Theory Paper : DUE 4/16/2018 8pm EST It is imperative that you read the entire instructions.

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Chapter 4: Systemic and Strategic Family Therapies

“Through time, you learn how to look at a system and appreciate it for what it is. Never expect the system to be different. It’s important… to train themselves to see the system, to be interested in it, to appreciate this kind of a system without wanting to change it.”—Boscolo, Cecchin, Hoffman, & Penn, 1987, p. 152

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Lay of the Land

Three Teams with Systemic and Strategic Theories:

Mental Research Institute (MRI; a.k.a. The Palo Alto Group)

Jackson, Watzlawick, Fisch and many others

The Brief Therapy Project designed to find the quickest resolution to client complaints, typically relying on action-based interventions.

Strategic Therapy:

One of the original associates at MRI, Jay Haley, developed own form of systemic therapy with wife, Cloe Madanes.

Their approach focuses on the use of power and love in family systems

Milan Systemic Therapy:

Mara Selvini Palazzoli, Gianfranco Cecchin, Giuliana Prata, and Luigi Boscolo formed the Milan team.

Designed model embodying cybernetic systems theory of Gregory Bateson.

Milan therapists closely attend to how client language shapes family dynamics.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

MRI Systemic Therapy

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

In a Nutshell: The Least You Need to Know

Overview

Developed with the intention of being a brief therapy.

Conceptualize symptoms of individuals within larger network of family and social systems; maintains non0blaming stance.

MRI approach based on general systems and cybernetic systems theories.

Therapists rarely attempt to “educate” family; instead tap into systemic dynamics to effect change.

Introduce small yet meaningful alterations to family interactions; allows family to naturally reorganize.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Juice: Significant Contributions to the Field

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Systemic Reframing

Reframing

Central technique; MRI team took constructivist position:

World experienced through categorizations of objects, people, events.

Once categorized, very hard to see it as part of another.

“Fact” that supports one categorization used to support another.

How it works

Reframe is an alternative yet equally plausible explanation of same facts.

Considers symptom in relational system: how it helps maintain homeostasis.

Clients not expected to adopt proposed reframe; it’s “news that makes a difference.”

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Rumor Has It: The People and Their Stories

Don Jackson

John Weakland

Richard Fisch

Paul Watzlawick

Art Bodin

William Fry

Jules Riskin

Wendel Ray

Barbara Anger-Diaz and Karin Schlanger

Giorgio Nardone

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Big Picture: Overview of Treatment

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Process of Systemic Therapy

Overview

Therapists focus on resolving presenting problem, not imposing other goals.

Presenting problem is a relational one, specifically an interactional one.

Problem is part of interactional behavior sequence.

Attempted solution: Prior unsuccessful problem-solving done by client.

Interventions used to interrupt behavioral sequences.

The Process

Assess the interactional sequence and associated meanings.

Intervene by interrupting the interactional sequence.

Evaluate outcome and client response.

Interrupt the new pattern.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Making Connections: The Therapeutic Relationship

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Respecting and Trusting the System

Outlook

Therapists see family as a system, w/unique epistemology.

There is a deep, abiding trust that the system can reorganize itself without the therapist forcing change.

Therapists provide opportunities for the family to reorganize itself.

Symptoms never seen as indicators of individual pathology.

Byproducts of family interactional sequences that served purpose.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Adapting to Client Language and Viewpoint

How it is Achieved

Establish positive, trusting relationship with client.

Adapt to client’s language, communicative style, and worldview.

Speaking logically with clients who focus on reason; more intensely with clients who are more emotionally expressive.

Respectfully engage with client’s representational framework, including beliefs, values, and language.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Maneuverability

What it is

Maneuverability: therapist’s freedom to use personal judgment in defining the therapeutic relationship

How it works

Depending on what is most helpful to a family:

Therapist may maintain an expert position or a one-down stance.

Therapist may be more distant or emotionally engaged.

Therapist may choose to be the “bad guy” to achieve desired change in the family system.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Viewing: Case Conceptualization and Assessment

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Interaction Patterns

How to Detect

Focus less on content of conversation, more on metacommunication and interactions.

Trace behavioral sequences in which symptom is embedded.

Ask series of questions to assess interaction sequence.

Four phases

Things being normal (homeostasis)

Tensions escalating (early positive feedback)

The symptomatic feelings and behaviors (positive feedback)

Self-correction with ultimate return to normal (homeostasis)

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Interactional/Systemic View of Problems

Systemic View of Individual Pathology

Problems fundamentally interactional not individual pathology.

“Individual pathology” conforms to, is shaped by, and shapes social systems.

“Biologically based” symptoms are shaped by cultural context: not only content but also type of hallucination.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

“More of the Same” Solutions

What it is

“More of the same” solutions: ones that perpetuate problem

Mishandling Problem in 1 of 3 Ways:

Terrible simplifications (action necessary but none taken)

The utopian syndrome (action taken when not necessary)

Paradox (action taken at wrong level)

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Metacommunication

What it is

Metacommunication: Communication about communication

Attend to command aspect of conversation.

Nonverbal clues to interpret verbal messages.

Forms of Metacommunication

Voice, tone, gestures, eye glances, or smirks

May reinforce verbal message (congruent).

May satirize it (openly contradict).

May create a double bind (contradiction that can’t be directly commented on).

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Complementary and Symmetrical Patterns

Overview

Complementary patterns problematic if rigid and exaggerated.

Symmetrical patterns take the form of competition.

Common Complementary Patterns

Pursuer/distancer

Logical one/emotional one

Helpless one/rescuer

Overfunctioner/underfunctioner

Good parent (friend)/bad parent (disciplinarian)

Social/recluse

Oversexed/undersexed

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Type of Change

First-Order Change

Typically involves change in roles within the system.

Ex: Pursuer becomes a withdrawer.

Basic interactional pattern stays the same.

Ex: One pursuer and one withdrawer; level of intimacy maintained.

Second-Order Change

Fundamentally changes rules for relating in the system.

This is type of change necessary for problems to be resolved.

Changes tracked week-to-week to assess type of change.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Observation Team

What it Does

Hallmark of MRI systemic viewing

Teams would sit behind one-way mirror to observe sessions.

Team could see systemic dance more rapidly/completely than therapist.

Reason therapists still train with a mirror is to develop ability to see system’s dynamics.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Targeting Change: Goal Setting

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Goals of MRI Systemic Therapy

General Goals

Symptom-free interaction patterns: Homeostasis that is problem-free/doesn’t involve facing same problem over and over.

No theory of health: Family system reorganizes itself from within in response to perturbations.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Goals of MRI Systemic Therapy (cont.)

The problem is the attempted solution

Define the problem: Concrete, behavioral terms describe actions and reactions.

“When I ask my son to do something, he says ‘no’ and when I push he starts yelling/cursing; that’s when I give in.”

Identify attempted solutions: Listen for patterns in various attempted solutions (e.g., threats that are not carried out).

Describe the desired behavioral change: Develop concrete, behavioral goals.

Goals must be realistic, specific, and time-limited.

Develop a plan:

MRI therapists use two basic systemic principles:

The target of change is the attempted solution.

The tactic of change is to use the client’s own language to speak directly to the client’s view of reality.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Doing: Interventions

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Reframing and Less-of-Same

Reframing

Key technique in the MRI approach to facilitate second-order change.

Less-of-the-same behavior prescription

Identify alternative behavior that will alter pattern.

“Prescribe” behavior; clients leave sessions with behavioral prescriptions.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Therapeutic Double Bind

More-of-the-same behavior prescription

Undo double-bind message in a family or relationship.

Problem-generating form: No matter what you do, you’re wrong.

Therapeutic form: No matter what you do, it’s different.

Ex: A wife demands her husband spontaneously be romantic. If he does what she asks, it’s not spontaneous; if he does nothing, he doesn’t care.

Therapeutic double-bind has him show his romantic side in any way other than his wife demands.

If he follows directive, he initiates new romantic behavior; if he doesn’t and uses wife’s suggestions, he does so without command.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Dangers of Improvement

What it is

Dangers of improvement involves asking clients to identify potential problems that might arise if problem was resolved

Examples:

If a child becomes more independent in doing homework and chores, what will the parents do to feel that they are parenting their son?

If a couple suddenly stops arguing, how will they keep the flame of passion alive in their relationship?

If a person stops being depressed and starts socializing again, how will he protect his solitude and quiet time?

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Restraining, Going Slow

Restraining

The directive to go slow; another paradoxical intervention.

“Restrain” or tell clients to “go slow;” warn clients to avoid changing too fast.

If client complies, change will happen and client will be better prepared for setbacks.

If client has rebellious response, he/she attempts to rebel by working harder toward desired change.

Either way, change process is supported and “immunized” against setbacks.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Strategic Therapy

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

In a Nutshell: The Least You Need to Know

Jay Haley developed his own approach with his wife, Cloe Madanes

Strategic therapy and MRI similarities:

Grounded in general systems and cybernetic theories.

Brief therapy approaches.

Use uniquely crafted behavioral prescriptions.

Differences in case conceptualization and approach to behavioral prescription.

Strategic session characterized by use of enigmatic, creative and dramatic directives.

Behavioral prescriptions that interrupt problem interaction sequence.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Juice: Significant Contributions to the Field

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Directives

Definition

Directives are directions for the family to complete a specific task.

Tasks rarely linear solutions to problem; instead “perturb” system’s interaction patterns to create new ones.

How they work

If a couple is arguing, they argue but change key elements.

Ex: Directive to have “normal” argument, but fully clothed in tub.

Directives get people out of ruts with the smallest change possible.

Clients experience simultaneous shift in emotions, insight, and behavior.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Rumor Has It: The People and Their Stories

Jay Haley and Cloe Madanes

Eileen Bobrow

Jim Keim

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Big Picture: Overview of Treatment

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Initial Interview

Five Formal Stages:

Social Stage

Problem Stage

Interaction Stage

Goal-setting stage

Task-setting stage

Phone Contact

Initial interview begins with first contact, typically by phone.

Gather information in matter-of-fact way and ask all members of household to come to the initial appointment.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Stages of Initial Interview

Social Stage

Everyone personally greeted and made comfortable before discussing problems.

Therapist carefully observes the following:

Who sits near whom?

What is the mood of the family?

What are the parent-child relations like?

What is the relationship like between the adults?

Therapist is assessing interactions and mood.

Doesn’t share observations as they are tentative.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Stages of Initial Interview (cont.)

Problem Stage

Therapists share what they’ve been told to get everyone's opinion on the situation.

Who to ask first:

First engage the adult who is less involved in the problem.

Treat person with the most influence in bringing the family back with the most respect.

Be careful to avoid gender-based coalitions.

Don’t start with a child, as the child may feel on the spot or blamed.

How to listen:

Avoid offering advice or asking how someone feels about situation.

Focus on facts, behaviors, and opinions.

Avoid interpretation or attempts to create insight.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Stages of Initial Interview (cont.)

Interaction Stage

After each family member has answered therapist’s question, the family discusses it amongst themselves.

Therapist removed from the discussion long enough to watch the family interact.

Goal of stage is to see family structure and interaction patterns.

Goal Setting Stage

Therapist reengages by getting a clear change statement all family members can agree to.

Change goal should be defined in terms that are observable, measurable, or countable.

Focus on identified patient/presenting problem rather than shift to systemic view of situation.

Family more willing to stay engaged by focusing therapy as expected.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Stages of Initial Interview (cont.)

Task-Setting Stage

Therapist has developed directive by end of first session

Send family home with simple task to complete.

Subsequent Sessions

Involve following up on directive given for homework and developing another directive based on response.

The therapist continues this until the symptoms are resolved.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Making Connections: The Therapeutic Relationship

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Strategic Positioning

What it is

Therapist’s role/demeanor shifts depending on client needs.

Strategic position: What response from therapist is most likely to promote change?

Ex: If family may benefit from joining together in not liking therapist, a strategic therapist is willing to serve that role too.

Commonly used positions:

Social courtesy

The one-down position

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Strategic Positioning (cont.)

Social courtesy

During social stage, therapist engages in casual social conversation to make clients comfortable and reduce sense of shame.

“The model for this stage is the courtesy behavior one would use with guests in the home.”

Therapist engages them from a casual and down-to-earth position.

The one-down stance or helplessness

Used to increase clients’ motivation, often paradoxically by claiming “I’m not sure if I am able to handle such a problem.”

Often helpful with clients who are hopeless; when therapist takes hopeless stance, client is motivated to find hope.

Therapist doesn’t control; instead, there is deep respect for family systems ways.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Viewing: Case Conceptualization and Assessment

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Strategic Conceptualization

6 Ways to Think About a Problem

Involuntary vs. Voluntary: Clients view problem as involuntary; therapists view symptoms as voluntary.

Helplessness vs. Power: Symptomatic people seem helpless, but symptoms give power.

Metaphorical vs. Literal: Symptoms may be metaphor for other problem behaviors in system.

Hierarchy vs. Equality: Problem may be demand for more or less hierarchy, depending on family circumstances.

Hostility vs. Love: Many family interactions can be viewed as motivated by either hostility or love.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Stages of Family Life

How it is used

Symptoms indicate a stage-of-life problem, which therapist can use to identify where/how to intervene.

Life stages include:

Birth and infancy

Early childhood

School age

Adolescence

Leaving home

Becoming a parent

Becoming a grandparent

Old age

Person may have difficulty transitioning to new phase.

Family must renegotiate balance of independence/interdependence.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Hierarchy and Power

Definition

Family hierarchy: Who has the influence and in what arenas?

Depends on family/culture.

How it it used

Observe family interactions, how they respond to demands.

Not identified from single interaction; repeatedly observed.

Patterns of hierarchy can be used to develop interventions.

Parent-child hierarchy: Child acts on parent requests or parents cave in to child.

Effective hierarchy, ineffective hierarchy, excessive hierarchy

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Strategic Humanism

Latest developments

Emphasize increasing family’s ability to love and nurture, not dominate and control.

Case conceptualizations focus on family’s unsuccessful attempts to show love rather than on attempts to control one another.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Targeting Change: Goal Setting

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Strategic Goals

“The main goal of therapy is to get people to behave differently and so to have different subjective experiences.”—Haley, 1987, p. 56

No predefined set of long-term goals other than to promote change that alters people’s subjective experiences (mood, thoughts, and behaviors).

Ultimate goal is to help clients find ways to love without dominating, intruding upon, or harming others.

How goal may be achieved:

Correcting the couple or family hierarchy.

Reducing intrusion or increasing engagement.

Reuniting family members.

Changing who is helpful and how.

Repenting for an injustice and forgiving.

Increasing the expression of compassion and unity.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Doing: Interventions

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Directives

What they are:

Behavioral tasks given to clients to alter interaction patterns.

Types of directives

Straightforward directives: Used when therapist has power and influence to get people to do what is asked.

Indirect directives: Used when therapist has less authority with client.

Generally take form of paradoxical or metaphorical tasks.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Straightforward Directives

Designing straightforward directives

Assess the situation

Target a small sequence change

Motivate the family

Give precise, doable instructions for directive

Review the task

Request a task report: Following week, therapist asks how it went. 1 of 3 things happen:

They do it: They are congratulated.

They partially do it: Therapist doesn’t excuse them too quickly since it would undermine authority.

They don’t do it:

Nice response: “I must have misunderstood you or your situation to ask that of you, otherwise you would have done it.”

Not-so-nice response: Emphasize that family has missed an opportunity to make changes for own good and this is a loss for them.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Indirect Directives: Paradoxical Interventions

Paradoxical interventions

Symptom prescription: Instructing clients to engage in problem behavior in some fashion.

Paradox with families that avoid change

Family stable around problem member; resistant to attempts to change perception.

Therapist restrains or cautions against certain changes or encourages relapse to prevent it.

Paradox with uncontrollable symptoms

Clients with symptoms they claim they cannot control; symptom prescription changes context of problem behavior.

If context changes, meaning of behavior must change.

If meaning changes, thoughts, feelings, and subsequent behaviors automatically change also.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Indirect Directives: Metaphorical Tasks

Metaphorical tasks

Used when it’s not appropriate to explicitly address a problem.

Pretend techniques

“Fake it ’til you make it.”

Clients “pretend” they achieved their goal for a designated period of time to help make desired changes.

Faking behavior leads to genuine change in perspective, feeling, or behaviors.

Ordeal therapy

Ordeals used when client feels helpless in controlling symptoms.

“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.”

Allow symptom with twist: client must complete another task, “ordeal,” first or afterwards.

Need not be directly related to undesired activity; often carries metaphoric relation.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Milan Systemic Therapy

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

In a Nutshell: The Least You Need to Know

The Milan approach

Began as attempt to put “pure” cybernetics into systematic practice.

Much of its work done on children with severe disorders, such as schizophrenia or eating disorders.

“Long-term brief therapy;” sessions conducted once per month but meet only 10 times.

Uses more language-based interventions, such as reframing and circular questions.

Interaction patterns are “family games;” positive connotation to reframe symptoms.

Shift family interactions by shifting family’s epistemology and view of problem.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Juice: Significant Contributions to the Field

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Circular Questions

Definition

Useful techniques when working with more than one person in room.

Helps assess and make overt overall dynamics in the system.

Reframes problem for all without therapist verbally providing reframe.

Forms of circular questions

Behavioral sequence questions: Use questions to trace entire sequence of behaviors that constitute problem.

Behavioral difference questions: Use questions when clients start labeling/assuming behavior is part of person’s inherent personality.

Comparison and ranking questions: Useful for reducing labeling and rigid descriptions in family.

Before-and-after questions: Useful in assessing how event affected family dynamics.

Hypothetical circular questions: Used to offer scenario and have family members describe how each is likely to respond.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Rumor Has It: The People and Their Stories

The Milan Team

Mara Selvini Palazzoli

Gianfranco Cecchin

Luigi Boscolo

Guiliana Prata

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Big Picture: Overview of Treatment

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Long-Term Brief Therapy

Structure of session

Pre-session: Team meets to discuss family and develop hypotheses and interventions.

Session: Conductor of session meets with family as rest of team observes from behind mirror.

Intersession: Conductor takes a break and develops intervention with help of team.

Intervention: Conductor returns to session and delivers intervention.

Discussion: Family leaves, team meets to discuss session, refine hypothesis, decide how to proceed.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Session Overview

Example of sessions

Session 1: All family members invited so the team may observe interactional patterns and family game; develop initial hypothesis of the role of symptom.

Session 2: All family members present, and focus is on problem member; after this, only non-problem member comes back.

Session 3: Team prescribes the invariant prescription.

Session 4: Non-problem members become focus of treatment.

Session 5: Therapist addresses success or failure to address symptoms of identified patient.

Sessions 6-10: Team continues to monitor success of invariant prescription; additional interventions offered as needed to resolve presenting complaint.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Making Connections: The Therapeutic Relationship

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Neutrality and Multipartiality

What it is

Neutrality: Non-partiality toward family members/problems.

Multipartiality: Willingness to honor all perspectives.

Refers to pragmatic effect therapist has on family, not therapist’s feelings.

Family should not be able identify which “side” therapist took.

Not attached to specific meanings, descriptions, or outcomes .

Extends to therapist’s own hypotheses and ideas about family.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Curiosity and Esthetics

Therapeutic stance is of curiosity

Therapeutic curiosity: Sincere interest in hearing multiple voices within system.

No singular truth; rather an esthetic curiosity about emerging patterns.

Curious about multiple stories families have of single interaction.

How the multiple stories fit together.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Irreverence

What it is

Captures therapist’s relationship to problem (not client).

Irreverent regarding the “catastrophic” appearance of problems.

Doesn’t acknowledge “personality flaw,” “illness,” “unresolved childhood issue.”

Problem not a mighty foe; its power is dependent on context.

Felt in therapist’s confidence and unpanicked response to problem.

Driven by fearlessness.

Systems are inherently self-correcting; therapist maintains an openness, creativity, and flexibility.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Therapist Unavoidable Influence

Role of therapist

Therapist must actively monitor influence on client system.

Therapists not neutral observers in the interactions they observe.

In responses received from clients, therapists responsible for monitoring effects of their beliefs, actions, and words on clients.

Hypothesis about family abandoned if it’s incorrect/unhelpful.

Even theoretical notions to be abandoned if not serving purpose.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Viewing: Case Conceptualization and Assessment

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Family Games (Interactional Sequences)

What they are

Game: Focuses on relational rules for how family interacts.

Rules not consciously created; emerge from family interaction pattern.

Therapists also ask circular questions to assess the interactional sequence.

Can be used with individuals, couples, or families.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Tyranny of Linguistics

What it is

How language, particularly descriptions of self and others, shape reality.

Ex: “I am depressed” or “he’s an angry person” are global labels that suppress times in the day when other feelings/identities experienced.

How it is used

Encourage description of action.

Ex: When I “do” depression or when he is “doing” anger.

Subtle shift of words opens new opportunities for experiencing self.

Positive labels, such as “intelligent” or “good,” also limiting as they obscure relational context.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Family Epistemology and Epistemological Errors

What it is

Note how family punctuates events: how events are described in terms of cause, effects, ordering, etc.

How it works

Identify family’s epistemological errors that maintain symptom.

Common epistemological error punctuates a mutually generated interaction as a one-directional causal event.

Ex: Husband says, “because she nags, I withdraw.” Wife responds: “It’s because you won’t engage that I have to nag.” Both fail to capture the systemic interaction that is going on.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Targeting Change: Goal Setting

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

New Meaning

Achieving new meaning

Generate new meanings (punctuations) that change the “games” (interactional behavior sequences) in the family.

Milan therapists don’t believe in “fixing” family interactions.

Therapists can only shake up the system so that it self-corrects.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Goals

No predefined goals

Goals are simply:

Symptom reduction by means of new systemic interaction patterns.

Family integrates new information and alters “rules” of family game so no member has symptoms .

Family is able to maintain stability and cohesion as a system.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Doing: Interventions

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

The Hypothesizing Process

Two phases:

Hypothesizing for conceptualization: Developing and revising hypotheses; used to provide overall focus.

Hypothesizing as intervention: If beneficial, hypotheses shared with family as in-session intervention.

Defines role of symptom in maintaining family’s homeostasis.

Show how family wants to keep things the same but change.

Must be plausible in family’s current worldview.

Three common types of hypotheses

Hypotheses about alliances

Hypotheses about myths and premises

Hypotheses that analyze communication

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Positive Connotation (Milan-Style Reframe)

How it is used

Positive connotation used to respect family’s fear of change and request for change.

Interpret behavior of each family member positively, with underlying benevolent motivation.

Ex: Reframing a child’s problematic behavior as a way to keep the parents together.

Therapist views family members less judgmentally and with greater hope.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Circular Questions and Counterparadox

Circular questions

One of the primary interventions used in Milan therapy.

Often so effective in revealing structure of system to family that it often makes other reframes unnecessary.

Counterparadox

Similar to the MRI therapeutic double-bind.

Therapeutic response to family created paradoxes.

Request family not change; amplifies problem so that family spontaneously gives it up.

Particularly appropriate with uncooperative families.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Rituals

What they are

Rituals: Behavioral assignments addressing double-binds; helps shift meanings.

Originally used to reinforce positive connotations.

Ex: To reinforce positive connotation of child’s symptomatic behavior, each night family members thank child for sacrifice citing specific benefits.

Later, more subtle ritual put conflicting directives in sequence.

One set of messages true on odd days, another true on even days.

Ex: Woman caught in triangle with husband and child is a wife on odd days, a mother on even days, and spontaneous on 7th day.

Family response is new information; refines working hypothesis/interventions.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Invariant Prescriptions

What it is

Invariant prescription: Intervention that is not varied across families.

Severs covert coalitions between parent and child.

Used primarily with families of anorexic or schizophrenic children.

How it works

Parents arrange date (or other outing), don’t tell children where or why.

Creates secret between parents.

Ends inappropriate coalitions.

Creates clear boundary between unified parents and child.

Child loses status of special confidant.

Lessens emotional burden and results in fewer problem symptoms.

Effective with modern parents who overemphasize open communication.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Tapestry Weaving: Diversity Considerations

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Ethnic, Racial, and Cultural Diversity

Easily adaptable

“Since in strategic family therapy a specific therapeutic plan is designed for each problem, there are no contraindications in terms of patient selection and suitability.” (Madanes, 1991, p. 396)

Work from within client’s worldview; adapts language and interventions to client’s values and beliefs.

Latino Brief Therapy Center at MRI creates unique meaning with each client; doesn’t rely on cultural stereotypes.

Brief strategic family therapy has elements of systemic and structural family therapies.

Developed specifically to treat high-risk Hispanic youth.

Also effective with African-American youth.

McGoldrick, Giordano, and Garcia-Preto (2005) describe how systemic ideas/approaches can be modified to meet needs of 46 different ethnicities.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Sexual Identity Diversity

5 Principles for adapting systemic therapy to GLBTQ:

Understanding heterosexism: Daily marginalized, judged, ignored, and rarely see their reality reflected in advertisements, movies, etc.

Therapist self-reflectivity: Heterosexuals must reflect on privilege of having own sexual and gender orientations generally approved by society.

Locating your position, transparency, and self-disclosure: Disclose own gender and sexual orientation to GLBTQ clients; addresses issue of power and hierarchy.

Too much self-disclosure can be non-productive.

Client as expert, and therapist as curious: Assume curious stance, viewing client as the expert in their lives and lifestyle.

Connecting to wider systems: Consider larger social systems of GLBTQ clients; encourage them to seek positive, supportive communities.

Approaching GLBTQ couples

Different meanings of sex, gender roles, monogamy, family-of-origin/-choice, ex-partners.

Gender roles have more impact than sexual orientation; internalized gender roles may restrict same-sex relationships.

Particular issue in couples with a transgendered partner.

Family life cycle looks different.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Adolescents Coming Out to Family

Considerations

LGBT youth have higher rates of suicidality, substance abuse, self-harm, depression, anxiety, and school issues; important to monitor safety.

Most adolescents able to predict parents’ response based on prior comments about sexuality.

Stage theory for coming out

Subliminal awareness: Child’s sexuality is suspected and sometimes provoked by inquiries about dating and same-sex friendships.

Impact: Child announces his/her sexuality and suspicions are confirmed.

Adjustment: Family struggles to maintain homeostasis; child expected to hide or deny sexuality.

Resolution: Family comes to accept the child’s sexuality identity.

Integration: Family shifts their values related to gender and sexual norms.

Many parents of gay child report “loss” of dreams; much of initial response may reflect personal losses.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Transgendered Youth

Nine domains to cover

Early awareness/family context: General family structure; parents’ and youth’s early gender experiences.

Parents’ attunement with youth’s affirmed gender: Parents’ and family’s response to transgender identity.

Current gender expression: Youth’s current preference for expressing gender.

School context: Youth’s experience at school related to gender identity.

Sexual relationships/development: Ask in private; address sexual orientation, abuse, and activity.

Current intimate relationship(s): Inquire about relationship and partner’s knowledge of youth’s gender identity/possible interest in transitioning.

Physical and mental health: Assess for physical/mental health issues: self harm/ substance abuse.

Support: Identify sources of support for family and youth.

Future plans/expectations: Plans for gender transition, hormone therapy, surgery, children, etc.

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart

Research and The Evidence Base

Systemic therapy began as research: Bateson team studied communication in families with schizophrenic members.

Growing research on effectiveness of evidence-based systemic approaches for:

Adolescent substance abuse/conduct issues, depression/relationship distress, severe mental illness, and couple distress.

Treatments incorporating elements of systemic/strategic therapies:

Multisystemic family therapy

Brief strategic family therapy

Ecosystemic structural therapy

Multidimensional family therapy

Functional family therapy

Emotionally focused couples therapy

Mastering Competencies in Family Therapy (2nd ed.)

Diane R. Gehart