SOCW 674 Social Work And Families Lecture No. Eleven

1. SOCW 674 Social Work And Families Lecture No. Eleven Strategic Models

3. Strategic therapies Strategic therapies derive their work from the Palo Alto Group ( 1952-1962) Gregory Bateson, Don Jackson, Jay Haley, John Weakland, Paul Watzlawick.. Concepts such as feedlack loops, the redundancy principle, double binds, family rules, marital quid pro quo, family homeostasis were developed through the environment of the Palo Alto group.

4. The Communications Outlook Communication theorists pay attention to the question of what is occurring rather than why it is occurring. The Strategic therapist�s primary way of viewing problems is to attend to the family�s sequence of interactions and its hierarchy of interactions ( Keim, 1998 ).

5. Communication theorists Communication theorists argue that a circular interaction continues between people because each participant imposes his or her punctuation, each arbitrarily believes that what he or she says is caused by what the other person says. Weakland ( 1976) contends, it is meaningless to search for a starting point in a conflict between two people because it is complex, repetitive interaction, not a simple linear, cause and effect situation with a clear beginning and end.

6. Mental Research Institute MRI Interactional Family Therapy Leading Figures Founded by Don Jackson in 1959, also Virginia Satir and others.

7. Developing A Communication Paradigm All behavior is communication at some level. Just as one cannot not behave, so one cannot not communicate. Communication may occur simultaneously at many levels. One level is Meta communication, which qualifies what is said on the first level. Problems may arise when a message at the first level (Nice to see you) is contradicted by a facial expression or a voice tone that communicates another message. (How can I make a quick getaway from this boring person? ) At the second level.

8. Every communication has a content Every communication has a content ( report ) and a relationship ( command ) aspect. It conveys a relationship between communicants. (Example husbands says to wife � I�m hungry,� with the expectation that she should fix a meal.. The spouse may respond, � It�s your turn to fix dinner tonight or she could say let�s go out or she could say I�m not hungry yet. � etc. )

9. Relationships are defined by command messages Relationships are defined by command messages. The rules preserve family homeostasis. Messages constitute regulating patterns for stabilizing relationships and defining family rules. In a family when a teenager gets pregnant, parents decide to get a divorce, handicapped child is born, family member becomes schizophrenic, it�s the equivalent of flinging open a window when the home heating system has been warmed to the desired temperature. The family goes to work to re-establish the balance.

10. Relationships may be described Relationships may be described as symmetrical or complementary. If the relationship is based on equality the interactive pattern is symmetrical. If the context of the behavior is oppositional the pattern is complementary. Symmetrical relationships run the risk of becoming competitive Each partner�s actions influence the reactions of his or her partner in a spiraling effect called symmetrical escalation. Here quarrels can get out of hand between both partners.

11. Complementary communication Complementary communication invariably involves one person who assumes a superior position and another who assumes an inferior position ( a bossy wife, a submissive husband or vice versa ) Each person punctuates a sequence of events in which he or she is engaged in different ways. Such punctuations organize behavioral events taking place into each participant�s view of cause and effect and thus are vital to ongoing interactions. Program develops and are maintained within the context of the redundant interactive patterns and recursive feedback loops. The struggle for power and control in every relationship that is inherent in the messages that sender and receiver exchange.

12. Paradoxical Communication A double-bind message is a particularly destructive form of a paradoxical injunction. A double-bind message is communicated when one person , especially someone in a powerful position, issues an injunction to another that simultaneously contains two levels of messages or demands that are logically inconsistent and contradictory, producing a paradoxical situation for the recipient. Paradoxical injunctions are forms of communication that must be obeyed but that must be disobeyed to be obeyed. Two conditions typically must exist; ( a ) the participant must have a closed complementary relationship; and ( b ) the recipient of the injunction cannot sidestep or otherwise avoid responding to the communication or the metacommunication.

13. Admittedly, a linear construct Admittedly, a linear construct, the double-bind concept ( Bateson, Jackson, Haley and Weakland, 1956 )was groundbreaking and heralded a breakthrough in the psychotherapy field by providing a new language and a set of assumptions regarding relationships reflected in communication patterns to account for symptomatic behavior. Treating a family system using Strategic theory involves first delineating the problem in clear and concrete terms. Next , solutions that were previously attempted by the family must be scrutinized.

14. First-Order And Second-Order Changes First-order changes are superficial behavioral changes within a system that do not change the structure of the system itself. These changes are apt to be linear and little more than cosmetic or perhaps simply a reflection of the couple�s good intentions- for example not to raise their voices and argue anymore. First-order changes are likely to be short-lived, even if the symptom is removed- the couple tries to control their quarreling- the underlying systemic rules governing the interaction between them have not changed, and the cease-fire is likely to be violated sooner or later.

15. Second �Order Changes Second �Order Changes require a fundamental revision of the system�s structure And function. Here the therapist moves beyond merely helping remove the symptom, also striving to help the family alter its systemic interaction pattern- not just calling a halt to fighting, but changing the rules of the family system and consequently reorganizing the system so that it reaches a different level of functioning. . If the therapy is successful, the old rules are discharged as obsolete; as a result the family may become temporarily confused, but then will attempt to reconstitute itself in a new way. According to Walzlawick ( 1976) , therapy must accomplish second-order changes ( a change in viewpoint, often due to a therapist�s reframing of the situation ) rather than mere first-order changes ( a conscious decision by clients to behave differently ).

16. The Therapeutic Double-Bind Strategic therapists argue that it is their responsibility to provide the family with an experience that will enable the members to change their rules and metarules concerning their relationships with one another and with the outside world.. Faulty, but persistent, solutions to everyday difficulties must be examined to learn if the family ( a ) ignores a problem when some action is called for; (b) overreacts, taking more action than is necessary or developing unrealistic expectations from actions taken; or (c ) takes action at the wrong level ( making cosmetic first-order changes when second-order changes are necessary ). When presented with the presenting problem, strategists will often try to induce change by offering explicit or implicit directives-therapeutic tasks aimed at extinguishing ineffective interactional sequences. The overall purpose of such paradoxical approaches is to jar or interrupt the family�s established, but ineffective, pattern of interaction by powerful indirect means. The therapeutic double bind- is a general term that is used to describe a variety of techniques used to change entrenched family patterns.

17. A therapeutic double-bind A therapeutic double-bind is designed to force the patient or the family into a no-lose situation: a symptomatic person is directed by the therapist not to change ( for example a depressed person is told not to be in such a hurry to give up the depression), in a context where the individual is expected to be helped to change. In effect, the therapist�s directive is to change by remaining the same.

18. Prescribing the Symptom Prescribing the Symptom, here Strategists try to produce a runaway system by urging or even coaching the client to engage in or practice his or her symptoms, for at least the present time. A family is instructed to continue or even to exaggerate what it is already doing( for example, a mother and daughter who continually fight must be directed to have a fight on a regular basis, every evening for fifteen minutes following dinner ). The therapist is actually on the way toward outwitting any resistance to change. At the same time, the therapist is challenging the function or purpose of the symptom, suggesting family members behave that way because it serves to maintain family balance. The therapist is challenging the function or purpose of the symptom, suggesting that the family behaves that way because it serves to maintain family balance.

19. Another form of therapeutic double-bind Another form of therapeutic double-bind is relabeling ( essentially changing the label attached to a person or problem from negative to positive) attempts to later the meaning of a situation by altering its conceptual and/or emotional context in such a way that the entire situation is perceived differently.

20. Mental Research Institute MRI Brief Family Therapy Brief therapy calls for finding alternative ways of facilitating beneficial changes that are relatively quick and inexpensive, and that are especially suited at symptomatic junctures in the life cycle of individuals and families ( Peake, Borduin, & Archer, 1988 )Typically, they are active, highly focused, short-term methods that attempt to enable the family system to mobilize its underutilized resources to solve or resolve the problem (s) that led them to seek help. From the MRI Brief Therapy Perspective, the client�s complaint is the problem, not a symptom of an underlying disorder, as more psychodynamic approaches might theorize.

21. Brief therapy advocates Brief therapy advocates argue that most therapists , in attempting to help a distressed person, encourage that person to do the opposite of what he or she has been doing- an insomniac to fall asleep, a distressed person to cheer up, a withdrawn person to make friends. These approaches, by emphasizing opposites of negative feedback, only lead to internal reshuffling; they do not change the system. Watzlawick and Associates (1974) call such moves superficial first-order changes, effecting change within the existing system without changing the nature of the system itself; it calls for a second-order change to make the system operate in a different manner. First-order changes, according to Watzlawick, Beavin and Jackson ( 1967) are � games without end �; they are mistaken attempts at changing ordinary difficulties that eventually come to a stalemate by continuing to force a solution despite available evidence that it is precisely what is not working ( Bodin, 1981).

22. Paradoxical interventions Paradoxical interventions, especially reframing, are emphasized in order to redefine the family�s frame of reference so that members conceptualize the problem differently and change their efforts to resolve it. Reframing involves a redefining process in which a situation remains unchanged but the meaning attributed to it is revised so as to permit a more constructive outlook. Reframing allows the situation to be viewed differently and thus facilitates new responses to it. As language changes about a problem, changes in feelings are likely to follow.

23. . Brief therapists Brief therapists urge their clients to � go slow � and be skeptical of dramatic, sudden progress; this restraining paradoxical technique is actually designed to promote rapid change as the family is provoked to prove the therapist wrong in his or her caution and pessimism. In general, the therapists do not struggle with the client�s resistance to change, neither confronting the family nor offering interpretations to which the family might react negatively or defensively. Brief therapy aims to avoid power struggles with the family while it reshapes the member�s perspectives on current problems and on their previous attempts to overcome difficulties.

24. MRI Brief therapy program MRI Brief therapy program works as a team. A primary therapist is assigned to the family who conducts the interviews, other team members may watch from behind the one-way mirror and telephone the therapist with advice, feedback, and suggestions while treatment is in progress-all efforts directed at speeding up a change in family interactive patterns. Evaluation of change in the presenting problem is done at a three month and twelve month interval after the last interview.

25. The cybernetic nature The cybernetic nature of both problem formation and problem resolution, with its recursive feedback loops and circular causality metaphors, is basic to MRI thinking and therapeutic endeavors. Ineffective solutions to everyday difficulties lead to symptomatic behavior; once a family member manifests a symptom, the family, believing it has the best way to deal with the problem, responds by repeating the interactive behavior that produced the symptom in the first place. The further repetition of poor solutions intensifies the original difficulty, as the family clings to behavior pattersn that are no longer functional or adaptive ( Peake, Borduin & Archer, 1988 )

26. Schlanger and Anger-Diaz ( 1999 ) Schlanger and Anger-Diaz ( 1999) directors of the Latino Brief Therapy Center at MRI ( Mental Research Institute ) outline the following steps in their brief therapy approach in response to the client�s initial phone call: -Defining the problem -Identifying the attempted solutions -Determining the position of the client -Designing an intervention -Selling the intervention to the client -Assigned homework -Doing a home work follow-up -Terminating

27. Strategic Family Therapy ( Jay Haley and Chloe Madanes ) Jay Haley and Chloe Madanes Jay Haley and Chloe Madanes Strategic Family Therapy defines a presenting problem in such a way that it can be solved; goals eliminating the specific problem are clearly set; therapy is carefully planned, in stages, to achieve these goals; problems are defined as involving at least two and most likely three people, thus allowing for an examination of problematic family structures ( broken hierarchical rules, cross-generational coalitions ) and the dysfunctional behavioral sequences, The thrust of the intervention is to shift the family organization so that the presenting problem or symptom no longer serves its previous function in the family. Change occurs not through insight and understanding, but through the process of the family carrying out directives issues by the therapist.

28. Leading Figures Jay Haley was a key member in Gregory Bateson�s schizophrenia research project in the 1950�s and helped develop the double-bind concept. In 1953 Haley along with John Weakland, became interested in understanding the communication occurring in in hypnosis between hypnotist and subject, and with Bateson�s encouragement began to attend workshops on that subject led by Milton Erikson.

29. Erikson�s influence Erikson�s influence on many of the underlying assumptions and subsequent therapeutic techniques of strategic therapy is great. Haley credits Erikson as the inventor of the general approach of strategic family therapy. Erikson�s therapy was brief, active, directive, and carefully planned. Taking responsibility for change, he tailored a novel approach for each case, typically looking for the person�s area of resourcefulness and putting it to work (Hoffman, 2002). His use of hypnotic techniques, typically focused on symptom removal, required the therapist to assume full charge of the treatment and to issue directives ( however subtle or indirect ) as a way of gaining leverage for eliminating the troublesome symptom. Erikson argued that the effective therapist needed to be a strategist who approaches each new client with a specific therapeutic plan, sometimes a simple directive or a paradox, fitted to that individual and intended to solve his or her problem.

30. Noted for his creative and unconventional Noted for his creative and unconventional hypnotic techniques, Erikson was particularly skilled at:� bypassing client resistance � through the use of paradoxical directives. That is, he was able to persuade patients to hold onto a symptom ( by not fighting it or insisting the client work at giving it up )and then subtly introduce directions to induce change.

31. The Meaning Of Symptoms Haley ( 1963) too the position that a symptom, rather than representing behavior beyond one�s control, is a strategy, adaptive to a current social situation, or controlling a relationship when all other strategies have failed. All participants are caught up in the repetitive sequence that keeps the process going. The symptomatic person simply denies any intent to control by claiming the symptom is involuntary. ( It�s not that I am rejecting you. It�s my headache that keeps me from wanting to be sexually intimate with you tonight.� ) Thus symptoms often control another person indirectly, and this oblique way of communicating through symptom formation may serve a function for the overall family system.

32. Triangles, Sequences and Hierarchies In the Haley-Madanes approach, problems involve the interaction of at least three parties (with a coalition of a minimum of two against at least one other). They are argue that the triangle is the preferred way of describing family interaction ( Keim, 1999 ) Strategic therapists also track interactional sequences of events, which of course as likely to be circular. Keim ( 1999) cites the case of shoplifting by a teenager as more than an individual act; it is a sequence of events involving peers and parents. Rather than focus on treating the individual offender, strategists focus on changing the relevant interactional sequence of the presenting problem, helping the family replace any painful or escalating sequences between members who care about each other with a calmer and more conciliating sequence.

33. According to Chloe Madanes According to Chloe Madanes ( 1981) the emphasis in strategic therapy is not a devising therapeutic method applicable to all cases, but rather on designing a unique strategy for each specific presenting problem. The focus is on artfully alleviating the presenting problem, not exploring its roots or buried meanings. Jay Haley-Chloe Madanes strategic therapy is likely to be short-term, since it is limited to specific problems and is tailored to solutions.

34. Haley was criticized Haley was criticized for his manipulative style. He stated that therapists and patients continually maneuver with each other in the process of all forms of family treatment. Family members, fearful of change, may try to manipulate, deceive, exclude, or subdue a therapist in order to maintain the homeostatic balance they have achieved, even if it is at the expense of symptomatic behavior in one of its members.

35. Haley ( 1976 ) Haley ( 1976 ) sees his task as taking responsibility for changing the family organization and resolving the problem that brought the family to see him. He is highly directive, giving the family members precise instructions or directives and insisting that they be followed. Haley cites the case ( 1976 ) of a grandmother siding with her granddaughter ( age 10 ) against the mother. He saw the mother and child together, instructing the child to irritate the grandmother and instructing the mother to defend her daughter against the grandmother. This task forced a collaboration between mother and daughter and helped detach the daughter from the grandmother, releasing the family to develop a more appropriate hierarchical structure.

36. Another strategic tactic Another strategic tactic is to emphasize the positive, usually be relabeling previous defined dysfunctional behavior as reasonable and understandable. In one often quoted example, allegedly attributed to Haley, he boldly ( and at first glance, outrageously ) told a wife whose husband had chased after her with an ax that the man was simply trying to get close to her. Here Haley was following a principle of communication theory, namely communication occurs at two levels, and that the message at the second level ( metacommunication ) qualifies what takes place on the surface level.

37. The Initial Interview Haley ( 1976 ) insists that the whole family attends the first interview together. Haley has specific stages that he utilizes in his work with families. The opening brief social stage , strategists create a cooperative and relaxed atmosphere while observing family interaction and trying to get all members to participate, thus indicating that all are involved ( not merely the identified patient ) and should have a voice in therapy.

38. Next, strategists Next, strategists shift to the problem stage. They pose such questions as Why do you seek help now? What would each of you like to change ? Do you wish to realize what is happening or just to change ? Are you willing to make sacrifices to change ? In this information �gathering phase ( Haley,1988) , in which all members are urged to participate, conversation is directed at the therapist, who displays an interest but does not interpret the thoughts or feelings being expressed. How each family member views the presenting problem is noteworthy here.

39. The interactional stage The interactional stage is which the family discusses the problem aloud with one another in the presence of the therapist, permits the therapist to observe any dysfunctional communication sequences, coalitions, problematic hierarchies, conflicts between any duos, thereby offering clues about future therapeutic interventions.

40. The interactional stage The interactional stage is which the family discusses the problem aloud with one another in the presence of the therapist, permits the therapist to observe any dysfunctional communication sequences, coalitions, problematic hierarchies, conflicts between any duos, thereby offering clues about future therapeutic interventions. of the first interview, the goal-setting stage, gives the therapist and the family together an opportunity to precisely determine the presenting problem they wish to solve or eliminate. This phase results in a contract that clearly defines goals, allowing all participants to measure change or gauge the success of their efforts as therapy grows.

41. In the final or task-setting stage In the final or task-setting stage, the strategic therapist ends the initial interview with the first set of simple homework assignments or directives, beginning the process of changing sequences of interaction within the family. If the initial interview is done successfully, the family members feel comfortable with the therapist and committed to working together for change. ( Haley,1976 ).

42. The Use Of Directives Directives or assignments of tasks are to be performed outside of the therapy session, they play a key role in strategic family therapy, and are given for several reasons ( a) to get people to behave differently so that they will have different subjective experiences (b) to intensify the therapeutic relationship by involving the therapist in the family�s actions during the time between sessions; and ( c ) to gather information, by their reactions, as how family members will respond to the suggested changes. Chloe Madanes ( 1991 ) emphasizes, � The directive is to strategic therapy what the interpretation is to psychoanalysis. It is the basic tool of the approach. �

43. Quite often, Quite often, asking someone to stop engaging in a certain behavior is a difficult directive to enforce; its success depends upon the status of the therapist giving the instruction, the severity or chronicity of the behavior, how often the directive is repeated, and the willingness of family members to cooperative with the therapist in accomplishing the task. This last point regarding motivation is a particularly essential factor determining whether the therapist will succeed in this direct approach.

44. Frequently, the direct approach Frequently, the direct approach will be unsuccessful. (If direct suggestion were successful, the chances are great that the family would follow advice from friends and not come to a therapist�s office). Another kind of task assignment, more indirect, is one in which the therapist attempts to influence clients to take some action without directly asking them to do so. Often couching the task in paradoxical form ( see Table 11.1) the strategic therapist hopes to provoke the family to rebel or resist him or her so that they give up the symptom. Assignment of paradoxical tasks can be directed at individual family members, pairs of people, or at the family system ( Weeks & L�Abate, 1982 ).

45. Paradoxical directives Paradoxical directives generally take one of two forms-prescriptive or descriptive. Prescriptive paradoxes ask the client (s ) to do something, while descriptive paradoxes relabel something already being done by giving it a positive meaning or connotation. Paradoxical interventions represent a particularly ingenious way of maneuvering a person or family into abandoning dysfunctional behavior. Similar to �prescribing the symptom �, this technique is particularly appropriate for strategists because they assume that families who come for help are also frightened and therefore resistant to the help being offered.

46. The strategic paradoxical approach, The strategic paradoxical approach, aimed at families who defy compliance-based interventions and based on putting clients in a double-bind, encompasses several stages. First, the therapist attempts to set up a relationship with the family in which change is expected. Second, the problem to be corrected is clearly defined; third, the goals are clearly stated. In the fourth stage, the therapist must offer a concrete plan; it is helpful if a rationale can be included that makes paradoxical task seem reasonable. In the fifth stage, the current authority on the problem (such as a physician or a parent ) is disqualified as not handling the situation the right way; in the sixth stage, the therapist issues the directive. In the seventh and last stage, the therapist observes the response and continues to encourage the usual problem behavior in order to maintain the paradox.

47. In another form of prescriptive directive In another form of prescriptive directive called ordeal therapy ( Haley, 1984) , once again based up on the work of Erikson, the strategic therapist will instruct a client to carry out an unpleasant chore ( for example, rising in the middle of the night to wax the kitchen floor ) whenever the symptom appears during the day, thus making the distress of the consequences greater hardship than the distress of the original symptom. By selecting a harmless or mildly noxious task, but one consistent with the client�s desires ( say, keeping a spotless house )yet like an ordeal in its execution.

48. Haley Haley again tries to make it more difficult for the client to have the problem or symptom than to give it up. Ordeal therapy calls for a clear statement of the problem or symptom to be addressed and a commitment to change on the part of the client even if suffering is required, as well as promised willingness to follow a therapist�s directive regardless of its logic or relevance to the presenting problem.

49. There are three major steps There are three major steps in designing a paradox, according to Peggy Papp (1983): redefining, prescribing and restraining. Redefining is intended to change the family�s perception of the symptom. Towards this end, behavior that maintains the symptom is defined as benignly motivated, loving gestures the family employs to preserve its stability. This anger maybe relabeled as caring, suffering as self-sacrifice, distancing as a way of reinforcing closeness. Instead of trying to change the system directly, the therapist appears to be supporting it, respecting the emotional logic upon which it runs. Next the wording of the prescription �Practice being depressed,� �Continue to be rebellious against your parents �must be brief, concise and unacceptable (in order for the family to recoil at the instruction ), but the therapist must appear sincere by offering a convincing rationale for the prescription.

50. Later Later, when the family members press for change, the therapist attempts to regulate the pace of change by urging restraint, pointing out to them what new difficulties might arise. At the same time, the therapist seems to be cautiously allowing the family to change despite these anticipated difficulties.

51. Restraining strategies Restraining strategies ( � go slow � ) are efforts to emphasize the system�s homeostatic balance is in danger if improvement occurs too quickly. If the directive is presented with a creditable rationale (�Change takes time and must proceed step by step, otherwise there is danger of relapse if too much change occurs too fast�), client is likely to go along with it. The tactic is intended to prepare clients for change, to acknowledge their reluctance to change, and to solidify change once it begins ( Shoham, Rohrbaugh & Patterson, 1995 ) provide the additional benefit of reducing the client�s sense of urgency about finding new solutions. Such messages have the added effect of normalizing relapse should it occur, without the family becoming demoralized or giving up trying.

52. Haley (1976) Haley (1976) inquired, in a case of a young, middle- class couple concerned that their young child was soiling his pants, what the consequences would be if he began to go to the toilet normally. (This move suggested by Haley could help them with the problem but would rather not until he was sure of the positive consequences to the entire family. )

53. When the couple returned When the couple returned the next week and indicated that they could think of no adverse consequences, the therapist suggested some possibilities: for example, could the mother tolerate being successful with her child? This effort to challenge the mother�s involvement with her child and reframe her behavior contained messages at several levels: (a) Haley thought she could tolerate success, (b) he was benevolently concerned so he wanted to make sure she could tolerate it; and (c) the mother could find the suggestion of not tolerating success to be unacceptable. No mother is likely to think she cannot be successful with her own child, as Haley well knew. Thus provoked (the father was similarly confronted), both parents became highly motivated to solve their problem to prove that they could tolerate being normal; the boy�s problematic behavior ceased.

54. Effectiveness of Strategic Approaches In some early studies ( Watzlawick et al, 1974 ) a telephone follow-up at regular intervals after ending therapy found favorable results: forty percent claimed complete symptom relief, thirty-two percent considerable relief, twenty-eight percent no long term help. Stanton, Todd etc (1982) offered a well �designed and carefully controlled study in which structural-strategic techniques were successfully employed for treating families with an adult member who engaged in heroin addiction. And positive results were found in follow-ups. Szapocznik, Kurtines etc (1989) utilized similar techniques to reduce drug alliance in adolescent substance abusers.

55. . Stanton and Shadish (1997) Stanton and Shadish (1997) in a more recent comprehensive survey, found that structural-strategic family therapy produced more favorable outcomes than on-family based interventions. However, the overall effectiveness of this approach with a variety of problems (i.e. marital conflict, intergenerational conflict) awaits further research examination.