Strategic Family Therapy

1. Strategic Family Therapy

2. Problem-solving Therapy With their compelling application of cybernetics and system theory, strategic approach once captivated family therapy. Part of their approach was a pragmatic, problem-solving focus, but there was also a fascination with strategies to outwit resistance and provoke families into change, with or without cooperation. It was a manipulative aspect that eventually turned many people against strategic therapy.

3. The dominant approaches of the twenty-first century elevated cognition over behavior and encouraged therapist to be collaborative rather than manipulative Instead of problem-solving and provoking change, therapist began to reinforce solutions and inspire change. Once the new face of strategic therapy was created the original voices: Jay Haley, John Weakland, Mara Selvini Parazzole were forgotten.

4. Too Bad, because their strategic approach introduced two of the most powerful incites in all family therapy The families often perpetuate problems by their own actions And that directives tailored to the needs of a particular family can sometime bring about sudden and decisive change

5. Sketches of Leading Figures Strategic therapy grow out of the communications therapy developed in Betson's schizophrenia program, which evolved into three different models: MRIs brief therapy, Haley and Madane's strategic therapy, and Milan systemic model. This groups similar projects can be considered the intellectual birthplace of family therapy.

6. Their goal was to observe families: they stumbled into family therapy more or less by accident. Where was a little irony with Bateson, although he did not care about manipulating people in the family, he did give his subjects to Milton Erickson who believed that therapy should be brief and used hypnotherapy believing that people could change instantly.

7. Many of what have been called paradoxical techniques came from Erickson's application of hypnotherapeutic principles to turn resistance into advantage. Example a hypnotherapist might not tell a fighting person that they are refusing but could tell them to keep their eyes open and that they are getting very heavy.

8. Don Jackson founded the Mental Research Instatute in 1959, assembled a staff who included: Risken, Satir, Haley, Weakland, Watzlawick, Bodin, and Beavin. After a few years many staff members became fascinated with the pragmatic, problem-solving approach of Erickson. This led Jackson to establish a brief therapy project under Fisch’s direction. What emerged was an elegantly brief approach based on identifying and interrupting vicious cycles that occurs when attempt to solve problems that would only make them worse.

9. In 1976 Haley moved to Washington D.C., where with Cloe Madanis he founded the family therapy institute. Madanis was known as one of the most creative therapists in the field. Selvini Palazzoli was a prominent Italian psychoanalyst, specializing in eating disorders and after being frustrated with that approach decided to develop her own approach to families. In 1987, she led a group of eight psychiatrists who turned to the idea of Bateson, Haley, and Watzlawick and formed the center of the study of the family in Milan, where they developed Milan systemic model

10. Theoretical Formulations The prognostics of human communication, Watzlawick, Beavin, and Jackson (1967) sought to develop a calculus of human communication, which they say is a series of axioms. The first of these axioms is that people are always communicating. Because all behaviors are communicative and because one cannot not behave, thus one cannot not communicate. The second axion that all messages have report and command functions. The report (or content) of the message conveys information, while the command is a statement about the definition of the relationship. Example "mommy, Sandy Hit me" Conveys information but also implies a command. Do something about this!

11. Notice however, that implicit commands is ambiguous. In families, command messages are patterned as rules (Jackson, 1965). Jackson used the term family rules as a description of regularity, not regulation. Nobody lays down the rules. In fact families are generally unaware of them. The rules, or regularities, of family interaction operate to preserve family homeostasis

12. Communications theorists didn't look for understanding motives; instead, they assumed circular causality and analyzed patterns of communication linked together in additive chains of stimulus and response as feedback loops. When the response to a family member's problematic behavior exacerbates the problem, that chain is seen as a positive feedback loop.

13. Strategic therapist took the concept of the positive loop and made it the centerpiece of their model. Families counter many difficulties over the course of their lives, but whether a difficulty becomes a problem depends on how family members respond to it.  In most families, unspoken rules govern all sorts of behaviors. Where a rule promotes the kind of rigid attempted solutions described previously, it isn't just the behavior but the rule that needs to be changed. When only a specific behavior within a system changes, that is first-order change, as opposed to second-order change, which occurs when the rules of a system change.

14. The MRI approach to problems is elegantly simple: first, identify the positive feedback loops that maintain problem; second, determine the rule that support those interactions; and third, find a way to change the rules in order to interrupt the problem maintaining behavior. Jay Haley added a functionalist emphasis to the cybernetic interpretation, with his interest in the interpersonal payoff of behavior. Haley believed that the rules around the hierarchal structure of the family were crucial and found inadequate parental hierarchies lurking behind most problems.

15. To counter a problem's payoff, Haley borrowed Erickson's technique of prescribing ordeals, so that the price of keeping a symptom outweighed that of giving it up Haley tried to explain all therapy as based on ordeals, suggesting that people will change to avoid the many ordeals inherent in being a client. Cloe Madanes (1981, 1984) also emphasized the functional aspect of problems, particularly the rescuing operations involved when children use their symptoms to engage their parents. Example: when a daughter sees her mother looking depressed, the daughter can provoke a fight that prods the mother into taking change.

16. Madanes's approach involves finding ways for symptomatic children to help their parents openly, so that they don't have to resort to symptoms as sacrificial offerings. Like Haley, Mara Selvini Palazzoli and her associates focused on the power games in families and on the protective function symptoms served for the whole family. The team searched through several generations for evidence of their hypothesis about how the children's symptoms came to be necessary. They concluded that the patient developed symptoms to protect one or more other family members so as to maintain the delicate network of extended family alliance.

17. Normal Family Development According to general systems theory, normal families, like all living systems, depend on two vital processes in which we talked about in the past. To maintain integrity in the face of environmental challenges through negative feedback. And lastly that no organism can survive without a coherent structure. But too much structure leaves the family unable to change. This is why normal family's also have mechanisms of positive change as well. The MRI group resolutely opposed standards of normality: "as therapists we do not regard any particular way of functioning, relating, or living as a problem if the client is not expressing discontent with it" (Fisch 1978).

18. The Milan associates strove to maintain an attitude of neutrality. They didn't apply preconceived goals or normative models to their client families. Instead, by raising questions that helped families examine themselves and that exposed hidden power games, they trusted that families would reorganize on their own. Haley's therapy was designed to help families reorganize into more functional structure, with clear boundaries and generational hierarchies (1976)

19. Development of Behavior Disorder According to communication theory, the essential function of symptoms is to maintain the homeostatic equilibrium of family systems. Symptomatic families were seen as trapped in dysfunction, homeostatic patterns of communication. These families cling to their rigid ways and respond to signs of change as negative feedback.

20. In strategic model, there are three explanations of how problems develop. 1 is cybernetic: difficulties are turned into chronic problems by misguided solutions, forming positive feedback rapidly. 2 structural: problems are the result of incongruent hierarchies. 3 is functional: problems result when people try to protect or control one another covertly, so that their symptoms serve a function for the system. A case 16-yr-old kid recently began refusing to leave the house.

21. An MRI therapist the focus would be on the parents attempted solution A Haley-style therapist would also look at the parents as well as the full family interaction. Maybe based on a dysfunctional triangle. A Milan systemic therapist would not focus on solutions but instead past and present relationships within the family. They would be looking to uncover power alliances, across generations, that constituted the family games. The essential insight of the strategic model was that problems are often maintained by self defeating patterns of behavior. That self-defeating patterns maybe embedded in dysfunctional family organization. Basically families must also modify their structure to accommodate changes in the lives of family members.

22. Goals of Therapy: MRI Therapy MRI therapists viewed people who have problems as being stuck rather than sick; so their goal was simply to help them get moving again Therapy was over, once the presenting problem was resolved Defined clear and reachable goals Most of the time, the processes of pushing clients to set concrete behavioral goals was most helpful and therapeutic MRI model: behavioral In it’s goals of trying to achieve problem resolution; therapists strive to change individuals’ behavioral responses to their problems by trying to interrupt their vicious feedback loops

23. Goals of Therapy: Haley’s Approach Haley didn’t like the idea of therapies that only helped clients understand why they did things and not get them to change Therefore his approach was also behavioral and it especially downplayed the importance of insight Goal: is often a structural reorganization of the family, hierarchy and generational boundaries (similar to structural therapy but would only focus on reorganizations, related to the presenting problem) Example: improving the relationship between polarized parents of a rebellious teenager A structural therapist might get the parents to talk about their marital problems Where as, Haley would have them talk only about their difficulty working together to deal with their son

24. Goals of Therapy: Milan Group Early work: largely influenced by both the MRI and Hailey models But they were less behavioral and less problem focused, and more interested in changing families beliefs And were still just as manipulative: responsibility for change rested on the therapists After the breakup of the Milan group, Luigi Boscolo & Gianfranco Cecchin moved away from strategically manipulating families and moved towards collaborating with them to form systemic hypotheses about their problems Entered therapy with no specific goals or strategies, but with curiosity

25. Conditions of Behavior Change Early days: goal of family therapy was simple to improve communication Later: goal was to alter specific patterns of communication that maintained problems To achieve these goals, a therapist could: 1. point out problematic patterns: relies on insight and depends on a willingness to change 2. manipulate them: an attempt to beat families at their own games with or without their cooperation

26. Behavior Change: MRI group Resolving problems involved changing the behavior associated with them And by seeing the results of the change in behavior, clients will become more flexible in their problem-solving strategies Further, by becoming more flexible in strategies, they achieve a second order change; a change in the rules governing their response to problems Example: Maria argues with father about her curfew, he grounds her & she runs away 1st order intervention might be to help Maria’s father find a more effective punishment 2nd order strategic intervention might be to direct the father to act disappointed implying that he has given up trying to control her (this shifts Maria from feeling trapped to feeling concerned & more reasonable) Her father then learns that when an attempted solution isn’t working, try something different (which is a second order change- that alters the rules governing the way father and daughter interact. Example: Maria argues with father about her curfew, he grounds her & she runs away 1st order intervention might be to help Maria’s father find a more effective punishment 2nd order strategic intervention might be to direct the father to act disappointed implying that he has given up trying to control her (this shifts Maria from feeling trapped to feeling concerned & more reasonable) Her father then learns that when an attempted solution isn’t working, try something different (which is a second order change- that alters the rules governing the way father and daughter interact.

27. Behavior Change: Haley & Milan Haley believed that behavior change rooted in changes in behavior which would alter perceptions Milan group, on the other hand, believed that behavior change relied on getting families to see things differently, through reframing techniques

28. Therapy: MRI Assessment Goals of MRI assessment: Define the problem/complaint and identify who sees it as a problem and why it’s a problem now It is important for the therapist to inquiry exactly what these complaints mean: Example: “We don’t communicate”, might mean “my son argues with everything I say” or “my husband hides behind the newspaper and never talks to me.” A useful device: if we had a videotape of this, what would it look like?

29. Therapy: MRI Assessment Once the problems been identified, the therapists tries to determine who has tried to solve it and howOnce the problems been identified, the therapists tries to determine who has tried to solve it and how

30. Therapy: MRI Assessment Goals of MRI assessment: 3. Understand the clients’ unique language for describing the problem this is important in suggesting how to intervene and how to frame suggestions in a way they will accept Example: a devoutly religious wife might be more willing to the suggestion that she pray for her husband to become more involved with the family, in place of her usual criticism of his failings. The first two goals show where to intervene, while the third suggests how. The first two goals show where to intervene, while the third suggests how.

31. Therapy: Haley’s Assessment Also began with a clear definition of the problem From the point of view of every member of the family Unlike the MRI group, Haley also observes how family members interact in the session: to identify any structural arrangements in the family that may be contributing to their problems; i.e., pathological triangles, or cross-generational coalitions

32. Therapy: Milan Model Assessment Begins with a preliminary hypothesis, which is confirmed or disconfirmed in the initial session These hypothesis are generally based on an assumption that the patient’s problems serve as a protective function for the family Therefore, assessment of the presenting problem is based on questions designed to explore the family as a set of interconnected relationships Example: a reply to, “who has been more worried about this problem, you or your wife?” will suggest a hypothesis about the closeness and distance of family members Ultimately, the goal of assessment is to achieve a systemic perspective of the problem

33. Therapeutic Techniques: MRI The MRI model follows a 6 step treatment procedure: 1. Introduction to the treatment setup 2. Inquiry and definition of the problem 3. Estimation of the behavior maintaining the problem 4. Setting goals for treatment 5. Selecting and making behavioral interventions 6. Termination Strategic therapists shared a belief in the need for indirect methods to induce change in families but they had distinctly different techniques for doing so. Strategic therapists shared a belief in the need for indirect methods to induce change in families but they had distinctly different techniques for doing so.

34. Therapeutic Techniques: MRI 2. Inquiry and definition of the problem: if problem is stated in a vague way, the therapists goal is to help translate it into a clear and concrete goal “what will be the first small sign that things are getting better?” 3. Estimation of the behavior maintaining the problem: Therapists inquiry about attempted solutions which might be maintaining the problem [generally fall into 3 categories]: Deny problems existence (action is needed but none is taken) Effort to solve something that isn’t really a problem (action is taken when it shouldn’t be) Effort to solve a problem within a framework that makes a solution impossible (action is taken but at the wrong level Once a strategy for changing the problem-maintaining sequence is established, clients must be convinced to follow this strategy

35. Therapeutic Techniques: MRI Techniques: Reframe problems (to sell their directives) Example: telling an angry teenager that when his father punishes him, it’s the only way his father knows how to show his love Try to get family members to do something that runs counter to common sense (to interrupt problem-maintaining sequences) Example: paradoxical interventions- a couple was bothered by their parents need to treat them like children. It was then suggested to become less rather than more competent; to act helpless and dependent. The parents then backed off

36. Therapeutic Techniques: Haley & Madanes Approach Haley’s approach is tailored to address the unique requirements of each case and is therefore harder to describe Directives are used as thoughtful suggestions targeted to the specific requirements of each case Emphasis is put on the beginning of therapy Haley began by interviewing the entire family, regardless of who the “patient” was Four stages to initial interview: a social stage, a problem stage, an interaction stage, and a goal-setting stage

37. Therapeutic Techniques: Haley & Madanes Approach Social stage: Haley believed that families came into therapy defensive because they don’t know what to expect and are afraid of blame, therefore in this stage, he greeted every one and made sure they were comfortable Problem stage: Asked each person for his or her perspective He recommended speaking to the father first so that they have increased involvement, which mothers usually already have (illustrates Haley’s strategic maneuvering) He also looked for clues about triangles and hierarchy

38. Therapeutic Techniques: Haley & Madanes Approach Interactional stage: Haley encouraged families to discuss their points of view among themselves So he can observe, rather than just hear about the problems He looked for: coalitions between family members against others how functional is the hierarchy? do the parents work well together or do they undercut each other?

39. Therapeutic Techniques: Haley & Madanes Approach Directives play a central role According to Haley, the effective therapist isn’t one who tells people what to do but one who gets them to do it From Haley’s problem-solving therapy Couple out of the habit of being affectionate with each other, were told to behave affectionately “to teach their child how to show affection” A mother who is unable to control her 12 yr old son had decided to send him away to military school. Haley suggested that since the boy had no idea how tough life would be at military school, it would be a good idea for the mother to help prepare him. They followed instructions as if playing a game, and after 2 weeks the son was behaving so well that his mother, no longer wanted to send him away.

40. Therapeutic Techniques: Haley & Madanes Approach Haley believed that people’s struggles have meaning and therefore suggests that reasonable solutions can be found By helping families find new ways to solve their problems Addressed interpersonal power in families: observed power struggles in families and how power was misused, in hopes to help families resolve them

41. Therapeutic Techniques The Haley and Madanes Approach Madanes addresses power balancing in couples and its role in a wide range of symptoms. Looking at areas where power is regulated, such as finances, education, children, etc. Symptoms include depression, headaches, eating disorders, and substance abuse It is found that the partner with the least power develops the most emotional problems. The symptomatic person may refuse help to maintain “a perverse sort of power” by holding on to the troublesome symptoms.

42. The Haley Approach Haley’s strategic therapy suggested to look at the problems of high-conflict couples from a developmental approach and in terms of the family life cycle. This approach helps find the best hypotheses that describe clients more positively, rather than pathological. E.g., instead of looking at ex-spouses as personality disordered, a Haley-styled therapist would acknowledge a need for an emotional divorce between the two.

43. James Keim & Jay Lappin Keim and Lappin describe a strategic approach where they would reframe the presenting problem as a breakdown in the negotiation process. This technique was meant to translate from negotiating easy tasks within therapy to more difficult issues at home. They recommend introducing couples to the negotiation process as experimenting with a fun exercise designed to get them to reach agreements. A negotiation is a conversation in which one party makes a request and the other names a price. The couples were warned that sometimes they may decide not to go forth with the negotiation because sometimes it’s better to endure certain problems than pay the price of change.

44. Madanes – Pretend Technique Madanes used the observation that people will often do something they wouldn’t normally do if it’s reframed as play to develop a whole range of pretend techniques. One strategy would be to ask a symptomatic child to pretend to have a symptom and encourage the parents to pretend to help. The child can give up the actual symptom now that pretending to have it is serving the same family function. Case Studies: “Night Terrors” & “Temper Tantrums”

45. Ordeal Therapy Haley referred back his Ericksonian roots (Ordeal Therapy) in which ordeals were prescribed to make symptoms more trouble than they’re worth keeping. Haley also used ordeals to restructure families. If one makes it more difficult for a person to have a symptom than to give it up, the person will give up the symptom.

46. Haley/Madanes Therapy Strategic Humanism The strategic humanism technique represents a movement away from power elements of hierarchy and toward ways to increase harmony. This approach still involves giving directives, but a therapist first will work on encouraging family members to be sympathetic and supportive. This strategy puts parents back in charge of oppositional children without high intensity drama.

47. Therapeutic Techniques The Milan Model Original Milan model – highly scripted Families were treated by male-female cotherapists Standard format: Presession: coming up with initial hypothesis Session: validate, modify, or change the hypothesis Intersession: team would meet alone to discuss hypothesis and arrive at an intervention. Intervention: deliver the intervention to the family (ritual or positively connotation) postsession discussion: analyze the family’s reaction and plan for the next session

48. The Milan Model The primary intervention was either a ritual or a positive connotation. Rituals were used to engage families in a series of actions that ran counter to exaggerated rigid family rules and myths. Positive connotations served as a protective function. E.g., Carlo continues to be depressed to distract his parents from their martial issues; the positive connotation avoided the implication the family members benefited from the Carlo’s symptoms.

49. The Milan Model Positive connotations and rituals were powerful interventions; the therapist-family relationship became crucial in order to keep families engaged. Theorists advised therapists to remain neutral and avoid taking sides. However, this neutrality was often perceived as distant and aloof so families often did not return to therapy.

50. The Milan Model Then, in the early 1980s, Palazzoli stopped using paradoxical interventions, although she maintained the model’s strategic approach. Instead, she experimented with a specific ritual, invariant prescription; which was assigned to every family treated. Palazzoli believed psychotic and anorexic patients are caught up in a “dirty game” with their parents. Parents were directed to tell their children they had a secret and to go out together without telling family members until the patient’s symptoms stopped.

51. Palazzoli Palazzoli then moved from short-term, strategic therapy to long-term therapy with patients and their families. This therapy incorporated a psychodynamic approach, focused on family patterns, and long-term therapy that emphasized insight and focused on the individual.

52. Circular Questioning Boscolo and Cecchin also moved away from strategic interventions, but moved toward a more collaborative style of therapy. This approach grew from their conclusion that the value of the Milan model was not in the directives, but in the interview process; their therapy centered around circular questioning Circular questions are designed to decenter clients by orienting them toward seeing themselves in a relational context from the perspective of other family members. Questions are structured so that one has to give a relational description in answer.

53. Other Contributions Originally the MRI group used teams behind one way mirrors to help brainstorm strategies, as did the Milan group. Jim Alexander, a behaviorist, incorporated strategic ideas resulting in functional family therapy; which is concerned with the function that family behavior is trying to achieve.

54. Evaluating Therapy Theory & Results Communications family therapy was a new conceptualization that altered the nature of imagination. It focused on the form and impact of communication, rather than content. Only when someone outside the family system provides input, then can correction occur within the family. 1990s- strategic approaches where replaced by more collaborative models.

55. Evaluating Therapy and Results However, valuable aspects of strategic therapy remain: Clear therapeutic goal Anticipating how families might react to interventions Understanding and tracking sequences of interaction The creative use of directives

56. Results Research on the effectiveness of family therapy is difficult to gage; most of the information is exchanged through case report format. Although the Milan model has disappeared, there are still two thriving models: the MRI group (West Coast) and the Washington School (East Coast). Strategic therapists are (currently) integrating new ideas and evolving with the times.