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then, must direct their efforts at helping families substitute new behavior patterns (new solutions) to replace the old ones.

Schlanger and Anger-Diaz (1999), directors of the Latino Brief Therapy Center at the MRI, outline the following steps in their brief therapy approach in response to the client’s initial phone call:

•Defining the problem

•Identifying the attempted solutions

•Determining the position of the client

•Designing an intervention

•Selling the intervention to the client

•Assigning homework

•Doing a homework follow-up

•Terminating

The case description in Box 11.2 (Segal, 1982) illustrates the effectiveness of the MRI brief therapy approach. The therapy team helps a concerned wife to revise her earlier self-defeating solutions to a problem and thus to institute second-order changes in her interactions with a resistant husband.

STRATEGIC FAMILY THERAPY (HALEY AND MADANES)

If the original MRI communication/interaction approach drew the greatest attention from family therapy professionals in the 1960s, and Minuchin’s structural model was the most consistently studied and emulated in the 1970s, then it is fair to say that the various strategic approaches took center stage in the 1980s (and that social constructionist and narrative approaches gained ascendance in the 1990s and into the present century). As we’ve noted, the main characteristic of this approach is that the therapist takes responsibility for devising a strategy for solving the client’s presenting problem. Typically their interventions involve creating novel ways of disrupting those entrenched family interactive sequences that help produce and maintain the problem the family comes to therapy to alleviate.

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

Leading Figures

The career of Jay Haley plays an important part in the development of the strategic approach to family therapy. Haley was a key member of Bateson’s schizophrenia research project in the 1950s, and helped develop the double-bind concept. Bateson himself was interested in the concept’s theoretical significance, as a description of interaction, but not in the clinical issues of interpersonal influence within a family.

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required to do things against their will. Once they feel safe, and with the aid of a therapist jumpstarting the change process, people can begin to call upon their own resources to attempt new ways of thinking and behaving.

Haley was also influenced by his long association (1967–1973) as trainer and theory builder with Salvador Minuchin and Braulio Montalvo at the Philadelphia Child Guidance Center. Mitrani and Perez (2003) actually classify Haley’s position as a structural-strategic approach; Minuchin himself points out that there are obvious similarities between the structural and strategic outlooks (Simon, 1984). Haley’s concern with maintaining family generational hierarchies and avoiding disabling coalitions4 (joint action by two family members against a third) allies him with the structural group, while his interest in paradoxical directives and other unobtrusive ways of managing resistance identifies him with the latter.

By 1975 Haley and Cloé Madanes, then his wife, who had trained at the MRI before moving on to the Philadelphia Child Guidance Clinic, together formed the Family Therapy Institute of Washington, D.C., a highly respected training program for family therapists. Haley, a prolific writer, described his strategies for changing the way a family is organized in Problem-Solving Therapy (1976); the following decade he published Ordeal Therapy (1984), an account of treatment based on the premise that if a client is maneuvered into a position where he or she finds it more distressful to maintain a symptom than to give it up, the client will abandon the symptom. In addition to Haley and Madanes (1981), leading strategic therapists today include social worker James Keim (1998, 2000) in Colorado and Jerome Price (1996) in Michigan, both formerly affiliated with the Family Therapy Institute in Washington, D.C. Their efforts, as well as those of like-minded therapists, are frequently described in the Journal of Strategic and Systemic Therapies (now renamed the Journal of Systemic Therapies).

The Meaning of Symptoms

Although the generally accepted view at the time was that symptoms were by definition involuntary and maladaptive, Haley early on (1963) took the position that a symptom, rather than representing behavior beyond one’s control, is a strategy, adaptive to a current social situation, for controlling a relationship when all other strategies have failed. All participants are caught up in the repetitive sequence that keeps the process going. The symptomatic person simply denies any intent to control by claiming the symptom is involuntary. (“It’s not that I am rejecting you. It’s my headache that keeps me from wanting to be sexually intimate with you tonight.”) Thus, symptoms often control another person indirectly, and this oblique way of communicating through symptom formation may serve a function for the overall family system.

Power and control are at the very core of Haley’s thinking about family functioning. Jockeying for control occurs in all families and in every relationship between two or more people. (“You can’t boss me around anymore; I’m not a baby” is a familiar

4As Mitrani and Perez (2003) observe, coalitions are especially detrimental to family functioning because they detour conflict and do not allow relationships to develop fully between the three participants. If Julia and Samantha have a conflict they cannot manage directly, and Emily enters the fray by aligning herself with one against the other, the original two do not have an opportunity to work out their problem, and their relationship does not develop. Haley is interested in changing the repeated sequence of interaction in such a triangle.

an issue between spouses; rather, he or she will look at the effect of others (children, in-laws, work associates) on the couple. Strategic therapists also track interactional sequences of events, which of course are likely to be circular. Keim (1999) cites the case of shoplifting by a teenager as more than an individual act; it is a sequence of events involving peers and parents. Rather than focus on treating the individual offender, strategists focus on changing the relevant interactional sequence of the presenting problem, helping the family replace any painful or escalating sequences between members who care about each other with a calmer and more conciliating sequence.

Hierarchy within a family, so central to Minuchin’s structural ideas, is incorporated into strategic thinking, no doubt influenced by Haley’s work with Minuchin at the Philadelphia Child Guidance Clinic. Without viewing a client family’s hierarchical structure as functional or dysfunctional, strategists want to know what roles each member plays and whether problems arise because people are unhappy with their roles. As Keim (1999) illustrates, a child who is functioning as an adult within a family is not a problem in and of itself, according to strategic thinking; but the child’s role becomes a problem if unhappiness develops in the family because he or she is assuming the adult role. Strategic therapists are especially attuned to oppositional behavior that may develop in a family when assigned or ascribed roles are uncomfortable or no longer fit and conflictual communication and behavioral sequences follow.

Developing Therapeutic Strategies

Strategic family therapists direct their interventions at a specific presenting problem, deal with the present ways the problem is maintained, and customize strategies (straightforward or indirect directives) designed to track and ultimately alter problemrelated interactive sequences. Rather than offer interpretation or provide insight or insist the family reorganize its overall set of relationships—the family usually resolves a problem without knowing why or how—strategic therapists respectfully attempt to change only those aspects of the family system that are maintaining the problematic or symptomatic behavior. The emphasis in strategic therapy, according to Madanes (1981), is not on devising a therapeutic method applicable to all cases, but rather on designing a unique strategy for each specific presenting problem. The focus throughout is on artfully alleviating the presenting problem, not exploring its roots or buried meanings. Thus, Haley-Madanes strategic therapy is likely to be short-term, since it is limited to specific problems and tailored to solutions.

Criticized for his manipulative style, Haley (1963) points out that therapists and patients continually maneuver with each other in the process of all forms of family treatment. Family members, fearful of change, may try to manipulate, deceive, exclude, or subdue a therapist in order to maintain the homeostatic balance they have achieved,

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attention, then formulate a plan of action to change the family’s dysfunctional sequences or faulty hierarchy in order to eliminate the problem. Typically, in the opening brief social stage, strategists create a cooperative and relaxed atmosphere while observing family interaction and trying to get all members to participate, thus indicating all are involved (not merely the identified patient) and should have a voice in the therapy.

Next, in this highly structured process, Haley-influenced strategists shift to the problem stage, getting down to the business of why (for example, to solve what specific presenting problem) the family is there. They pose such questions as“Why do you seek help now? What would each of you like to change? Quickly or slowly? Do you wish to realize what is happening or just to change? Are you willing to make sacrifices to change?”(Haley, 1988). In this information-gathering phase, in which all members are urged to participate, conversation is directed at the therapist, who displays an interest but does not interpret the thoughts and feelings being expressed. How each family member views the presenting problem is particularly noteworthy here.

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

The fourth segment of the first interview, the goal-setting stage, gives the therapist and family together an opportunity to precisely determine the presenting problem they wish to solve or eliminate. This phase results in a contract that clearly defines goals, allowing all participants to measure change or gauge the success of their efforts as therapy progresses.

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

The Use of Directives

Directives, or assignments of tasks to be performed outside of the therapeutic session, play a key role in strategic family therapy, and are given for several reasons: (a) to get people to behave differently so they will have different subjective experiences; (b) to intensify the therapeutic relationship by involving the therapist in the family’s actions during the time between sessions; and (c) to gather information, by their reactions, as to how the family members will respond to the suggested changes. Advice, direct suggestions, coaching, homework, even assignments of ordeal-like behavior to be followed if a symptom appears, are examples of straightforward directives by the therapist aimed at changing an unworkable system and achieving problem solution. They are typically prepared with care, tailored to the family’s style, and issued in a precise manner, with the expectation that the family will report back at the next session about carrying out the task.

As Madanes (1991, p. 397) emphasizes,“The directive is to strategic therapy what the interpretation is to psychoanalysis. It is the basic tool of the approach.” In some cases, strategists issue a straightforward directive (simultaneously a report and a command) to family members to take specific action (for example, instructing a mother to

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stop intruding when the father and son try to talk to each other) because they want or expect them to follow it in order for them to change their behavior toward one another. However, asking someone to stop engaging in certain behavior is a difficult directive to enforce; its success depends upon the status of the therapist giving the instruction, the severity or chronicity of the behavior, how often the directive is repeated, and the willingness of family members to cooperate with the therapist in accomplishing the task. This last point regarding motivation is a particularly essential factor determining whether the therapist will succeed in this direct approach.

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

To be used with relative infrequence, as when a client is in crisis or especially resistant to change, paradoxical directives commonly take one of two forms— prescriptive or descriptive. Prescriptive paradoxes ask the client(s) to do something, while descriptive paradoxes relabel something already being done by giving it a positive meaning or connotation.

As Wachtel and Wachtel (1986) illustrate the former, a client seeking help for his procrastination is asked not to try to accomplish more in the coming week between sessions, but rather to record the various ways he wastes time each day and how long each takes. The changing set, or perhaps the unpleasant task, often leads to a reduction of procrastination. The client may report that there was little to write down the previous week because he got his work done. Or in the case in which a list is made, the client will often gain greater awareness of his self-defeating behavior or perhaps learn that he is less a procrastinator than overdemanding or expecting too much from himself. We offered an example of a descriptive paradox earlier in this section in Haley’s relabeling the ax-wielding of the husband as a loving act.

As used by strategists, and borrowed from Erickson’s hypnotic techniques, a paradoxical directive asks clients to restrain from change, and is designed to provoke defiance in the recipient. The client is told to continue to do what he or she came to therapy to get over doing (that is, to continue having the symptom). The therapist, on the other hand, is trying indirectly to get the client or family to decide that they won’t do what they have now been directed to do. Confused, the family members perceive that through the assignment of such a task the therapist is asking them not to change at the same time that the therapist has declared the intention of helping them change.

For example, an intelligent son, failing in school, is told to continue to fail so that his less well-educated father can feel good about himself. If the boy conforms to the directive, he admits control and acknowledges how his behavior contributes to family secondary gain (an advantage or benefit, such as reassuring the father, that arises due to an illness or appearance of a symptom). If he rebels against the directive to continue to fail, he gives up the symptom. This paradoxical prescription subtly reveals the secondary gain that the patient’s symptomatic behavior (poor grades) provides for the family, covertly suggesting change is both possible and desirable.

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Paradoxical interventions5 represent a particularly ingenious way of maneuvering a person or family into abandoning dysfunctional behavior. Similar to “prescribing the symptom,” this technique is particularly appropriate for strategists because they assume that families who come for help are also frightened and therefore resistant to the help being offered. The result may be a standoff, a power struggle with the therapist trying to help family members change but in doing so destabilizing their previous homeostatic balance, and the family trying to get the therapist to fail but to go on trying because they realize something is wrong. Andolfi (1979), who is also considered a structural-strategic therapist, describes such an encounter as a game into which the therapist is drawn, and in which every effort by the therapist to act as an agent of change is nullified by the family group. If not careful, Andolfi warns, the therapist can easily get entangled in the family’s contradictory logic of “help me to change, but without changing anything.” The strategic paradoxical approach, aimed at families who defy compliance-based interventions and based on putting clients in a double bind, encompasses several stages.

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

It is of utmost importance for the therapist using a paradoxical intervention that prescribes the symptom to carefully encourage the member(s) with the behavior to be changed to continue that behavior unchanged—a domineering wife to continue to run everything in the family; a daughter refusing to attend school to stay home; an adolescent boy masturbating in public to continue doing so but to keep a chart of how often, what days he enjoyed it most, and so on. Strategists might tell a couple who always fight unproductively to go home and fight for three hours. The issue becomes one of control. The domineering wife no longer runs everything if the therapist is telling her what to do, and if she resists his directive she will become less domineering

5By now the reader is aware that this approach is employed by many family therapists, especially in dealing with defiant or resistant families. We particularly underline its use in our discussion of those therapeutic approaches that emphasize clear communication, because a paradoxical injunction (for example, “Be spontaneous”) is a prototype of a double-bind situation. To command someone to be spontaneous is to demand behavior that cannot be spontaneous because it is commanded. Thus, with seeming innocence, the sender is trapping the receiver into a situation where rule compliance also entails rule violation (Watzlawick, Weakland, & Fisch, 1974). The receiver is faced with two conflicting levels of messages, is bewildered, and cannot respond effectively. As Haley, Watzlawick, Erickson, and others use the paradox therapeutically, the family is told, in effect, “Disobey me.” As in the case of commanding someone to be spontaneous, instructing the person to disobey what you are saying creates a paradox. Thus, the family told not to change in effect defies the therapist’s injunction; the family begins to change to prove the therapist wrong in assuming it could not change. If the therapist allows himself or herself to be put down as wrong and even suggests that the change is very likely to be temporary and a relapse probable, the family will resist relapse and continue to change to prove the therapist wrong again. It is essential that the therapist never claim credit for helping the family—indeed, the therapist remains puzzled by the change—in order to preclude the family’s need to be disobedient in the form of a relapse.

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TABLE 11.1 Common Examples of Paradoxical Interventions

Source: Weeks & L’Abate, 1982; Seltzer, 1986

in relation to her husband. Similarly, strategists assume in the other cases that the symptom presented, originally a way of gaining an advantage, will be resolved if the symptom now places the person at a disadvantage. In the case of the couple, strategists expect them to stop fighting; people do not like to make themselves miserable because someone else tells them to do so.

Should the individual or family follow instructions and continue the problematic or symptomatic behavior, the therapist has been given the power and control to make the symptom occur at his or her direction. Should the individual or family resist the paradoxical intervention, the symptomatic behavior is, in the process, given up (and, again, the therapist retains power and control). Strategic therapists devote a great deal of time to devising nonharmful, if sometimes seemingly absurd, paradoxical tasks appropriate to the problem of the person desiring to change or get rid of a disturbing symptom. We catalogue some common paradoxical interventions in Table 11.1.

In another form of prescriptive directive called ordeal therapy (Haley, 1984), once again based on the work of Erickson, the strategic therapist will instruct a client to carry out an unpleasant chore (for example, rising in the middle of the night to wax the kitchen floor) whenever the symptom appears during the day, thus making the distress of the consequences a greater hardship than the distress of the original symptom. By selecting a harmless or mildly noxious task, but one consistent with a client’s desires (say, keeping a spotless house) yet like an ordeal in its execution, Haley again tries to make it more difficult for the client to have the problem or symptom than to give it up. Ordeal therapy calls for a clear statement of the problem or symptom to be addressed and a commitment to change on the part of the client even if suffering is required, as well as a promised willingness to follow a therapist’s directive regardless of its logic or relevance to the presenting problem.

There are three major steps in designing a paradox, according to Papp (1983): redefining, prescribing, and restraining. Redefining is intended to change the family’s perception of the symptom. Toward this end, behavior that maintains the symptom is

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defined as benignly motivated, loving gestures the family employs to preserve its stability. Thus, anger may be relabeled as caring, suffering as self-sacrifice, distancing as a way of reinforcing closeness. Instead of trying to change the system directly, the therapist appears to be supporting it, respecting the emotional logic upon which it runs. Next, the wording of the prescription (“Practice being depressed”; “Continue being rebellious against your parents”) must be brief, concise, and unacceptable (in order for the family to recoil at the instruction), but the therapist must appear sincere by offering a convincing rationale for the prescription. Later, when the family members press for change, the therapist attempts to regulate the pace of change by urging restraint, pointing out to them what new difficulties might arise. At the same time, the therapist seems to be cautiously allowing the family to change despite these anticipated difficulties.

Restraining strategies (“go slow”) are efforts to emphasize that the system’s homeostatic balance is in danger if improvement occurs too rapidly. If the directive is presented with a creditable rationale (“Change takes time and must proceed step by step; otherwise there is danger of relapse if too much change occurs too fast”), the client is likely to go along with it. The tactic is intended to prepare clients for change, to acknowledge their reluctance to change, and to solidify change once it begins (Shoham, Rohrbaugh, & Patterson, 1995).“Go slow”messages, according to Fisch, Weakland, and Segal (1982), provide the additional benefit of reducing the client’s sense of urgency about finding new solutions. Such messages have the added effect of normalizing relapse should it occur, without the family becoming demoralized or giving up trying.

Haley (1976) inquired, in a case of a young, middle-class couple concerned that their young child soiled his pants, what the consequences would be if he began to go to the toilet normally. (This move suggested that Haley could help them with the problem but would rather not until he was sure of the positive consequences to the entire family.) When the couple returned the next week and indicated that they could think of no adverse consequences, the therapist suggested some possibilities: for example, could the mother tolerate being successful with her child? This effort to challenge the mother’s involvement with her child and reframe her behavior contained messages at several levels: (a) Haley thought she could tolerate success; (b) he was benevolently concerned so he wanted to make sure she could tolerate it; and (c) the mother would find the suggestion of not tolerating success to be unacceptable. No mother is likely to think she cannot be successful with her own child, as Haley well knew. Thus provoked (the father was similarly confronted), both parents became highly motivated to solve their problem to prove they could tolerate being normal; the boy’s problematic behavior ceased.

Effectiveness of Strategic Approaches

Is strategic therapy effective? Unfortunately, rigorous research is lacking, and the advocates of this approach rely heavily on anecdotal case reports. In some early studies (Watzlawick et al., 1974) a telephone follow-up at regular intervals after ending therapy found favorable results: 40 percent claimed complete symptom relief, 32 percent considerable relief, 28 percent no long-term help. Stanton, Todd, et al. (1982) offered a well-designed and carefully controlled study in which structural-strategic techniques were successfully employed for treating families with an adult member who engaged in heroin addiction, and positive results were found in follow-ups. Szapocznik,