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perceptions about relationships (“Who is closer to Father, your daughter or your son?”);

(b) investigated degrees of difference (“On a scale of one to ten, how bad do you think the fighting is this week?”); (c) studied now-and-then differences (“Did she start losing weight before or after her sister went off to college?”); and (d) sought views of family members on hypothetical or future differences (“If she had not been born, how would your marriage be different today?”). The idea was to search for mutually causal feedback chains underlying family interactive patterns, and to incorporate these findings into systemic hypotheses, which in turn would form the basis for asking further circular questions, leading to further refined hypotheses, and so forth. The technique is particularly ingenious in that it allows very little room for a refusal to answer, since questioners are given choices.

The technique focuses attention on family connections rather than individual symptomatology, by framing every question so that it addresses differences in perception by different family members about events or relationships. Asking a child to compare his mother’s and father’s reactions to his sister’s refusal to eat, or to rate each one’s anger on a 10-point scale, or to hypothesize what would happen if they divorced—these are all subtle and relatively benign ways to compel people to focus on differences. By asking several people the same question about their attitude toward the same relationship, the therapist is able to probe deeper and deeper without being directly confrontational or interrogating the participants in the relationship (SelviniPalazzoli, Boscolo, Cecchin, & Prata, 1980).

Family members reveal their connections by communicating information, expressed verbally as well as nonverbally. Information about the family lies in differences in meaning each participant gives an event. Such differences in turn reflect views of family relationships. Circular questioning aims at eliciting and clarifying confused ideas about family relationships and introducing information about such differences back to the family in the form of new questions. Table 12.1 provides examples of common types of circular questions.

Such triadic questioning (addressing a third person about the relationship between another two) often produces change in the family in and of itself, as well as providing information to the therapist. Families learn in the process to think in circular rather than linear terms, and to become closer observers of family processes. Another member’s perspective may prove enlightening when compared with one’s own view of an event or relationship.

QUESTIONING FAMILY BELIEF SYSTEMS

Despite the continuing evolvement of the Milan team’s ideas, their basic therapeutic mission has remained constant: to help families recognize their choices and to assist members in exercising their prerogatives of choosing. Fundamental to accomplishing these goals is the creation of a therapeutic climate wherein family members can hear each other’s perspectives as each answers therapist questions. If differences in viewpoint continue to exist, at least members listen and learn to accept other viewpoints or belief systems as viable (Gelcer, McCabe, & Smith-Resnick, 1990). Questioning family members, hypothesizing about the family game, and constantly feeding back information to the family have remained the key methods of achieving those goals.

As we have noted, heavy use of the paradox-counterparadox phenomenon characterized the early Milan team efforts. Dysfunctional families with a symptomatic member, presumably seeking change, themselves seemed to behave paradoxically—the

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moves each member of the system made seemed to keep change from occurring. In effect their common message was that they had a problematic member who needed to change, but as a family the rest of the members were fine and did not intend to change.

Recognizing from a systems perspective that it is impossible for a part to change without a complementary change in the whole, the Milan group began to design interventions in the form of counterparadoxes directed at breaking up such contradictory patterns, thus freeing up the family to change. One common counterparadox, as we have seen, was to declare that although they were change agents, they did not wish to upset what appeared to be a workable family homeostatic balance and therefore would prescribe no change for now (Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1978). Thus, the therapist might say, “I think the family should continue to support Sophia’s behavior for the present.”

In a later revision that shifted their thinking away from the MRI version of families as self-correcting systems governed by rules, the Milan team began to think of systems as evolving and unfolding rather than seeking a return to a previous homeostatic level. Extrapolating from Bateson’s (1972) work, they theorized that dysfunctional families are making an“epistemological error”—they are following an outdated or erroneous set of beliefs or “maps” of their reality; that is why they appear to be “stuck” or in homeostatic balance. Put another way, the family was having problems because they had adopted a set of beliefs that did not fit the reality in which they were living their lives. In effect, they were being guided by an outdated map; the signs and streets had changed since the map’s publication.

In fact, according to this new perspective, the family’s beliefs about itself were not the same as the actual behavior patterns of its members. They only gave the impression of being“stuck”; in reality, their behavior was changing continuously. The Milan group decided they needed to help families differentiate between these two levels— meaning and action. Therapeutically, they began to introduce new information, new distinctions in thought and action, carefully introducing a difference into the family’s belief system.

Relying now on circular questioning to present differences for the family to consider, the team attempted to activate a process in which the family creates new belief patterns and new patterns of behavior consistent with those beliefs (Tomm, 1984a). New information was given the family explicitly through reframing or implicitly through the prescription of family rituals.

By uncovering connecting patterns, by revealing family “games,” by introducing new information into the system through opinions or requests that certain family rituals be carried out between sessions, Milan therapists were trying to bring about a transformation in family relationship patterns. Note that unlike Haley, whom we discussed in Chapter 11, they did not issue prescriptions to arouse defiance and resistance. Rather, they offered“information”about family connectedness and the interrelatedness of members’ behavior. By deliberately trying not to provoke resistance to change, they were offering input in the form of information in order to help the family discover its own solutions (MacKinnon, 1983).

Milan therapeutic procedures also changed over time. The classic method—male and female co-therapists, two team members behind the one-way mirror—was amended so that a single therapist was likely to work with the family while the rest of the team (often students learning the technique) observed. The observers were free to call the therapist out of the room to share ideas and offer hypotheses. The fixed

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monthlong interval between sessions became more flexible, depending on feedback from the family and consultants. Generally speaking, a 10-session limit extended over an indeterminate period of time still qualifies the approach as long brief therapy ( Jones, 1993).

In offering a case study in which acting-out children“provide a shield for marital difficulties,”Prevatt (1999) outlines the following steps in her work with the family:

1.Constructing a working hypothesis

2.Exhibiting a therapeutic stance of neutrality

3.Using circular questioning as both an assessment and therapeutic technique

4.Working with a team to monitor the process

5.Identifying the labels used by the family

6.Identifying openings or themes to be explored

7.Using positive connotation for problematic behaviors

8.Using an end-of-session intervention

The Invariant Prescription

In their evolving therapeutic approach, Selvini-Palazzoli and Prata sought to avoid employing hit-or-miss end-of-session prescriptions for each new family by specifically seeking a universal prescription that would fit all families. Their research focused on finding similarities in the games that “crazy” families play, and formulating countermoves so that the therapist can interrupt these games and force a change in family interactive patterns (Pirrotta, 1984).

In a later therapeutic modification, developed from research begun with Prata, Selvini-Palazzoli (1986) focused on the impact of a single sustained intervention to unhinge collusive parent-child patterns. Seeking a way to successfully intervene with chronically psychotic adolescents and adults, she and a new set of associates (SelviniPalazzoli, Cirillo, Selvini, & Sorrentino, 1989) began to elaborate on her earlier conceptualization of severely dysfunctional behavior as linked to a specific power struggle “game” within the family. Reacting to a struggle between parents, psychotic and anorectic family members were thought to have developed symptoms in an effort to defeat one of the parents in favor of the other. To break up the game, Selvini-Palazzoli and associates now offered the controversial proposal that therapists offer a specific ritual for the parents. Later, Selvini-Palazzoli proposed that this universal or invariant prescription be applied to all families with schizophrenic or anorectic children. This method calls for a more directive therapist in control of the sessions. Its underlying paradoxical message is that a family member’s (say, a child’s) symptoms represent understandable motives but contribute to the damaging family games.

The invariant prescription is based on a six-stage model of psychotic family games. Selvini-Palazzoli contends that a single process takes place in all schizophrenic and anorectic families, beginning with a stalemated marriage (stage 1) in which a child attempts to take sides (stage 2). Eventually drawn into the family game, the child erroneously considers the actively provoking parent to be the winner over the passive parent, and sides with the “loser.”The subsequent development of disturbed behavior or symptomatology in the child (stage 3), requiring parental attention, represents a demonstration to the passive parent of how to defeat the “winner.” Instead of joining the child, however, the passive parent or “loser” sides with the “winner” parent (stage 4) in disapproving of the child’s behavior. The child, in this scenario,

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feels betrayed and abandoned and responds by escalating the disturbed behavior, determined to bring down the “winning” parent and show the “loser” what can be done (stage 5). Ultimately the family system stabilizes around the symptomatic behavior (stage 6), with all participants resorting to “psychotic family games”as each tries to turn the situation to his or her advantage (Selvini-Palazzoli, 1986).

A provocative therapeutic strategy in such a situation is to offer the parents an invariant prescription—a fixed sequence of directives they must follow if the therapist is to help them interrupt the family game. After an initial family interview, the therapist sees the parents separately from the child and gives them the following prescription intended to introduce a clear and stable boundary between generations (Selvini-Palazzoli, 1986):

Keep everything about this session absolutely secret at home. Every now and then, start going out in the evenings before dinner. Nobody must be forewarned. Just leave a written note saying,“We’ll not be home tonight.”If, when you come back, one of your (daughters) inquires where you have been, just answer calmly,“These things concern only the two of us.”Moreover, each of you will keep a notebook, carefully hidden and out of the children’s reach. In these notebooks each of you, separately, will register the date and describe the verbal and nonverbal behavior of each child, or other family member, which seemed to be connected with the prescription you have followed. We recommend diligence in keeping these records because it’s extremely important that nothing be forgotten or omitted. Next time you will again come alone, with your notebooks, and read aloud what has happened in the meantime. (pp. 341–342)

The parental alliance, reinforced by joint action and by secretiveness, is strengthened by the prescription (Selvini-Palazzoli, Cirillo, Selvini, & Sorrentino, 1989; Prata, 1990) and previously existing alliances and family coalitions are broken. Parental disappearance exposes and blocks family games, over which none of the players had complete control but which nevertheless perpetuated psychotic behavior. The overall therapeutic thrust, then, is to separate the parents from the rest of the family, alter previous family interactive patterns, and then reunite the family in a more stable alliance at the conclusion of the treatment.

Although Selvini-Palazzoli (1986) initially claimed a high success rate for this powerful intervention technique, the therapeutic power of a single prescription for all disturbed families has yet to be established. Selvini-Palazzoli herself, in the early 1990s, again reflecting her restless desire for change and new exploration, seemed to downplay the use of brief techniques, including the invariant prescription, by returning to long-term, intergenerational family therapy. Nevertheless, this description of the psychotic process occurring in certain families is intriguing, and the use of this potent intervention procedure aimed at strengthening parental alliances and dislodging family coalitions is an admirable effort to break up a rigid, destructive family game and force family members to invent more flexible ways of living together.

A Post-Milan Systemic Epistemology

Taking a different path, Boscolo and Cecchin continued to elaborate the systemic ideas first presented in the hypothesis-neutrality-circularity paper. Departing from strategic interviewing techniques, these therapists developed a post-Milan collaborative therapeutic intervention style based on the interviewing process itself, particularly the use of circular questioning. By listening to the differing views of the same situation

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Consistent with postmodern ideas, therapists do not have the answers but, together with the family, can co-construct or co-evolve new ways of looking at the family system, deconstructing old family assumptions and creating the possibility of new narratives or versions of reality that are less saturated with past problems or past failed solutions.

Tomm’s Reflexive Questioning

Karl Tomm, in a series of papers (1987a, 1987b, 1988), has elaborated on these secondorder cybernetics ideas, arguing that the presence of the therapist in the enlarged therapist-family system calls for him or her to carry out continuous “interventive interviewing.”More than simply seeking workable interventions, Tomm (1987a) urges therapists to attend closely to the interviewing process, especially their own intentionality, adopting an orientation in which everything an interviewer does and says, and does not do and say, is thought of as an intervention that could be therapeutic, nontherapeutic, or countertherapeutic.

Tomm thus adds“strategizing”to the original set of Milan techniques of hypothesizing, circularity, and neutrality. His circular questions are carefully constructed, not simply for information-gathering purposes but also as a change-inducing technique, activating reflective thinking about one’s belief system and the meanings given to events. Tomm is interested in the therapist’s ongoing cognitive activity, evaluating the effects of past therapeutic actions, developing new plans of action, anticipating the consequences of possible interventions, and deciding, moment to moment, how to most effectively achieve maximum therapeutic influence. More specifically, Tomm concerns himself with the kinds of questions a therapist asks to help families extract new levels of meaning from their behavior, in the service of enabling them to generate new ways of thinking and behaving on their own.

Of greatest relevance are what Tomm (1987b) refers to as reflexive questions. Intended to be facilitative, they are designed to move families to reflect on the meaning they extract from their current perceptions, actions, and belief systems, stimulating them to consider alternative constructive cognitions and behavior. Tomm differentiates eight groups of reflexive questions:

1.Future-oriented questions (designed to open up consideration of alternate behavior in the future) (“If the two of you got along better in the future, what would happen that isn’t happening now?”)

2.Observer-perspective questions (intended to help people become self-observers) (“How do you feel when your wife and teenage son get into a quarrel?”)

3.Unexpected counterchange questions (opening up possibilities of choices not previously considered by altering the context in which the behavior is viewed) (“What does it feel like when the two of you are not fighting?”)

4.Embedded suggestion questions (allowing therapist to point to a useful direction) (“What would happen if you told her when you felt hurt or angry instead of withdrawing?”)

5.Normative-comparison questions (suggesting problem is not abnormal) (“Have any of your friends recently dealt with the last child leaving home, so that they would understand what you are going through now?”)

6.Distinction-clarifying questions (separating the components of a behavior pattern) (“Which would be more important to you—showing up your boss’s ignorance or helping him so that the project can be successfully completed?”)