What is strategic family therapy?
Families engage in complex interactional sequences that involve both verbal and nonverbal (for example, gestures, posture, intonation, volume) patterns of communication. Family members continually send and receive complicated messages. Strategic family approaches are designed to alter psychological difficulties that emerge from problematic interactions between individuals. Specifically, strategic therapists view individual problems (for example, depression or anxiety) as manifestations of disturbances in the family. Psychological symptoms are seen as the consequences of misguided attempts at changing an existing disturbance. For example, concerned family members may attempt to “protect” an agoraphobic patient from anxiety by rearranging activities and outings so that the patient is never left alone; unfortunately, these efforts serve only to foster greater dependency, teach avoidant behaviors, and maintain agoraphobic symptoms. From a strategic viewpoint, symptoms are regarded as communicative in nature. That is, symptoms have distinct meanings within families and usually appear when a family member feels trapped and cannot break out of the situation via nonsymptomatic ways.
The strategic model views all behavior as an attempt to communicate. In fact, it is impossible not to communicate, just as it is impossible not to act. For example, adolescents who run away from home send a message to their parents; similarly, the parents communicate different messages in terms of how they react. Frequently, the intended message behind these nonverbal forms of communication is difficult for family members to discern. Moreover, when contradictions appear between verbal and nonverbal messages, communication can become incongruent and clouded by mixed messages.
Gregory Bateson, who was trained as an anthropologist and developed much of the early theory behind strategic approaches, worked with other theorists to develop the double-bind theory of schizophrenia. A double-bind message is a particularly problematic form of mixed communication that occurs when a family member sends two messages, requests, or commands that are logically inconsistent, contradictory, or impossible. For example, problems arise when messages at the content level (“I love you” or “Stay close to me”) conflict with nonverbal messages at another level (“I despise you” or “Keep your distance”). Eventually, it is argued, a child who is continually exposed to this mixed style of communication, that is, a “no-win” dilemma, may feel angry, helpless, and fearful, and may respond by withdrawing.
Since Bateson’s early work in communication theory and therapy, the strategic approach has undergone considerable revision. At least three divisions of strategic family therapy are frequently cited: the original interactional view of the Mental Research Institute (MRI) of Palo Alto, California; the strategic approach advocated by therapists Jay Haley and Cloe Madanes; and the Milan systemic family therapy model. There is considerable overlap among these approaches, and the therapy tactics are generally similar.
The MRI interactional family therapy approach shares a common theoretical foundation with the other strategic approaches. In addition to Bateson, some of the prominent therapists who have been associated with the institute at one time or another are Don Jackson, Haley, Virginia Satir, and Paul Watzlawick. As modified by Watzlawick’s writings, including The Invented Reality (1984), the MRI model emphasizes that patients’ attempts to solve problems often maintain or exacerbate difficulties. Problems may arise when the family either overreacts or underreacts to events. For example, ordinary life difficulties or transitions (for example, a child beginning school, an adult dealing with new work assignments) may be associated with family overreactions. Similarly, significant problems may be treated as no particular problem. The failure to handle such events in a constructive manner within the family system eventually leads to the problem taking on proportions and characteristics that may seem to have little similarity to the original difficulty. During family therapy, the MRI approach employs a step-by-step progression of suggested strategies toward the elimination of a symptom. Paradoxical procedures represent a mainstay of the MRI approach.
Haley and Madanes’s approach to strategic family therapy argues that change occurs through the process of the family carrying out assignments (to be completed outside therapy) issued by the therapist. As described in Madanes’s Strategic Family Therapy (1981), strategic therapists attempt to design a therapeutic strategy for each specific problem. Instead of “suggesting” strategies, as in the MRI approach, therapists issue directives that are designed deliberately to shift the organization of the family to resolve the presenting problem. Problems are viewed as serving a function in the family and always involve at least two or three individuals. As detailed in Haley’s Leaving Home: The Therapy of Disturbed Young People (1980) and Ordeal Therapy: Unusual Ways to Change Behavior (1984), treatment includes intense involvement, carefully planned interventions designed to reach clear goals, frequent use of therapist-generated directives or assignments, and paradoxical procedures.
The Milan systemic family therapy model is easily distinguished from other strategic approaches because of its unique spacing of therapeutic sessions and innovative team approach to treatment. The original work of therapists Mara Selvini-Palazzoli, Luigi Boscolo, Gianfranco Cecchin, and Guiliana Prata has been described as “long brief” family therapy and was used to treat a wide variety of severe problems such as anorexia and schizophrenia. The first detailed description of the Milan group’s approach was written by the four founding therapists and called Paradox and Counterparadox: A New Model in the Therapy of the Family in Schizophrenic Transition (1978). The original Milan approach incorporated monthly sessions for approximately one year. The unusual spacing of sessions was originally scheduled because many of the families seen in treatment traveled hundreds of miles by train to receive therapy. Later, however, the Milan group decided that many of their interventions, including paradox, required considerable time to work. Thus, they continued the long brief model. Another distinguishing factor of the Milan group was its use of therapist-observer teams who watched treatment sessions from behind a two-way mirror. From time to time, the therapist observers would request that the family therapist interrupt the session to confer about the treatment process. Following this discussion, the family therapist would rejoin the session and initiate interventions, including paradox, as discussed by the team of therapist observers who remained behind the mirror. In 1980, the four originators of the Milan group divided into two smaller groups (Boscolo and Cecchin; Selvini-Palazzoli and Prata). Shortly thereafter, Selvini-Palazzoli and Prata continued pursuing family research separately. The work of Boscolo and Cecchin is described in Milan Systemic Family Therapy (1987), while Selvini-Palazzoli’s work is presented in Family Games (1989), which she wrote with several new colleagues.
Haley argued that conventional mental health approaches were not providing effective treatment. Based on his work with schizophrenics, he observed that patients typically would improve during their hospitalizations, return home, and then quickly suffer relapses. He also suggested that if the patient did improve while away from the hospital, then a family crisis would often ensue, resulting in the patient’s eventual rehospitalization. Thus, effective treatment from a strategic framework often required family members to weather crises and alter family patterns of communication so that constructive change could occur.
Related to Haley’s work with hospitalized patients was his treatment of “disturbed” young adults who exhibited bizarre behavior, continually took illegal drugs, or both. In Leaving Home: The Therapy of Disturbed Young People (1997), Haley suggests that it is best to assume that the problem is not an individual problem, but a problem of the family and the young person separating from each other. That is, young adults typically leave home as they succeed in work, school, or career and form other intimate relationships. Some families, however, become unstable, dysfunctional, or distressed as the son or daughter attempts to leave. To regain family stability, the young adult may fail in attempts to leave home (often via abnormal behavior). Furthermore, if the family organization does not shift, then the young adult may be destined to fail over and over again.
Haley’s approach to treating such cases includes several stages of strategic therapy. First, the entire family attends the initial interview, and the parents are put in charge of solving their child’s problems. During treatment, the parents are told that they are the best therapists for their child’s problems. Because the family is assumed to be in conflict (as shown by the patient’s problems), requiring the family to take charge and become active in the treatment of the identified patient allows for greater opportunities to intervene around the conflict. In particular, it is assumed that the hierarchy of the family is in confusion and that the parents must take an active role in shifting the family’s organization. Also, all family members are encouraged to adopt a position in which they expect the identified patient’s problems to become normal.
As the identified patient improves, the family will often experience a crisis and become unstable again. A relapse of the identified patient would follow the usual sequence for the family and return stability (and familiarity) to the system. Unfortunately, a relapse would only serve to perpetuate the dysfunction. Therefore, the therapist may further assist the family by dealing with concerns such as parental conflicts and fears, or attempt to assist the young adult by providing opportunities away from therapy sessions that foster continued growth. Eventually, termination is planned, based on the belief that treatment does not require the resolution of all family problems, but instead those centered on the young adult.
Strategic therapists share a common belief in the utility of paradoxical procedures. In fact, the history of modern paradoxical psychotherapy is frequently credited as beginning with the MRI group, although paradoxical techniques have been discussed by various theorists from other orientations. Paradox refers to a contradiction or an apparent inconsistency that defies logical deduction. That is, strategic paradox is employed as a means of altering behavior through the use of strategies in apparent opposition to treatment goals. The need for paradoxical procedures is based on the assumption that families are very resistant to change and frequently attempt to disrupt the therapist’s effort to help them. Thus, if the therapist suggests common therapeutic tactics (for example, communication homework, parenting suggestions), then the family may resist (for example, may “forget” to do the homework, sabotaging the exercise) and fail to improve. On the other hand, if the therapist tells the family to do what they are already doing, then the family may resist by getting better.
A variety of explanations have been offered to explain the manner in which paradox works. In Change: Principles of Problem Formation and Problem Resolution (1974), written by Watzlawick and his colleagues, paradox is described as producing a special type of change among family members. That is, there are two levels of change: first-order and second-order change. First-order change is change within a family system (for example, a parent increasing punishment as the child’s behavior becomes more disruptive). First-order change is typically conducted in a step-by-step fashion and involves the uses of problem-solving strategies. On the other hand, second-order change refers to changing the family system itself, and it typically occurs in a sudden and radical manner. The therapist attempts to change the system by unexpected, illogical, or abrupt methods. Paradoxical procedures are designed to effect second-order change. A paradoxical approach might be to encourage the child to act out every time he or she believes that the parents are about to have a fight. In such a case, the family system may be transformed by family members receiving important feedback about the manner in which they operate, by increased understanding of one another’s impact on the system, and by efforts to discard “old family rules” by initiating new procedures for effective family living.
Several different classes of paradoxical interventions are highlighted in Gerald Weeks and Luciano L’Abate’s book Paradoxical Psychotherapy: Theory and Practice with Individuals, Couples, and Families (1982). These include reframing, prescribing the symptom, and restraining.
Reframing refers to providing an alternative meaning or viewpoint to explain an event. A common example of reframing is Tom Sawyer, who described the boredom of whitewashing a fence as pleasurable and collected cash from his peers for the opportunity to assist him. Reframing provides a new framework from which to evaluate interactions (for example, “Mom is smothering” versus “Mom is caring and concerned”).
Prescribing the symptom refers to encouraging or instructing patients to engage in the behavior that is to be eliminated or altered. Symptom prescription is the most common form of paradox in the family therapy literature. Following the presentation of an appropriate rationale to the family (for example, to gain more assessment information), the therapist offers a paradoxical instruction to the family, typically as part of the week’s homework. For example, a child who frequently throws temper tantrums may be specifically instructed to engage in tantrums, but only in certain locations at scheduled times. Another common use of paradox involves symptom prescription for insomniacs. A patient with onset insomnia (difficulty falling asleep) may be encouraged to remain awake to become more aware of his or her thoughts and feelings before falling asleep. As might be guessed, anxiety is often associated with onset insomnia, and such an intervention serves to decrease anxiety about failing to fall asleep by introducing the idea that the patient is supposed to stay awake. Frequently, patients describe difficulty completing the homework because they “keep falling asleep too quickly.”
Restraining strategies include attempts to discourage, restrain, or even deny the possibility of change; the therapist might say, “Go slow,” “The situation appears hopeless,” or “Don’t change.” The basis for restraining strategies is the belief that many patients may not wish to change. Why would patients seek treatment and spend money toward that end if they do not wish to improve? All change involves risk, and with risk comes danger or uncertainty. Moreover, the future may be less predictable following change. In fact, it is possible to conceive of most recurring patterns of family dysfunction or individual difficulties as a heavy overcoat. At times, the heavy overcoat serves a useful purpose by protecting one from harsh weather. As time passes, however, the overcoat becomes uncomfortable as the weather becomes warmer. Still, many people dread taking off the overcoat because they are used to it, it has become familiar, and the future seems uncertain without it. From the patient’s viewpoint, discomfort may be more acceptable than change (and the uncertainty it brings).
Perhaps the most common restraining strategy is predicting a relapse. In predicting a relapse, the patient is told that a previous problem or symptom will reappear. By so doing, the therapist is in a no-lose situation. If the problem reappears, then it was predicted successfully by the therapist, is understood by the therapist, and can be dealt with by the therapist and patient. If the problem does not reappear, then the problem is being effectively controlled by the patient.
Strategic approaches, based on communication theories, developed from research conducted at the Mental Research Institute in the 1950s. In contrast to psychodynamic approaches, which emphasize the importance of past history, trauma, and inner conflicts, strategic therapies highlight the importance of the “here and now” and view psychological difficulties as emerging from problematic interactions between individuals (family members or married partners). Moreover, strategic therapists tend to follow a brief model of treatment, in contrast to many individual and family therapy approaches.
The effectiveness of family therapy approaches, including strategic approaches, is difficult to measure. Although there has been a clear increase in research evaluating the efficacy of family interventions since about 1980, the results are less than clear because of difficulties with research methodologies and diverse research populations. For example, psychodynamic therapists prefer to use case studies rather than experimental designs to determine effectiveness. Strategic therapists have conducted only a handful of research studies, but these results are encouraging. A structural-strategic approach developed by psychologist M. Duncan Stanton has demonstrated effectiveness in the treatment of drug abuse. Also, the Milan approach has been found to be effective for a variety of problems identified by families who participated in a three-year research program. Further research is warranted, however, before definitive conclusions about the empirical effectiveness of strategic approaches can be reached.
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