 1,

cultural insecurity contributed to the interruption of the birth story. With Family 2 it led to

cultural avoidance, while with Family 3 the therapist seemed to ignore the realities of life

in Sweden as experienced by a refugee. Gender relationships, like male authority within

the family and the reluctance of some men to look directly at the therapists were mentioned

in some video-reflections, but these seem less important.

Our ‘‘Background’’ section discussed how trauma could inhibit dialogue and the ther-

apeutic alliance. The Methodology section mentioned the traumatised father who could not

bear to reflect on his situation. The re-enactment of a traumatic birth was too over-

whelming for one therapist to bear. Reluctance to bear trauma could also have influenced

the way the ‘‘baby bottle’’ sequence developed.

As discussed in ‘‘Background’’ section, collaborative therapy developed because the

relative power positions of client and therapist were regarded as an obstacle to therapy

(Anderson and Goolishian 1992); Guilfoyle 2003, Sutherland 2007). Here the potential

power difference between therapist and client is exacerbated by the refugee’s vulnerable

life situation. Many refugees are still awaiting a residence permit, while those who have

received one can seldom find work. Both their status and the ongoing physiological and

psychological effects of trauma imply a greater need for medical certificates than native

citizens. This too can lead to distrust. In their video-reflections, therapists remarked that

they did not always know whether a refugee really wanted treatment or only a certificate.

Finally, dialogue requires empathy. It can be difficult for a therapist to identify with

people from a very different culture, living in ways that are difficult for them to understand.

This was demonstrated with all three families—with Family 2 in the text analysis, and with

the others by video-reflections (‘‘the father is passive’’, ‘‘the mother has a worms-eye

view’’). Many of the human qualities needed in a therapist to promote dialogue echo those

promoting the therapeutic alliance. Escudero et al. (2010, p. 250) lists ‘‘warm, secure,

down-to-earth, informal, trustworthy, optimistic, secure, humorous, caring, and under-

standing’’. Unfortunately informality and humour are difficult to communicate across

language boundaries (Guregard 2009).

Promoting Dialogue

‘‘Social conversation’’, where the therapist introduces a non-threatening topic, promoted

dialogue with all three families. For example, focussing on the Problem Boy’s achieve-

ments allowed the boy to become engaged in a positive way and drew his parents into the

discussion. This is also an example of involving children with respect, an effective strategy

with other families not discussed here. Meeting 1 with Family 3 showed how a conver-

sation about common interests could help bridge cultural boundaries. This also allowed the

therapist to bring out the mother’s professional skills. Conversation can also serve a deeper

purpose by focussing on activities that give meaning to life in a family where ‘‘with the

52 Contemp Fam Ther (2014) 36:41–57

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disruption of life-long attachments and external stabilities, meanings are uprooted.’’

(Falicov 1995, p. 380).

Dialogue begins when a therapist shows interest in people as individuals, not just as

members of a troubled family. The other side of personal curiosity is personal sharing, and

with another family (not discussed here) the therapist shared pregnancy experiences with

the mother. Several interviewed family members said that their second meeting felt better

than the first ‘‘because they had got to know the therapists a little’’. Meeting as individuals

also helps to reduce the inherent power differences. Engaging in dialogue is itself

empowering—the client becomes an agent in the conversation (Seikkula 2003).

The opposite of cultural avoidance is cultural acknowledgement. Falicov (1988, p. 353)

writes: ‘‘Mutual accommodation and recognition of cultural consonances and dissonances

between therapists and family are good starting points for the process of joining and

forming a therapeutic alliance’’. To some extent, recognition of cultural dissonances was

achieved in the Family 3 ‘‘gossip’’ sequence. Cultural differences can even be an advan-

tage, because they allow the therapist to show genuine curiosity about the family’s way of

life. The same applies in reverse. The ‘‘outsidedness’’ of the therapist’s experience com-

pared with the refugee’s enriches the dialogue (Rober 2005).

Summary: Open Dialogue

Many of the obstacles to dialogue, and strategies for promoting dialogue observed above

apply also to meetings with native Swedish families. However they do not apply equally. A

noisy environment can be particularly upsetting for trauma victims—Seikkula and Olson

(2003) stress the need for safety in the treatment environment. A series of factual questions

can recall unpleasant interrogations by the Swedish Immigration Authority. On the other

hand, practical help and advice acquires additional importance with refugees where there is

no a priori basis for trust.

While this article has excluded most discussion of language problems, they cannot be

altogether ignored. The research reveals difficulty in obtaining satisfactory interpreters.

Families and therapists usually prefer to keep the same interpreter for all their meetings.

Three different interpreters, not all competent, were provided by the agency for suc-

cessive meetings with Family 1. This reflects the shortage of qualified interpreters in a

small city (population around 100,000). Compare this situation with Brune et al. (2011)

where all interpreters had worked for several years in psychotherapy, and also received

specialised training, or with Raval (2005), where interpreters were directly employed by

his clinic. Such levels of skill and experience are far beyond the resources of most

hospitals.

The injunctions to meet as individuals rather than expert and client fit immediately with

the OD approach. Also therapists should avoid preplanning the meeting agenda, but tol-

erate uncertainty and follow where the clients lead. This injunction is even more important

with refugee families, where it is uncertain who will attend (Papadopoulos and Hulme

2002), and what they will say. However tolerating uncertainty can be difficult. In their

video-reflections, therapists often described themselves as ‘‘trevande’’, tentative, when it

was unclear where meetings were going. Our research shows different strategies in these

situations. Factual enquiry led to monologue, whereas inter-personal conversation devel-

oped into therapeutic dialogue. Silence was another important strategy, allowing feelings

to come to the surface. There is a suggestion in some OD articles that the lay members of

the network readily lead the discussion, and the professionals’ task is to respond. Here the

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therapists often needed to adopt a more active stance (cf. Werner-Wilson et al. 2003) to get

dialogue moving at all.

The OD approach does not imply any novel behaviour for a good therapist. On the other

hand, the requirements for self-awareness (Rober 2008), to bear painful stories, to experience

ones own culture as the refugee experiences it, and to empathise with unfamiliar people, place

heavy demands. Self-awareness implies maintaining an inner conversation in parallel with

the outer conversation, while that inner conversation is itself a dialogue between the thera-

pist’s experiential and professional selves (Rober 2005, 2008). These are the different voices

of the therapist present in the talk. There are also the different voices of the family. The choice

of which to follow can have a decisive effect on the meeting (cf. ‘‘baby bottle’’ sequence with

Family 2). The therapist’s task is to maintain focus by identifying the voices of pain or

disquiet, or the voices of initiative and hope, and decide which to respond to. There are also

decisions of timing—giving enough space to share painful experiences, but not to become

stuck in the past. The training needed to achieve these skills is both theoretical and personal.

Seikkula (2011, p. 185) writes of the difficulty that experienced therapists can have in

working dialogically; the need to ‘‘tolerate uncertainty’’ implies abandoning familiar struc-

tures. Falicov (1995, p. 383) writes that ‘‘Therapy is really an encounter between the thera-

pist’s and the family’s cultural and personal constructions’’ so her training method focuses on

making these constructions explicit. Rober (2010) outlines a training method involving

systematic changes of role between reflection and interaction.

Applicability

Although the families examined here all stemmed from Islamic cultures, this turned out to

play surprisingly little part in the investigation, except perhaps for a more patriarchal

family pattern than is usual in Sweden. We have written about the unwelcoming reception

of two families by Swedish Immigration, but Sweden was, and still is, one of the most

generous European countries for asylum seekers, so this negative experience is likely to be

reproduced elsewhere.

Limitations

Our main concern is with the video-recordings. There were strong reasons to review the

video-recordings soon after the therapy sessions, while they were still fresh in the minds of

the therapists involved. Unfortunately this meant choosing the video extracts before text

analysis had been carried out, so the opportunity to obtain the therapist’s own reflections at

some critical points in the meetings was not taken. Secondly, while all the written com-

ments of the reflecting team were used in the research, not all the following discussions

were transcribed for analysis. This was due to resource limitations. Ideally every team

discussion should have been transcribed and taken into account.

Admittedly few families and therapists participated in the research, but in retrospect we

are surprised by how much material emerged concerning both obstacles to, and promotion

of, dialogue.

Acknowledgments This research would not have been possible without the contribution of the fourtherapists in the Boras Clinic, and the therapist at the Gothenburg Crisis and Trauma Unit. Charlotte Burckat the Tavistock Clinic gave invaluable assistance as principal supervisor for the doctoral research. SGdisclosed receipt of the following financial support for the research and authorship of this article:

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The Southern Alvsborg’s Hospital provided time for doctoral studies and travelling expenses, while aresearch grant from South Alvsborg’s Research Unit covered most of the additional costs, including ther-apists time, transcription and therapists’ costs. Suzanne Guregard’s English husband made a valuablecontribution to the wording of the article.

Conflict of interest The authors declared no conflict of interests with respect to the authorship or pub-lication of this article.

References

Andersen, T. (1997). Conversation, language and possibilities. New York: Basic Books.Anderson, H. (2001). Postmodern collaborative and person-centred therapies: what would Carl Rogers say?

Journal of Family Therapy, 23, 339–360. doi:10.1111/1467-6427.00189.Anderson, H., & Goolishian, H. A. (1992). The client is the expert: A not-knowing approach to therapy. In

S. MacNamee & G. Gergen (Eds.), Therapy as social construction (pp. 54–68). London: Sage.Arborelius, E., & Bremberg, S. (1992). What can doctors do to achieve a successful consultation? video-

taped interviews analysed with ‘‘consultation map’’ method. Family Practice, 9(1), 61–66. doi:10.1093/fampra/9.1.61.

Blackwell, D. (1997). Holding, containing and bearing witness: The problem of helpfulness in encounterswith torture survivors. Journal of Social Work Practice, 11(2), 81–89.

Brune, M., Eiroa-Orosa, F. J., Fischer-Ortman, J., Delijaj, B., & Haasen, C. (2011). Intermediated com-munication by interpreters in psychotherapy with traumatised refugees. International Journal ofCulture and Mental Health, 4(2), 144. doi:10.1080/17542863.2010.537821.

Elvins, R., & Green, J. (2008). The conceptualisation and measurement of therapeutic alliance: An empiricalreview. Clinical Psychology Review, 28, 1167–1187. doi:10.1016/j.cpr.2008.04.002.

Escudero, V., Heatherington, L., & Friedlander, M. L. (2010). Therapeutic alliances and alliance building infamily therapy. In J. C. Muran & J. P. Barber (Eds.), The therapeutic alliance; An evidence-basedguide to practice (pp. 240–262). NY and London: The Guilford Press.

Falicov, C. J. (1988). Learning to think culturally. In H. A. Liddle, D. C. Breunlin, & R. C. Schwartz (Eds.),Handbook of family therapy: Training and supervision (pp. 335–351). NY and London: The GuilfordPress.

Falicov, C. J. (1995). Training to think culturally: a multidimensional comparative framework. FamilyProcess, 34(4), 372–388.

Fatahi, N., Nordhom, L., Mattson, B., & Hellstrom, M. (2010). Experiences of Kurdish war-woundedrefugees in communication with Swedish authorities through interpreter. Patient Education andCounseling, 78, 160–165. doi:10.1016/j.pec.2009.03.010.

Guilfoyle, M. (2003). Dialogue and power: a critical analysis of power in dialogical therapy. FamilyProcess, 42(3), 331–343. doi:10.1111/j.1545-5300.2003.00331.x.

Gunaratnam, Y. (2003). Researching ‘race’ and ethnicity: Methods, knowledge, and power. London: SAGEPublications.

Guregard, S. (2009). Open dialogue across cultures: Establishing a therapeutic relationship with the ref-ugee family. Doctoral Thesis in Systemic Psychotherapy, Tavistock Clinic, University of East London.

Hartzell, M., Seikkula, J., & von Knorring, A.-L. (2010). Parent’s perception of their first encounter withchild and adolescent psychiatry. Contemporary Family Therapy, 32(3), 273–289. doi:10.1007/s10591-010-9119-1E.

Heeren, M., Mueller, J., Ehlert, U., Schnyder, U., Copiery, N., Maier, T. (2012) Mental health of asylumseekers: A cross-sectional study of psychiatric disorders. BMC Psychiatry 12:114 on-line version:www.biomedcentral.com/1471-244X-12-114. doi:10.1186/1471-244X-12-114.

Holm, U. (1987). Empati: Att forsta andra manniskors kanslor.(Empathy, understanding others feelings).Stockholm: Natur och Kultur.

Horvath, A. O., & Bedi, R. B. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy relationships thatwork: Therapists contributions and responsiveness to patients (pp. 37–70). Oxford: Oxford UniversityPress.

Kagan, N. (1975). Interpersonal process recall: A method of influencing human interaction. Houston, Texas:Educational Psychology Department University of Houston-University Park.

Kurtz, R. R., & Grummon, D. L. (1972). Different approaches to the measurement of therapist empathy andtheir relationship to therapy outcomes. Journal of Consulting and Clinical Psychology, 39(1), 106–115.

Contemp Fam Ther (2014) 36:41–57 55

123

Laitila, A., et al. (2001). Narrative process coding system in marital and family therapy: An intensive caseanalysis of the formulation of a therapeutic system. Contemporary Family Therapy, 23(3), 309–322.doi:10.1023/A:1011183016456E.

Lambert, M. J., & Barley, D. E. (2001). Research Summary on the therapeutic relationship and psychotherapyoutcome. Psychotherapy, 38(4), 357–361. doi:10.1037/0033-3204.38.4.357.

Lantz, J., & Gyamerah, J. (2002). Existential family trauma therapy. Contemporary Family Therapy, 24(2),243–255. doi:10.1023/A:1015341307140E.

Leiman, M. (1998). Words as intersubjective mediators in psychotherapeutic discourse: The presence ofhidden voices in patient utterances. In M. Lahteenmaki & H. Dufva (Eds.), Dialogues on bakhtin:Interdisciplinary readings (pp. 105–116). Jyvaskyla: Centre for Applied Language Studies.

Leiman, M. (2004). Dialogue sequence analysis. In H. Hermans & C. Dimaggio (Eds.), The dialogical self inpsychotherapy. Brunner-Routledge: Sussex.

Linnel, P. (2009). Rethinking language, mind, and world dialogically. Charlotte NC: Information AgePublishing.

Miller, K. E., Martell, Z. L., Pazdirek, L., Caruth, M., & Lopez, D. (2005). The role of interpreters inpsychotherapy with refugees: An exploratory study. American Journal of Orthopsychiatry, 75(1),27–39. doi:10.1037/0002-9432.75.1.27.

Oxford (2006). In: C. Soames & A. Stevenson (eds.). Concise Oxford English Dictionary; 11th Edition,Revised. Oxford: Oxford University Press.

Papadopoulos, R. K. (2002). Refugees home and trauma. In R. K. Papadopoulos (Ed.), Therapeutic care forrefugees: No place like home (pp. 9–39). London and NewYork: Karnac.

Papadopoulos, R. K. (2007). Refugees, trauma and adversity-activated development. European Journal ofPsychotherapy and Counselling, 9(3), 301–312. doi:10.1080/13642530701496930.

Papadopoulos, R. K., & Hulme, V. (2002). Transient familiar others: uninvited persons in psychotherapywith refugees. In R. K. Papadopoulos (Ed.), Therapeutic care for refugees: No place like home (pp.139–163). London and NewYork: Karnac.

Pinsoff, W. M., & Catherall, D. R. (1986). The integrative psychotherapy alliance: Family, couple andindividual therapy scales. Journal of Marital and Family Therapy, 12(2), 137–151. doi:10.1111/j.1752-0606.1986.tb01631.x.

Raval, H. (2005). Being heard and understood in the context of seeking asylum and refuge: Communicatingwith the help of bilingual co-workers. Clinical Child Psychology and Psychiatry, 10(2), 197–216. doi:10.1177/1359104505051211.

Reichelt, S., & Sveaass, N. (1994). What is good conversation? Reflections based on therapeutic work withrefugee families. Family Process, 29, 273–287. doi:10.1111/j.1545-5300.1994.00247.x.

Rober, P. (2005). The therapist’s self in dialogical family therapy: Some ideas about not knowing and thetherapist’s inner conversation. Family Process, 44(4), 477–495. doi:10.1111/j.1545-5300.2005.00073.x.

Rober, P. (2008). Positioning in the therapist’s inner conversation: a dialogical model based on a groundedtheory analysis of therapist reflections. Journal of Marital and Family Therapy, 34(3), 406–421. doi:10.1111/j.1752-0606.2008.00080.x.

Rober, P. (2010). The interactive-reflective training exercise: addressing the therapist’s inner conversation infamily therapy training. Journal of Marital and Family Therapy, 36(2), 158–170. doi:10.1111/j.1752-0606.2010.00192.x.

Roth, G. (2006). A prospective study of mental health among mass-evacuated Kosovo Albanians [disser-tation]. Stockholm: Karolinska institutet.

Seikkula, J. (2002). Open Dialogues with good and poor outcomes for psychotic crises: Examples fromfamilies with violence. Journal of Marital and Family Therapy, 28(3), 263–274. doi:10.1111/j.1752-0606.2002.tb01183.x.

Seikkula, J. (2003). Dialogue is the change: understanding psychotherapy as a semiotic process of Bakhtin,Voloshinov and Vygotsky. Human Systems: The Journal of Systemic Consultation and Management,14(2), 83–94.

Seikkula, J. (2011). Becoming dialogical: Psychotherapy or a way of life? Australian and New ZealandJournal of Psychotherapy, 32(3), 179–193. doi:10.1111/j.1752-0606.2011.00238.x.

Seikkula, J., Alakare, B., & Aaltonen, J. (2011). The comprehensive open-dialogue approach (II). Long-termstability of acute psychosis outcomes in advanced community care; the Western Lapland Project.Psychosis, 3, 1–13. doi:10.1080/17522439.2011.598819.

Seikkula, J., Laitila, A., & Rober, P. (2012). Making sense of multi-actor dialogues in family therapy andnetwork meetings. Journal of Marital and Family Therapy, 38(4), 667–687. doi:10.1111/j.1752-0606.2011.00238.x.

Seikkula, J., & Olson, M. E. (2003). The open dialogue approach to acute psychosis: its poetics andmicropolitics. Family Process, 42(3), 403–418. doi:10.1111/j.1545-5300.2003.00403.x.

56 Contemp Fam Ther (2014) 36:41–57

123

Seikkula, J., & Trimble, D. (2005). Healing elements of therapeutic conversation; dialogue as anembodiment of love. Family Process, 44(4), 461–475. doi:10.1111/j.1545-5300.2005.00072.x.

Sutherland, O. (2007). Therapist positioning and power in discursive therapies: a comparative analysis.Contemporary Family Therapy, 29(4), 193–209. doi:10.1007/s10591-007-9050-2E.

Wadensjo, C. (1992). Interpreting as Interaction. Studies in Arts and Science, 83, Linkoping University.Wampold, B. (2001). The great psychotherapy debate. Mahwah, New:Jersey: Erlbaum Associates.Werner-Wilson, R. J., Michaels, M. L., Thomas, S. G., & Thiesen, A. M. (2003). Influence of therapist-

behaviors on therapeutic alliance. Contemporary Family Therapy, 25(4), 381–390. doi:10.1023/A:1027356602191E.

Wierzbicka, A. (2006). The concept of ‘‘dialogue’’ in cross-linguistic and cross-cultural Perspectives.Discourse Studies, 8(5), 675–703. doi:10.177/1461445606067334.

Woodcock, J. (2000). A Systemic approach to trauma. Context, The Magazine for Family Therapy andSystemic Practice, 51, 2–4.

Contemp Fam Ther (2014) 36:41–57 57

123