Systemic and Strategic Therapies

Hello and welcome welcome welcome everyone welcome to my live recording of my updated systemic and strategic therapy lecture um and so this is a live recording and an updated recording of um my kind of lectures on systemic strategic therapy to go with my textbooks and so I know I have a few them out there already and I thought you know it was time to update them so if You are joining live please go ahead and put your name in the chat I'd love to know what brings you here what you're excited about are you studying

for your licensing exam are you in grad school or you just didn't have anything uh more exciting to do tonight so I'd love to uh welcome you all here and um get a sense of H why you decided to show up for this go ahead put your uh your name and uh why you're here in the chat love to hear why what brings you Here tonight welcome welcome okay awesome okay so we're gonna go ahead and get started um with this lecture on systemic and strategic therapies and so this goes with um my textbook series

with sage and these theories whether you're in counseling or in Family Therapy tend to be the toughest theories um to learn so awesome awesome yeah okay oh the Chat's now uh people are coming in so I'll just say that uh I'll check in on this chat real quick here um yeah so looking for more uh let's see so Brooks here learning wanting to just have more learning opportunities before she starts internship and Michael is saying uh from Aurora Colorado studying for the national exam yes may it be your last and final time Tracy just saying

she uh found the he a textbooks to be helpful I was curious how this would go awesome H Jim's taking the mft exam here too Joy is here and she's finishing up her grad school um Kimberly is also taking her exam relle is here for a refresher awesome awesome Stacy's just always interested in strategic family therapy yeah don't uh and Sophia's here for insight and always Rebecca was wanting a review okay so Andrea is here to pass her test on December 22nd love it so yes absolutely a lot of folks yeah in um Taking the

exam Andrea there's another Andrea here who is also in a PhD program oh Tammy just's here because she likes my presentations oh thank you so much awesome awesome so lots of folks are here and I will say if you studying for your mft exam or actually any of the exams I will say generally the systemic strategic therapies are the hardest for all of us to learn and they are not intuitive there are ways you can say that's not even logical I would have to Say um and so that is why I I think this is

such an important topic um to be discussing and to review as some of you just always want a refresher hopefully um so be helpful but these are some of the more complex theories they're counterintuitive but I will tell you they are definitely one of the most powerful theories out there especially when you're working with complex cases you know clients or who aren't responding you know um to other Approaches that systemic approaches really do work when a lot of other approaches don't and so systemic uh family therapies actually have a um several evidence-based treatments based on

these theories to work with really difficult types of cases like conduct disorder and substance abuse and so often times when uh problems are complex very difficult to treat that these systemic ideas will work and I will tell you when I was in graduate school and I Read about Jay Haley and some of these uh strategic therapists um I didn't really appreciate these theories um my initial take was that they were kind of manipulative they kind of saw people in kind of cold ways to me and I was really not a huge fan of systemic therapies

when I first learned about them and then I remember one day fairly early in my career I was working with this really chaotic family and I remember I was working with them and at A certain point I'm like oh my God the only thing that's going to work here is like Paradox it like it made so much sense and I'm like oh this is why systemic family therapies exist there are times where this is going to really make so much sense nothing else is working um so if you're early in your career at some point

you will probably have a client where all of this clicks into place and even if you're not loving systemic uh strategic Types of approaches early in your career I promise you there will be a day if you keep doing this work where you're like oh this is what they were talking about so um hopefully that inspires you to stick with this and try to at least be a little bit curious because it did take me a while to get um curious enough to really understand these theories so let's go ahead and get started so in

terms of these approaches um I think of it as there were three Really major systemic approaches and if you're outside of the field of family therapy you probably think of all of family therapy as systemic which is also true if you're in the field of family therapy we think of the mental Research Institute the MRI Institute um Milan and Jay Haley is our systemic folks although it is also accurate to say that um you know Salvador minuchin structural family therapy is systemic that a tear therapy is systemic bow therapy is systemic but Within the field

of family therapy the systemic strategic we're talking about these early folks who are using cybernetic and general systems theories for the first time so I think most people would identify the MRI Institute with Paul vavic Don Jackson um Richard fish as kind of one of the leading first institutes um in systemic therapies and they were really the first brief therapy at the MRI and then Milan the Milan team was a group of Italian therapists who Came and studied at the MRI for several months and then they went back to Milan and kind of created an

approach um that fit that cultural context one of which things was was a long what they call long-term brief therapy which is where you know families would be driving into to come see them once a month they weren't just working in the local town of Milan there was you know a lot of folks had to drive very far to come into treatment this is before tella Health Obviously and so they developed what they call longterm brief therapy and what you'll notice about the Milan uh interventions we'll talk about those they're much more language focused where

the MRI was very behaviorally focused and then we have Jay Haley who was a member of the MRI team he kind of broke away over an an a debate over the term power which um was a term that Bateson and the MRI team preferred not to use it is a Metaphor that J Haley preferred to use so they literally broke up over you know a metaphor of power which um more than you probably need to know but Jay Haley and uh Chloe madonis uh focus on the use of power and love is how they kind

of built their um hypothesis uh and conceptualizations of treatment so in contemporary work um we have Carl Tom's work I have a whole YouTube video on that you should find I have another one on integrative systemic Therapy so these are two more um contemporary versions of systemic therapy and then there are many evidence-based treatments that use systemic therapy as well we'll be talking about a couple of those today but um virtually all of the approaches with adolescence around conduct disorder are primarily drawing from systemic and structural family therapies but there are many different approaches that

use these Concepts um that are Evidence-based treatments for spec specific disorders so all those details are in my book and we will touch on some of those here today today but there are many contemporary approaches that use these ideas as well so what's the least you need to know um so systemic strategic therapies conceptualize an individual symptoms within larger family and social systems certainly in initially the focus was on how the the individual symptoms worked Within the family and uh more contemporary approaches also really look at the larger societ you know layers of system as

well and one of the things I think that's very hard for folks to grasp in these approaches is they are very non-blaming and non-pathologizing even though you know the therapists often use um I don't know some techniques that seem manipulative or kind of harsh or they have an expert position there Really is this sense that the family system has developed you know its homeostasis and they're pretty neutral um about it and they try not to blame individual members of a family for the one who's causing all the problems now of course there there there can

be abuse there can be power differentials but that's not where they start and they try to minimize blaming one person or another in the system and and try to focus on how the whole system is working As a whole all of these are based on General systems and cybernetic theories and and I I think when you think of these approaches I think the thing to keep in mind is that systemic family therapists really were developed to deal with difficult and hard to treat cases actually there's a systemic therapist um in uh I believe it's Mississippi

and he actually had a uh um he worked with a juvenile court system and and you know was the Impossible cases Clinic you know gave us the cases that you think you know are hopeless and we will take them so many of these systemic approaches were built around very difficult to treat complex cases that weren't responding to normal treatment which means um so these approaches if you think about how they are different if you're taking a licensing exam for example systemic approaches are normally not going to go for very linear logical Solutions now There are

something we will talk about direct directives later today in this talk but in general they are not doing psycho educating clients on the correct way to communicate okay that is something CER might do or cognitive behavioral therapist might do but that's typically not what's happening here so they are working much more with the systemic Dynamics and there's a lot of counterintuitive interventions and and that is why this Is so good with cases that aren't responding to other types of interventions and so often what they're doing is trying to introduce very small innocuous but yet highly

meaning meaningful changes to the family system and so allowing the family to kind of reorganize um to naturally reorganize itself so this is uh it is a very different way of working compared to I think most other approaches this is the most Counterintuitive if you're taking a a licensing exam and you have strategic systemic questions you the most likely ones to probably you're going to miss and the theories you need to study the most when you go for a lure because the these are just not linear logic um they they are different because they're working

at this deeper level of the system so let's look at the juice um so MRI therapists really mastered the art of reframing and when MRI therapists um talk about res reframing they actually went to a lot of Phil if you read the original literature they go into a lot of philosophical ways that they do it I'm looking at recategorizing um how people are seeing thing but generally what they're doing is they're going to take the individual symptom and put it within the larger systems um reframe it as something as as part of something that's part

of the larger system so um for example they Could see a kid's kind of acting out um as a way of bringing the couple closer together very common hypothesis in family systems um you know there there's a classic video where they uh interview there's an older daughter who's not launched I forget she's in her 20s or 30s and they begin with the daughter being depressed but by the end of the session they're realizing everyone in the family has some version of depression so they're always shifting And reframing um and that's really a lot of what

they worked with was shifting and reframing um how the family was seeing the problem defining the problem and they were generally going to be expanding it to be um be have the larger systemic context accounted for in the understanding of of the reframes so circular questions are actually one of my favorite interventions in the entire field of systemic therapies um and this is Something that came from the Milan team and systemic qu and these circular questions are so helpful whether you're working with individuals couples or families to really help assess the interactional pattern in fact

I would say if you're working with individuals it is even more important to ask circular questions to understand the interaction pattern because you don't have the other family members to act out what's going on um in the system so but What's beautiful about these these are very it is I really think it was one of the most elegant um interventions in the entire field of psychotherapy because what you're doing with circular questions is you're just asking um about you know uh the sequence of of behavior and so you know you came home and um you

saw your son was playing video games rather than doing homework and so you you know told him to stop and then he you know did this and then what was your Husband and what's the sister doing so you're looking at what everyone's doing you know when this um what the sequence of events when there is this argument let's say over homework that you know happened and you're looking at for everyone's role in the system you're you're kind of putting connecting all of the dots and as you're doing that the family's also connecting dots right and

so everyone's beginning to understand those different little pieces a little Bit differently and so it's you're you're assessing but you're also intervening at the same time with these questions and it's often confronting um family members but in a uh very gentle way and and everyone is getting a reframe of what is going on so the most common one is looking at the sequence of Behavioral events right there's behavioral difference questions so when you you know when your father comes home and sees you're not doing Homework you know how does he handle it versus how does

your mother handle it you know what if it's the sister versus you know you and you know what if your sister's not doing homework how do they respond they do a lot of these behavioral difference questions and the therapist really is trying to get information you there is this curiosity it really comes from a place of curiosity um and and so they but they use this comparison and ranking you know And so who do you think is the most upset about you know these fights in the house who who's the most upset by these each

person gets to rank them they each could have different opinions and so you use this to help the family get a new perspective on what is going on you can have before and after you can also have hypothetical questions you know like if mother's in the hospital you know who um who would be the most upset who would be the one visiting who would be the one at Home taking you know you could just ask all of these questions and it helps both you and the family together in a very gentle way um assess what

is going on and to also get reframes and confrontation but it's also gentle it's just such a gentle way of working so I think circular questions are just brilliant and especially if you're working with an individual this helps you assess what's going the larger system around them and so that you Understand their role in the system and I I think one of the biggest misnomers in the field is that if I'm not working if I'm working with an individual I don't have to think systemically I'm like oh my God you need to think more systemically

when you work with an individual because if you don't understand the broader context it's going to be a lot harder to help them but these are great for questions for both individuals and couples and Families so um Jay Haley's strategic therapy he uses a lot of what's called a directive and this is where you're giving the family usually a task to complete um between sessions and the purpose of most directives um is to perturb or shake up the system okay you're not trying to fix the system normally there are direct directives but normally um you'll

be using directives that more shake the system up so that the family just cannot engage in the Symptomatic pattern again okay or you you can use as individuals and individual systems to individual symptoms as well so strategic you can this these directives you can use with individuals couples or families so um but you're perturbing the system meaning you're just shaking it up you're not asking it to totally adopt a a much healthier Behavior pattern what you're doing is you're you're you're you're tripping the them up in their symptom Pattern so they have to do something

different because when you have to do something different you generally make a better choice and so you can think about this as like if a family let's say conflict pattern is like they dance is like danc in the Tango is what their conflict is you know if you um if you start putting um different pieces of furniture in that room they're not gonna be able to dance the dance the same way they're Gonna have to do something different and so a good example of this is um you know for for couples you you know actually

for anxiety or for conflict you will often prescribe the symptoms such as telling them to go home and you know I want you to when you have your argument I want you have arguments on Tuesdays Thursdays and Saturdays at 7:30 to 800m you just like schedule it right or I want you if you're someone who worries I want you to go home and worry you know For 15 minutes every morning before you know you leave for work I want you to set aside 15 minutes and so you're taking the symptom but you're putting it in

a different context because now what was once uncontrollable is they're consciously engaging at it and so that totally shifts how it works so couples are like I just can't start a fight and then sometimes I'll have couples come back and sometimes they engage in that they're like oh I see how I start fights now I can you know because I was as prescribed to do it you know it changes how they experience it so they're usually and they're doing this because by shaking the system up by making them have to do something different um they

have to they become conscious you can no longer do the old pattern because this context or some piece of this has changed and they become aware of things that they're not aware of before and these are small Enough things that you're asking you're allowing them to have the symptom you're just kind of putting it in a different context then it doesn't feel so hard to do they're able to kind of you know experiment with these things and get insights and then the system is going to reorganize itself so these directives that the therapist is giving

the client is not to fix the problem it is to to shake up the system to perturb the system so that it reorganizes in a Better healthier way so that is what the purpose of these directives are so if you're taking a test about strategic therapy just be careful most of the directives are going to be counterintuitive and seem a little bit weird like why why are we doing this but it's because you're perturbing the system you're shaking things up so let's look at the big picture here so um so these approaches are really um

They were the briefest of brief therapies and so the idea is they focus really on resolving the presenting problem and they don't have other theories of Health about how a family should or shouldn't look and that they have these long-term goals for health or if you look at some other family therapy theories like structural or saer family therapy or Bowen family therapy they do have a definition for like these built-in long-term goals systemic Approaches are like we're going to come in we're going to treat this you know the um the presenting problem and then we

send them on their way we don't have other goals of Health that the therapist imposes the problem is always viewed as part of some kind of interactional sequence of behaviors um that have emerged um in the family system and so even if there is if you want to you know hypothesize or something biological going on it's like the family system is Still shaping how that looks and when you look at a diagnosis like schizophrenia it is interesting that across different cultures it is very much shaped even by the just the content of those cultures as

um and so basically in the early stages of all of these approaches you're getting a very clear behavioral description of the interaction pattern from you know normal or homeostasis how tension Rises the Symptom at it's worst and how they kind of get back to normal so everyone all of the systemic approaches are looking at that interactional behavior pattern and so basically once they understand what this pattern is and the logic of this pattern they're they're interrupting the sequence more than they're fixing it and so I think of cognitive behavioral family therapies as coming in and

really trying to educate the family on how to have a better Interaction pattern like it's very logical it's very linear so instead of doing XYZ you know when your child talks back to you you know we're going to do ABC so CBT would be a very logical way to handle it where in systems theory what they're going to do is they're going to just throw a monkey wrench into it and so if the parent normally yells and screams they're going to give them some kind of homework assignment where they're going to do Something other than

yell and scream okay almost doesn't matter what it is just don't yell and scream we can have them do a dance we can put it on paper we can could um set up a little you know courtroom we can wear hats we can do things that symbolize it's not going to be logical okay it's not going to Psycho educate them necessarily so um so that's typically what you're going to see in these approaches so the first thing you're Always assessing are those interactional patterns and the associated meaning so you know when the kid is talking

back how does the mother interpret that how does a child interpreting what the mother is saying right then you're to intervene you're going to try to interrupt the sequence more than you're going to fix it if you can fix it you know Jay Haley will say yeah you can do what he calls a direct directive where it's super logical linear good luck with That but he's like most of the time by the time they come in to see us all of those logical you know psychoeducational things don't work and this interrupting the pattern works better

and then they're going to evaluate so and then they evaluate how that went so they see themselves as this homework assignment this intervention is gives the therapist feedback about the rules and meaning making of the system so clients are never wrong if they don't Do the homework assignment that's feedback to the to the therapist about what they need to be doing differently and so it's this constant um almost like research process of you assess the system you do your best understand what's going on with that their pattern you come up with a intervention to kind

of Shake It Up and you see what they do with that new intervention you know what do they do when they you prescribe the symptom um And then you learn how that affected them that gives you more information about um what the homeostasis and meaning of the family might be so you try another intervention that that and then you find out how that goes and you it's this repetitive process until the family has reorganized their homeo homeostasis in a way that no longer has the symptom so so yes you keep interrupting um each new pattern

until you get to a Place where everyone's feels like you know till there has been a fundamental shift in the organization of the system so let's talk about the therapeutic relationship and the therapeutic relationship in systemic strategic therapies um it's kind of evolved over the years um but let's start with just some of the basics here so the first is there really is a deep trust and faith that the family can change and that I Don't that I as a therapist don't have to force the change in the family and they really there's this real

deep trust and respect for the system itself that and the system is bigger than the individuals it is beyond the conscious control of the individuals but they trust that the family system can reorganize itself and it doesn't need to be forced to change and the therapist is very respectful of this system there is this real deep profound Trust and Respect for the system and and how the system works how the family makes meaning including their beliefs their values the way they language things all of this they really are respectful of the system rather than trying

to get the system to look a particular way and so in this way with the when I think the way systemic therapy is intended there can be a very deep pers for a vast number of ways of being a family and many you know cross-cultural differences And and such there is a real emphasis on nut there two ways this has been phrased they talk about nonp partiality so you're trying not to take any any one member of the systems uh side and also also not even having a particular description of the problem that you're really

stuck on or believe this is the real cause of the problem they're very fluid they don't want to be take sides um and in sometimes they refer to this as multi partiality because when you're In a session you kind of almost have to take each person's side as you're listening to them and going around the room but you got to be very careful to balance all of that but sincerely um systemic family therapists really do not take sides and even when it comes to the description of what the problem is and usually in systemic work

you're going to let the definition of the problem kind of evolve over time it's not even rigid And so each time you come back you're going to refine your hypothesis about what might be going on um but there is this real profound neutrality both towards the people and towards the ideas of what the actual problem is um some of the uh unique characteristics of a therapeutic relationship is what they something that they call maneuverability and so maneuverability is referring to the Therapist assuming whatever role that they need to do um to take in the system

to be helpful and so in some cases being more emotionally distant or more emotionally engaged or you know there are times systemic therapists are like you know what if the family just is able to you know see me as a problem and they unite that's fine too I will take any role I need to take in this system to help it find a healthier better homeostasis and so they can be very Flexible and one of the more common ones um that was used is what they call the one down stance where it's used to really

increase clients motivation you know by saying you know if if it you know if things um evolve to a certain point sometimes they'll say I'm not sure if I'm going to be able to handle you know a family like this and so this has to be both uh sincere and there's a level of paradox um to use this one down stance But that is that is one of the positions they might use when working with the client and certainly um I think temporary systemic approaches um tend to have more of a warm and connected stance

as well that that just characterizes I think treatment and what is expected in the 21st century so I'm gonna go ahead here and uh let's go ahead talk about case conceptualization so um so when you're thinking from a systemic strategic Approach you're really focusing on those interaction patterns how a affects b b affects C and and how they go around you're really looking at Classic General system principles um and so and so these patterns can be kind of hard to I I think detect and to track um especially when you're early in your training and

so so when you're working with um from a systemic approach the the most important thing to do is to Get a description of exactly what everyone in the system is doing when the symptom happens especially when it first starts to happen how things escalate how things are at their worst and how things go back to normal because you're going to have to pick somewhere in that sequence of behaviors to intervene and do something different is what they're doing and so um they call this interaction pattern in Milan you'll hear it referred to as the family

game and I don't I don't think it translates well into English but it's like what's the pattern for interacting in what are the rules for relating in this system and so um the therapist is really focusing on that interaction pattern now the MRI team would talk about more of the same Solutions and they would talk about so what they would look at is what was the pattern um what's the interaction pattern and what is the more of the same Solution that that the family has been using for example with families oftentimes what you're going to

get is parents will punish a child's behavior um and if it's not working right um then the parent you know uses harsher punishments the next time and then harsher punishments the next time and so when you see a pattern like that you're like okay you know punishing a behavior is not working in this system so what would be a 180 degree shift what Would be the opposite so often times as building the attachment um bond with the parent so you know so not punishing and what would that look like and so they're looking because if

the family gets stuck because normally the time they're coming to see us they have tried all of the logical solutions they can think of within their system and so when they're coming to see us they're needing more of this 180 degree solution and they talk about different ways of mishandling Problems and there are the terrible simplifications um and that is where um you the family has oversimplified things and oftentimes there is action that needs to be taken but it's not being taken like oh this is just the way boys or girls or this is you

know are and there this a family's not taking action when it needs to be taken there's a utopian Sy syndrome where you're taking action but it doesn't action doesn't need to be taken And then there's Paradox which we will talk about more in depth which is where action is taken kind of at the wrong logical level but in general what they're looking for is how has the family been handling this problem and what's not working so this is a good guiding principle for any type of therapy you know when your client comes in what have

they been what Solutions have they been trying what hasn't been working and then look for Something that might be the opposite of that um they also get into what they call the tyranny of linguistics especially the Milan team um and they look at the labels that we use to describe each other so you know things like saying I am depressed he is an angry person he is abusive these Global um descriptions don't create space for seeing other moments of the relationship and you will very if you do Couple family work this will be very common

and actually when you do individual work people often come in and say my partner my parent or my child is always never you know fill in the blank right and so they were systemic therapists were some the first to look at how this tyranny of L when we start labeling things like this rather than saying a person's doing depression or doing anger that they are depressed or they are an angry person that um this Shapes identity and behavior and it becomes part of the problem so how we're working how we even talk about it so

they would talk about how when a person is doing depression or when they're doing anger rather than being one of these things and you see the same theme kind of move into narrative uh therapy and solution Focus therapy as well so but it certainly started first in systemic therapies and so they're looking at these subtle shifts of words To help people um see refrain things actually because when you refrain from being depressed to doing depression that's a huge reframe just right there in uh Jay Haley Madonna's strategic therapy they looked um when they built their

hypothesis for what might be going on they looked at the um polarity of invol voluntary versus voluntary behavior and they will often play um around with that like you know I can't keep myself from you know I can't Control my worrying or we can't control the arguing but then when you prescribe the symptom you're kind of playing with that polarity looking at helplessness versus Power and um helping family members kind of flip the script on some of that same with metaphorical things versus literal things hierarchy versus equality and hostility versus love and they they look

at how these different polarities play out and they would reframe things using these metaphors to Help families see what they're doing in a slightly different way and so you know like even you know reframing a couple you know a couple's kind of hostile arguments as you know they're you know in that they are often fighting for their relationship and because they do love each other this is why there there is this tension here and so helping to refrain what they may have seen as very hostile Behavior to see that there is also love in that

from Their partner so playing with a lot of these polarities um and as strategic therapy kind of evolved in the 21st century they evolved what they call more strategic humanism but emphasizing uh the family's ability to love and nurture rather than Dominate and control so moving more into the U metaphors related to love versus metaphors related to power when they're helping to reframe what's going on so conceptualizing what's going on in a Couple or a family is just unsuccessful temp attempts to show love rather than attempts to control and so um all of these approaches

really had this uh observation team that was sitting behind a mirror behind a camera and because when you're not in the room with the family you actually can often see these uh systemic Dynamics a lot more clearly than when you're in the room trying to manage it because when you're in the Room trying to manage it you actually become part of the system and oftentimes it makes it much harder to see what's going on so if you get an opportunity to train with a mirror I highly recommend it it really does help you to learn

to see systemic Dynamics much faster which is why classically family therapists have always trained with live supervision okay let's talk about goal setting um so basically the goal in all of these approaches is to help the Family develop a new set of interaction patterns that doesn't need the symptom to be part of it and so you're creating a homeostasis basically that is Problem free and um at least one that doesn't have the same problem over and over and over again and so you know systemic therapists are would would say it's you know if a family

just has different problems you know that's kind of normal but if it's the same problem over and over again that is where they are Stuck there isn't a theory of Health that defines exactly how the family should look at the end of therapy they really trust the family system to reorganize itself in a way that um is aligned with their values their cultural norms their own personal beliefs um rather than the therapist imposing that on the family um and they really trust that the family will find a healthy uh interaction pattern so when you look

at Um the MRI approach they often talk about the problem is the attempted solution like I said that 180 flip and so the stages of this particular model is they Define the problem in concrete behavioral terms they identify what Solutions the families have tried and failed and then they describe the desired change the goal has to be specific realistic and time limited and then they develop a plan um to change whatever that attempted solution is and They do try to use the client's own language in doing this as much as possible so they're very sensitive

to language ver is something we see also in the postmodern therapies so let's look at some of the language-based interventions in these approaches um one is a hypothesis so uh systemic family therapists would often deliver a hypothesis to the family um so so first you have a hypo working hypothesis which is what you think is Going on in the system and then there's also the intervention of delivering it um so it's really defines the role of the symptom and maintaining the homeostasis so your hypothesis is why does this system make sense and how does it

maintain a sense of normaly in this family so um and typic typically a hypothesis is going to simultaneously address how you know there's a desire for Change and a desire for stability and are these two counterbalancing Forces so a classic hypothesis would be that a child is acting out in order to to unite the parents and distract them from their parental um conflict is a very common hypothesis so and sometimes it will be delivered that the you know this the child is having these symptoms and kind of sacrificing themselves for the good of the whole

family it helps bring everyone together and so that's kind of a startling way for a parent to hear that description but they they will Sometimes you this is the hypothesis that you can deliver to the family you see how they react to it and work with it and then you refine your hypothesis so they're constantly shifting and refining it um based on how the family interacts with them now in Milan they always did their reframing and their hypothesizing with what they call positive connotation and that is no matter what the symptom is they found a

positive connotation for For it um and so the the and this positive connotation addresses and respects both the families everyone we all have fear of change even when we want it as well as a request for Change and so they use this positive connotation like you know your son is really um being very heroic to sacrifice himself you know by having these behavioral academic problems in order to to really help the family and make everyone have a have a role to be a Caretaker like the adult child who's not launching so that the parent you

know you know um mom doesn't know who who she is she's been a stay-at-home mom for 24 years and so you know it looks like this child is is not launching so that Mom has a role still you know she doesn't lose her purpose in life and that's a really big sacrifice um so they would reframe it in this way um which would get the family it perturbs the system let's say and it gets them seeing things And thinking about things differently and they don't worry so much about being 100% correct um they can be

tentative in delivering the hypothesis but they want to see what the family does with that and then they keep refining their hypothesis um from there um so some of the most complex and difficult understand um interventions are the therapeutic double bind and or what they call counter Paradox counter Paradox is um what the Milan team called It uh MRI called it a therapeutic double bind so this is done to undo a double bind message in a family or relationship and so um so these are interventions that were usually developed by the team um and so

for example a very common double bind you'll see in couple relationship is and like in a heterosexual couple for example the woman says you know my husband's never romantic anymore you know and and the the husband's like you know and you know What do I need to be doing and she's like well you need to take me you know on romantic dates again and you know do this or bring me flowers and she'll give them some ideas of how to be romantic right and then as soon as he takes her on a date and gives

her flowers she's like well you only did that because um I asked for it and so that doesn't count because that's not real romance right so that's a very common double bind you might see and so a therapeutic double Bind um would be like how do you help this poor guy and so in this case you can um tell the husband so I want you to do something romantic this week but it cannot be you know um taking her out to dinner or getting flowers or whatever the the command was so that you know if

he does follow through um on taking her out to dinner it still works or if he does something different it still works and so either way you're getting information for the system but it helps Counterbalance the double bind that was going on in the system so um these are often difficult to cook up by yourself immediately on the Fly that certainly takes time and these were often really developed by a team that's why it helps so much to have the team because they can sit there and sit back and analyze a little bit more but

um parox and double binds and I will tell you don't try doing this until there's a moment where you just know that the logical Intervention isn't going to work and that is when you can almost like feel when it's time to use something like this because they don't respond to linear logical Solutions so the invariant prescription is a brilliant intervention to remember even if you never think of yourself ever again as a systemic strategic therapist but this was used by the Milan team to um break up coalitions between parents and kids and the invariant prescription

They used with kids who had anorexia and behavioral problems because you the families are bringing in these kids for treatment and they called it the invariant prescription because it seemed to work for most of the kids issues um and what it was is uh if they suspect a triangle which means one child is aligned with one of the parents against the other parent this helps sever that um Alliance quickly and effectively and really shifts family Dynamics quickly and so what it is is basically you're going to create a secret between the parents and let the

kids know that there's a secret between the parents the kids don't know about it's basically reestablished ing the couple and parental subsystem if you want to think in structural terms but you're letting the kids know that the parents are on the same team and so typically it would be the parents would be going on date night um and not Telling the kids where they're going and and it's most critical obviously the parent that's aligned with the child does you know keeps that secret and doesn't tell them where they are going so this um they found

that this was a very helpful intervention Whenever there was um an unhealthy alliance between a parent and a child and so reestablishes basically the couple system dangers of improvement is another technique that they would use whereas Clients are getting better they would um caution people about moving too fast again it's kind of a paradoxical thing um trying to tell them to go slow don't change too fast because that could be too much for the system um but this often would help actually solidify change and help them clients actually change because humans we're we're riddled with

contradiction and this kind of addresses um that tendency um so that if there is a Setback they they're kind of ready for it and if they just keep moving forward you know it's kind of a therapeutic type of double bind or for some people if they want to rebel about against going um slower then they are going to actually um move them forward towards their goal so again it's a therapeutic type of double bind where you warn clients not to change too fast you know more the middle phases of therapy usually not the beginning but

it it's The czis Paradox so when those typical setbacks backs happen that makes sense and it fits within this Paradigm or if they want to rebel then they can go ahead and um you know make more change so and the therapist doesn't care you can Rebel you can have setbacks we're just going to keep working with the system as it moves forward and so there really is this neutrality that is hard to describe um when you work systemically this way It's like you don't make too much it doesn't almost matter which what the family does

because you're going to just keep taking that feedback designing a new intervention to address that and keep working with the system until it finds a healthy new normal for itself and you're just going to be with it every step along the way and not getting overly um upset which direction or whatever they decide to do So directives in MRI are uh and strategic therapy are these behavioral taset that therapists gives clients between sessions to interrupt the pattern not fix it usually interrupt so straightforward or direct directives are used when the um when the therapist has

power and influence to get people to do what they want to do and you can actually use these straightforward directives of how to improve that interaction and indirect directives or When the therapist has less Authority or the clients cannot follow through on those direct directives and if you worked with couple clients uh families individuals and your clients don't do their homework this is what where those indirect directives make more sense so straightforward directives you're assessing the situation you're uh addressing what's going on you're motivating the family and you're giving them very precise doable instructions For

how to handle let's say their conflict in a more effective way right you can um so you would take them through these various steps to just you know try to teach them what to do different and if that works that's great but Jay Haley said I develop strategic therapy because 95% of the time that didn't work so that's where you use this indirect directive or the paradoxical ones so typically um so if doing a Direct straightforward Direct directive doesn't work like you educate them on how to not have an argument for let's say or not

nag your child or your partner they can't control it they come back that I you know I got triggered and I just couldn't control myself which is more standard than not then you're going to be uh using some of the Paradox which is prescribing the problem Behavior but in a new cont context right um and it's considered paradoxical because Oftentimes why would you describe the symptom again but you're putting it in a new context so it has new meaning what is what happens um so and so when when you prescribe for example the symptom like

go home and worry for 15 minutes every day or argue for 30 minutes three nights a week at a specific time you're taking this uncontrollable behavior and you're suddenly making it quote unquote um you're shifting it because it's uh they Experience it normally as uncontrollable and you're shifting it in a new context where where they're doing it on demand um and this is going to kind of mess up the whole homeostasis and their whole experience of what is going on um and so and what also happens with a family let's say there's a family who

has a depressed family member but that stabilizes the rest of the system and all of their the other relationships oftentimes it can be very hard to you Know make progress with that depression or um with that type of anxiety so um so that's another reason why you would use Paradox is that it's too scary for the family to do those straightforward psychoeducational interventions so so prescribing the symptom or simply interrupting it you know um these directives can sometimes even use metaphors like there was you know giving the a child a dime every time they take

one parent side against The other they have done things like that they can do things like um I have a couple who who tends to get into bad arguments to set up you know next time you start an argument I want you to reorganize um you know pull out a gavel or something you know can be like a gavel and set your room up um like a a courtroom and you guys can like go ahead and hold court so it's kind of again playing with this metaphor but you're Shifting their behaviors there's one example where

they had the couple next time you argue when you guys go to the bathroom one of you is going to sit in the bathtub the other one's going to sit on you know the toilet and you guys can argue in that way fully closed you know not in the p in in the water or whatever and just to like change the context because putting them you they couldn't stop the couple couldn't stop arguing but when you change these context either Putting doing something that symbolized a courtroom or doing something nonsensical like sitting in the bathtub

and on a closed toilet to like have your argument there it just shook things up so that they couldn't do the same dance they normally did everything had different meaning and so that's so you're allowing them to argue but you're just tweaking it in some strange way that it shifts the meaning enough so that they kind of like Get out of their trance of the normal behavior that they do when they do something different they usually when you come out of that trance you do some you CH when you get to choose to do something

different you normally do something better and so that is what they are playing with um when they do these directives um so yeah when you change the context the me meaning of the behavior changes so if you describe the Argument it has a totally different meaning than when it spontaneously happens and so using metaphor using prescri prescribing of symptoms you're just tweaking it a little bit so it's just easier for people to engage in new behavior and to have new meaning because you're not telling them to stop doing it's the hardest thing in the world

is to stop thinking right what you're thinking shift the human mind's direction of thought um but so you're Not asking them to do something that is beyond what they can do you're asking them to do these little shifts that change the context and the meaning and then from that they can see what they're doing differently and then they can consciously choose better behavior um another brilliant um thing that uh Jay Haley did and I think this works really well with uncontrollable behaviors um often I tend to use these ordeals are actually used quite a bit

With individuals is when a client feels very helpless or in controlling a symptom you create an ordeal so it's something you need to do to before you engage in the behavior so um so before you start um I don't know neurotically uh texting someone that you're angry with you you you do you have to do some kind of ordeal which can be related to whatever the problem is or it could be um not related like non nonse or kind of Nonsensical so you could and it can be something like clean the toilet it can be

something like take a walk it can be something um directly or non-directly related to whatever is going on but you but you're interrupting the symptom right so you're interrupting the symptom pattern and again um you can do this with all sorts of symptoms um I I know people who've used it with um OCD so before you engage in the compulsion you have to do an XYZ Oftentimes it's a very almost nonsensical you know watch a YouTube video or do a um send a text or you can it can doesn't even have to be related like

therapeutically logical it can be illogical anything just do something different in that interaction cycle so um you know for a couple who is arguing you know before you uh sit down to you know when your next next argument starts I want you to you know each get different hats that might symbolize your Typical role in the system so again do anything different slowing them down interrupting the pattern and then you can let them have their symptom afterwards but you've shaken it up so that they have an opportunity to choose to do something different so in

terms of a T Health uh strategic family therapy these are approaches that work pretty well because there's more of a behavioral and language focus and so they certainly can Work well um on uh via tella Health they some of the specific considerations they've talked about is that you might need to spend more time working on the Therapeutic Alliance um making sure you can see all the family members and how they're responding to each other is a very high priority when doing a systemic therapy with families you got to be see the non-verbal communication between people

so you need good lighting you probably need a good siiz screen as a Therapist to see everything that's going you want everyone to be on the screen um and so but a lot of these interventions these directives and such this reframing these are things that can be easily done on tella Health in terms of working with diverse clients in general uh I I would say that most people would say that systemic strategic therapies do work cross-culturally but it's very important to be working from within the client's World view but there is from a systemic perspective

a classic systemic perspective of of deep deep respect for how the Family reorganizes itself which will generally be around you know cultural religious social economic class you know Norms the therapist is not a systemic strategic therapist is not trying to Define what the healthy family structure looks like they're allowing the family to do do that themselves and that is something that is different um Than a lot of other models so when it's properly implemented the therapist is very respectful of how that system reorganizes um they're really looking for as long as no member has symptoms

everyone's kind of hitting developmental Norms there's no abuse going on they don't have a lot to say about what how the family Homeostasis is defined they allow those cultural gender ecomic class religious Norms to to um Define that homeostasis um and there are definitely Some therapists I'm G um who systemic therapists who have developed specific approaches for latinx Hispanic families and African-American families so um these approaches have definitely been welldeveloped into evidence-based treatments that are specific even for specific cultural groups so the research on systemic therapies is less about these classic approaches like Milan strategic

MRI approaches but there have been many many Uh evidence-based treatments that are very heavily s systemic especially when you're looking at Child and Adolescent problems and so you know if you look at CBT is probably the largest number of evidence-based treatments I would say systemic therapies are number two in terms of the number of evidence-based treatments for specific disorders particularly with children and adolescen and I want to just touch on a Couple of them here so um there's multisystemic therapy which was developed in the 70s to treat serious juvenile offenders it is a very systemic

approach that pulls on this from the Strategic that we've been talking about here today structural social ecological and cognitive behavioral um but the in this MST that works for conduct and similar disorders the the whole focus is just what we've been talking about here today you're Going to take that adolescence behavior and put have it make sense reframe it within the the broader fam's broader uh context and social network so they're looking at it within a much broader family and societal context to make sense of the Adolescent conduct type of issues and they really look

at different risks and protective factors across individual family peer School neighborhood community so multiple levels of system So you there are um virtually every treatment I've ever heard of evidence-based treatment for conduct disorder you know has these the systemic looking at these various levels of systems at the heart of their approaches similarly we have brief strategic family therapy which draws both on structural and strategic family therapies it is was developed by Jose zapasnik um down in Florida working um with a lot of Cuban families and there Are versions of brief Strate iic family therapy that

are specifically treatment manual manualized treatment protocols for African-American Families versus um Hispanic latinx families and very well established so again um very similar um to B uh MST that you're working very systemically you're looking at the layers of social context as well and using those systemic dynamics of reframing looking at the adoles behavior in a larger social context to uh help The families and to help these youth um with conduct and similar disorders so this is just a couple examples of evidence-based treatments that rely on and draw very heavily from systemic family therapy okay um

that's it that is my uh in a nutshell um tour of strategic family therapy systemic family therapies hopefully you're feeling a little more confident on what these approaches are how they work why they are so counterintuitive and I promise you at Some point in your career you will uh come back to these theories and go oh wow now all of that makes sense now I know why they did what they [Music] did