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Expanding the Context of the
Patient's Explanatory Model
Using Circular Questioning
Larry B. Mauksch, M.Ed., and Thomas Roesler, MD
The explanatory model (EM) interview is designed to elicit a
patient's personal, family, social, and cultural beliefs about health,
etiology of the illness, onset of symptoms, pathophysiology, course of the
illness, and treatment. Although the originators acknowledged an
appreciation of the patient in a network of relationships, the actual
semantic structure of the EM interview questions limits the interviewer to the perspective of the patient. This article applies circular
questioning to the EM format. Circular questions enable patients,
family members, and health-care providers to understand differences
and similarities in their explanatory models, which enhances the
possibility of negotiating a viable treatment plan.
According to Kleinman, Eisenberg, and Good (8), understanding the
patient's personal, family, social, and cultural beliefs about health and
illness is essential to good medical treatment. Each person has a set of
beliefs or an explanatory model (EM) that includes information about "(l)
etiology; (2) onset of symptoms; (3) pathophysiology; (4) course of illness
(including type of sick role—acute, chronic, impaired—and severity of
disorder); and (5) treatment" (8, p. 256). Eliciting the patient's EM defines
areas of agreement and discrepancy between the patient and the provider
that influence clinical management and the outcome of health care. An
interview was described with questions designed to generate this informaLarry B. Mauksch, M.Ed., is clinical assistant professor and residency behavioral scientist, Department of
Family Medicine, University of Washington School of Medicine, and on the faculty at Montlake Institute,
Seattle, WA. Thomas Roesler, MD, is director, Montlake Institute, and clinical associate professor,
Departments of Psychiatry and Behavioral Science and Family Medicine, University of Washington School
of Medicine, Seattle, WA.
The authors wish to thank Noel Chrisman, Carole Jenny, Sally Kentch, Mark Mengel, and Ron
Schneeweiss for their many helpful comments during the preparation of this manuscript.
This paper was first presented by Mr. Mauksch at the 1988 meeting of the Family in Family Medicine
Task Force of the Society of Teachers of Family Medicine and later by both authors at a seminar at the
Montlake Institute, Seattle, WA.
Family Systems Medicine, Vol. 8, No. 1, 1990 © Family Process, Inc.
3
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Family Systems Medicine, Vol. 8, No. 1, Spring 1990
tion. Despite the intent to gather this information from influential sources
in the patient's life, such as family, peers, and clergy, the semantic structure
of the EM questions limits the interviewer to the patient's personal
perspective. This article describes how circular questioning supports and
augments the use of the EM interview.
Selvini et al. (16) introduced the concept of circularity to describe an
aspect of conducting an interview with patients. They define circularity to
mean "the capacity of the therapist to conduct his investigation on the
basis of feedback from the family in response to the information he solicits
about relationships" (16, p. 8). That is, data gathered from patients is
constantly influencing the therapist in the formation of hypotheses.
Hypothesis formation implies adjusting the overall therapeutic effort in a
way that is deemed to be most effective in helping the patient or patients.
Other family therapists (5, 12) have called attention to the importance of
the semantic design of the question. Briefly stated, a circular question asks
the patient to consider the perceptions or beliefs of another person in a
relationship with the patient. Information given in response to circular
questions is embedded in a relationship context.
RATIONALE FOR THE EXPLANATORY MODEL
In the past few decades, social scientists have emphasized the importance of health-care providers pursuing the patient's world view as it relates
to health and illness. One's world view may include beliefs about the locus
of control for change in the healing process or beliefs about causation of
the disease, as well as theories of effective cure. Kleinman, Eisenberg, and
Good (8) presented a cogent synthesis of this work. First, they defined the
difference between disease and illness. "Disease in the Western medical
paradigm is malfunctioning or maladaptation of biologic and psychophysiologic processes in the individual; whereas illness represents personal,
interpersonal, and cultural reactions to disease or discomfort" (p. 252).
Western medicine has been criticized for treating disease, not illness. Yet
studies suggest that in Western cultures, roughly 50 percent of patients'
visits to physicians are about illness problems (8, 9). When patients visit
their physicians, they are seeking a healing relationship. "Healers seek to
provide a meaningful explanation for illness and to respond to the
personal, family, and community issues surrounding illness" (8, p. 252).
The behavioral and social-science literature has presented many examples that demonstrate the value of eliciting patients' EMs. For example,
Blumhagen (2) described "The Meaning of Hyper-tension." He found that
patients gave varied explanations for the cause of hypertension. In his
study at the Seattle Veterans Administration Hospital, nearly half the
interviewees believed that chronic external stress was a significant factor in
the production of their illness. Other groups cited chronic internal stress or
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Expanding the Context of the Patient's Explanatory Model
5
acute stress. Still others believed that hypertension is caused by physical
factors, not psychosocial ones. Obviously, each belief concerning the
cause of hypertension suggests different treatment plans and negotiation
strategies.
Members of the family and the community deliver 70 percent-90
percent of health care (8). When professional health care is desired,
"decisions about where and when to seek care, how long to remain in care,
and how to evaluate treatment also occur in the popular domain, most
commonly in the context of the family" (8, p. 254). Often family values are
dissonant with either the physician or the patient. Patients may feel caught
between the belief system of their family and that of the physician or
between two factions of their family. Thus, soliciting the family's EM or
EMs is an important step in the development of a treatment plan (4, 6, 8).
Providers who do not pursue an understanding of the patient's illness
often have an adverse effect on the patient's compliance or adherence to
treatment plans (11). For example, if the patient or family views the illness
as less severe than does the physician, then follow-up may be lost. Or, if the
physician requests lifestyle changes that create significant discomfort for
the patient or family, then the prescribed behavioral change may not occur.
The family's opinions (4) and the patient's perception of the physician's
view (13) are both important factors that affect the patient's behavior. In
general, the quality of the doctor-patient relationship has direct effects on
the patient's compliance (15). The physician who incorporates an understanding of the patient's world view makes recommendations that are
more meaningful to the patient and family and that, therefore, are more
likely to be followed.
If there is a sufficient degree of congruence between the patient and the
provider, then proceeding with a plan is the easy next step. When the
provider's and patient's or family's perspectives differ, then a negotiation
process must occur. The desired result is a plan that the patient trusts and
believes in and that the physician can support. Several authors have
described negotiation approaches (1, 6, 13). For example, Berlin and
Fowkes (l) developed the LEARN Model (Listening to patient beliefs,
Explaining physician beliefs, Acknowledging differences and similarities,
Recommending treatment, and Negotiating treatment). Sometimes the
patient and the physician cannot arrive at a mutually acceptable plan. In
this case, the patient-provider relationship may end. This is neither poor
compliance nor a poor medical outcome. Instead, patients may leave with
a denned plan to search for a provider who is a better fit with their beliefs,
and physicians can feel that they have not compromised their standards.
Table 1 lists the questions designed to elicit the patient's EM (8). Table
2, compiled by Like and Steiner (10), presents a set of additional questions
designed to elicit patients' hidden agendas, illness prototypes, and requests. Although these questions are derived from medical anthropology,
6
Family Systems Medicine, Vol. 8, No. 1, Spring 1990
TABLE 1
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1.
2.
3.
4.
5.
6.
7.
8.
What do you call your problem? What name does it have?
What do you think has caused your problem?
Why do you think it started when it did?
What does your sickness do to you? How does it work?
How severe is it? Will it have a short or long course?
What do you fear most about your sickness?
What are the chief problems your sickness has caused you?
What kind of treatment do you think you should receive? What are the most important
results you hope to receive from the treatment?
an understanding of the patient's EM is appropriate for most, if not all,
patients, irrespective of their ethnic background (10). That is, each patient
has a different world view that has potentially important implications for
health-care efforts.
RATIONALE FOR CIRCULAR QUESTIONS
We define a circular question as a question asked by an interviewer of a
patient about a person or persons in a relationship with the patient, such as
family members, peers, or members of the family of origin. The focus of
the question is the patient's perception of the experience or the belief of
the third person whom the patient is discussing. For example, "What
concerns your wife most about your illness?" Or, "What would doctors
from the country you came from think caused your illness?"
Circular questions allow the provider to view the patient through the
eyes of others. They create context and contrast. Viewing the patient's
beliefs in the context of his or her family, community, and culture or in
contrast to his or her family members, friends, or co-workers helps explain
the patient's hopes and fears, predicts compliance, and identifies areas in
which trust (7) may be either strong or lacking.
Circular questioning can be used in the presence of just the patient or of
the patient and others. When only the patient is present, the interviewer
asks the patient about his or her views of family, peers, family of origin,
and so forth. For example, "Do others in your family think this is a serious
or a benign illness?" The patient may say, "My mother is the only one who
TABLE 2
1. Is there anything special about your problem that causes you concern [hidden agendas]?
2. Have you ever had this kind of problem before?
3. Have you ever known anyone else who has had or has this kind of problem ["significantother illness prototypes"]?
4. Have you ever read or heard anything before about this kind of problem (e.g., from magazines, books, newspapers, television, or radio)?
5. How did you hope to be helped today [patient's requests]?
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Expanding the Context of the Patient's Explanatory Model
7
is concerned." Now the interviewer learns of the patient's perception of his
or her family's concern: The patient feels isolated. To ensure that the
patient presents what he or she knows of another person's opinion, a
follow-up question might ask, "Does your father see himself as
unconcerned?" The patient is forced to look momentarily at the world
through his father's eyes and may reply, "Probably not, he just doesn't
know how to tell me." Now the interviewer understands more about the
patient's experience in the context of the family. An interesting contrast
exists between the mother-patient relationship and the father-patient
relationship. The questioning might be directed toward the third relationship in, for example, a father-mother-son triangle or toward the patient's
relationships with brothers or sisters. Eventually, the interviewer can gain a
greatly expanded view of the patient's family context.
The great power of circular questioning becomes apparent when it is
used in family interviews. The same question asked in front of family
members allows the health-care provider to gain information and the opportunity to observe the reaction of others. The response of other family
members helps define for the interviewer the nature of relationships:
between the patient and a third party in the circular question, between the
patient and others who may respond, and between others in the family.
Continuing with the example, the patient may answer, "The only person
who is concerned is my mother." The father may reply in frustration, "You
never talk to me, how would I know what is going on?" In this sequence,
the interviewer learns of the patient's perceptions of the concern of other
family members and observes an incongruent response from the father
suggesting the existence of concern but within a distant father-son
relationship.
In our discussion, a noncircular question will be referred to as linear.
Linear questions are asked of a second party about that party's own
experience or opinion. The patient is not asked to consider anyone else's
opinion. Less opportunity exists for a dialog loop to occur between the
patient and anyone else in a relationship with the patient. Much of the
time, linear questioning is appropriate and necessary. Patients need providers to show interest and to care because patient's opinions and experience
are of primary importance in making a diagnosis or providing treatment.
The patient who is asked only about what others believe could feel
discounted. Thus, circular questioning should be used to complement
linear questioning.
When compared with linear forms of EM questions, the differences and
potential results of circular EM questions become apparent, in relation to
both the patient alone and in the presence of others. In the first case, if only
the patient were present, one EM question would be, "What kind of
treatment do you think will work?" An answer might be, "A prescription
of antibiotics." A follow-up, circular form of this question might be,
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8
Family Systems Medicine, Vol. 8, No. 1, Spring 1990
"What do your parents think to be the best treatment?" One answer might
be, "They don't believe in taking medicine." This circular question also
addresses the dynamics of a relationship when viewed in contrast to the
patient's original answer ("antibiotics"). In this sequence, the provider now
wonders who is more influential in determining what the behavior of the
patient will be. If the two previous questions were asked in the presence of
the patient's parents, then proportionally greater information could be
gathered by observing the parents' response or by asking a follow-up
question, for example, "How is it that your son sees taking medicine
differently than you do?" or "If your son takes medicine, what will he fear
most about your response?" These questions essentially complete a
communication loop and force the parents and the son to address their
differences directly to clarify their disagreement.
Table 3 shows examples of the circular forms of the original EM
questions. Questions are asked in the plural form, inquiring about "family"
beliefs. Individual forms, for instance, sister or father, could just as easily
be used. The importance of gaining the family's perspective is illustrated in
the following example in which a hidden-agenda question (see Table 2) is
asked.
One of the authors was asked to consult with a family physician who
was caring for a 32-year-old woman who had, four days earlier,
delivered her first child. The delivery was uneventful except for a
second-degree episiotomy repair. The baby did well following birth,
but the mother developed a fever and was suspected to have
pyelonephritis. When the consultant arrived in the patient's room
with the attending physician, he observed that the patient was
agitated. The patient demanded to leave despite a temperature of
104°F. The physician asked if anything was wrong. She denied any
specific complaints and said she would seek consultation elsewhere
after going home. At this point, the consultant asked, "Has anyone
else you've known had a similar experience?" At this the patient burst
into tears. When she was born, she explained, her mother had a large
perineal tear and had gone home only to return to the hospital the
TABLE 3
1.
2.
3.
4.
5.
6.
7.
8.
What do family members call your problem?
What do they [family members] think caused your problem?
Why do they think it started when it did?
What does your family think your sickness has done to you?
How severe does your family feel it is?
What does your family fear most about your sickness?
What are the chief problems your family feels your sickness has caused you?
What kind of treatment does your family think you should receive?
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Expanding the Context of the Patient's Explanatory Model
9
next day with a fever. "She almost died in the hospital," the patient
related. The consultant then asked, "What is your mother's worst fear
about you being sick now?" The patient replied, "She almost died,
and if I stay in the hospital, I'll die." The physician, observing the
upset, reacted spontaneously and said, "Oh! I am sorry, I didn't
know." Now the physician could see that the woman's beliefs had
fused with what she understood her mother's fears to be. The
consultant asked, "Does your mother know how scared you are—that
you're afraid you might die?" The patient answered, "No, not really."
The consultant continued, "If your mother knew, would she share
your concern that you might die?" A short pause followed, and then
the patient replied, "I don't know, maybe not." At this point, the
patient began to see that she was living with the fear her mother
experienced 32 years earlier. She began to separate herself from her
view of her mother. The physician suggested that the patient might
call her mother and explore the meaning of this coincidence.
This example illustrates two important aspects of circular questioning.
Initially, circularity was discussed as part of a process that influences the
interviewer to think in a new way about symptoms and how they function
within family systems. As the interviewer learns more about the patient in
the family context, the ability to intervene is enhanced. In the foregoing
example, the physician spontaneously responded in a new way upon
understanding the meaning of the patient's fever in the context of her
family history. His exclamation represented a turning point in the treatment. The patient appreciated the physician's greater understanding of her,
and the physician could incorporate this understanding into planning for
future treatment.
A second aspect of circular interviewing refers to the semantic form of
the question. In the first question ("Has anyone else you've known had a
similar experience?"), the consultant left the potential relationship openended. The reader may recognize this as a variation of Question 3 in Table
2. This is the only question in either Table 1 or Table 2 that acknowledges
the patient in a network of relationships. The second circular question
("What is your mother's worst fear about you being sick now?") is a
variation of Question 6 in Table 3. The question allows the provider to
appreciate the relational origin of the patient's fears. The patient shares her
mother's fear that a woman can die in a hospital after childbirth with an
episiotomy and a fever. The remaining two questions ("Does your mother
know how scared you are—that you're afraid you might die?" and "If your
mother knew, would she share your concern that you might die?") are
circular questions, but not adapted from the EM interview. They are
designed to address the issue of the patient's fusion with her mother. The
semantic design puts the patient in the context of the relationship with her
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Family Systems Medicine, Vol. 8, No. 1, Spring 1990
mother and forces her to contrast her own beliefs with those of her mother
in the present.
Conducting an effective interview is an art. When creating linear or
circular questions, the interviewer must constantly appraise the nature of
the relationships between the patient, family, and interviewer (17, 18, 19).
Some questions may be geared more at orienting the interviewer, and other
questions may be aimed more at intervening with the patient (19). The
skillful use of circular questions requires an appreciation of the patient in a
larger social and cultural context. The creation of the semantic structure of
the question and knowing how and when to use the question takes
practice. Initial attempts to use circular EM questions may be difficult and
confusing. However, as one gains experience and as the literature better
describes the hows, whens, and whys of circular questioning, confusion
will diminish.
SYSTEMS DOMAIN OF INFLUENCE
Discrepancies and similarities among the EMs of various influential
groups in the patient's life are important to consider. Where to focus the
interview depends on characteristics such as the quality of relationships,
the patient's stage in the life cycle, and the nature of the illness (14). Figure
1 displays the systems domain of influence and illustrates the overlapping
nature of the forces that influence the patient.
Patient Family of
Origin
Health Care
Providers
Patient
Nuclear Family
Health Care
Providers
Figure 1. Systems Domain of Influence
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Expanding the Context of the Patient's Explanatory Model
11
The sources of influence in Figure 1 show that the questions outlined in
Table 3 represent a narrow range of possibilities. Figure 2 presents a much
broader range of possible questions and areas of focus. The illness issues
pursued in the original EM questions are listed (8) on the horizontal axis.
Personal, family, social (peer/work), and cultural/religious elements of the
belief system are on the vertical axis. Health-care providers serving the
patient's nuclear family and the family of origin have also been added.
These two groups are included because two or more health-care providers
frequently give different diagnostic or prognostic impressions to the same
patient. This list does not exhaust the possibilities but does follow the
spirit of the original EM questioning. Each represents a separate component of the belief system influencing the patient. The following list of
sample questions is referenced to grid positions in Figure 2:
B-2
F-2
D-4
B-4
E-2
E-5
G-8
A
What would your wife say caused your illness?
What would your mother's doctor say caused your illness?
How would your friends say your illness has affected you?
How do your children feel youc illness has affected you?
What do other doctors you have seen say is the cause of your illness?
How serious did your first doctor consider this illness to be?
If you had this illness back in Romania [where you grew up], what
would your doctor have done for you?
1
2
3
Name
Cause
Onset
4
Do to
You
5
6
Severity Fear
Most
7
8
Chief
TreatProblems
ment
Patient
B
Datient
C
Patient Family
of Origin
D
Patient
Peer / Work
Group
E
Muclear Family
HCPs
X
F
Family of
Origin HCPs
X
G
Culture /
Religion
-amily
Nuclear
X
X
X
X
X
X
X
X
Figure 2
12
Family Systems Medicine, Vol. 8, No. 1, Spring 1990
D-7 Does anyone at work think your illness has caused problems on the
job?
B-6 What does your husband fear most about your illness?
B-3 How did your wife first come to know you were ill?
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DISCUSSION
To compare the EMs of the patient with those of others in the systems
domain of influence places the patient's beliefs in context for all concerned
people, including the patient, the provider, and important third parties.
The examination of the patient's views in an expanded context, combined
with an appreciation of any conflicts among members of the systems
domain can bring participants to the brink of change (3). In the foregoing
example, the patient (and the provider) was able to see herself as undifferentiated from her mother's world view. Then she could proceed to negotiate with her mother, or her perception of her mother, regarding a
different way of understanding the meaning of her illness, one that was
much less anxiety provoking. Eliciting EMs provides clarity and contrast.
The need for negotiation is obvious. The viability of a treatment plan is
better understood when differing views become apparent.
Circular questioning is a technique that brings into relief the differences
and similarities in relationships. It can also be used to initiate a natural
negotiation process. This happens when one experiences a new understanding of oneself within the context of a relationship. Alternatively, negotiation can be opened when someone in a relationship with the patient
experiences the patient differently because of a new contextual understanding. In a circular fashion, one often follows from another. Understanding
differences does not always imply change. Sometimes difference or conflict
remains. But understanding this at least defines working parameters for the
health-care professional and the patient. This process may help prevent
unnecessary tests or treatment efforts that might otherwise be recommended.
CONCLUSION
Medical anthropologists appreciate the importance of context in understanding illness. It seems natural that ideas developed by family therapists
should complement these concepts. The original descriptions of the EM
listed its components and noted the various sources of influence—family
members, friends, health-care providers, and clergy. Original EM interview
questions were directed toward the index patient. No semantic structure
was outlined to elicit the perspectives of people in the various domains.
Original theorists might well have assumed that such questions as, "What
would your mother call your illness?" would follow naturally in an EM
interview. However, the authors' experience in teaching methods of
Expanding the Context of the Patient's Explanatory Model
13
circular questioning to family physicians and family therapists suggests
that thinking about a patient's illness within a larger context does not
easily translate into the formation of circular questions. The proponents of
the EM did succeed in arriving at a systemic formulation of illness. The
addition of circular questioning should enhance the health-care providers'
ability to utilize the EM in working with patients.
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Requests for reprints should be sent to Larry B. Mauksch, M.Ed., Family Medicine Center, University of
Washington Medical Center, RC-98, 1959 N.E. Pacific, Seattle, WA 98195.