Strategic_Therapies

Strategic Therapy: Its Origin and Influence Strategic therapies are a unique form of therapies, dealing with families, of which began in the early 1950’s. Even though this approach is critiqued by many professionals in the field of family therapy, it has been found to be fairly effective. In reading Family Therapy: An Overview, I discovered that strategic approaches are focused on changing or modifying the solutions, not the problem. The various models focus on the behavioral patterns in the family, the solutions in which the families utilize to respond or solve the problems and the hierarchies that lie within the families (Goldenberg & Goldenberg, 2008). The interventions within these models include paradoxical intervention, first-order and second-order changes, the therapeutic double bind approach, redefining, prescribing, reframing, etc. (Goldenberg & Goldenberg, 2008). There are four outlooks that Family Therapy: An Overview reviews: “the original Mental Research Institute (MRI) Interactional view, the brief therapy principles and therapeutic procedures that characterize current MRI activities, the strategic therapy refinements advanced primarily by Jay Haley and Cloe Madanes, and the strategic-related efforts developed in Milan, Italy, by Mara Selvini-Palazzoli and her associates” (Goldenberg & Goldenberg, 2008). The last outlook is based on social construction and will not be theory discussed in this document. Goldenberg & Goldenberg emphasize that the strategic approach to family therapy has a basis in the “Communications Outlook”, expressing that verbal and non-messages and their perceptions play a large role in the strategies. “Communication theorists argue that a circular interaction continues between people because each participant imposes her own punctuation; each arbitrarily believes that what she says is caused by what the other person says” (Goldenberg & Goldenberg, p. 263, 2008). This view of communication within the family offers clues of family dysfunction. The strategic therapists do not focus on why the type of communication exists, but they focus on what the communication patterns are and the ongoing processes among the individuals within the system. Strategic therapists do not practice the traditional therapy interventions, i.e. authoritative, psychoanalytic; they provide a strategically directive, manipulative approach in an effort for families to change “without fixed ideas of how the family should change” ( Goldenberg & Goldenberg, p. 263, 2008). I will attempt to present the different approaches of this therapy model without doing an injustice to the foundation that these therapeutic forefathers laid down for present day clinicians. As mentioned earlier, there are four different approaches involved when using the Strategic Models in a therapeutic environment. The approaches should be duly noted as the following: MRI Interactional Family Therapy, MRI Brief Family Therapy, Strategic Family Therapy, and Milan Systemic Family Therapy. One should be aware of the fact that based on the need for further research in this fairly modern type of therapy, therapeutic approaches tend to evolve as time moves on. With statistics and actual case studies, I will to prove the effectiveness of this model of family therapy. In Brief Strategic Family Therapy versus Community Control: Engagement, Retention, and an Exploration of the Moderating Role of Adolescent Symptom Severity, authors: Coatsworth,, et al conducted a research to investigate the effectiveness of Brief Strategic Family Therapy for families and/or youth in treatment (2001). This study contrasted Brief Strategic Family Therapy (BSFT) with a Community Comparison (CC) condition selected to represent the common engagement and treatment practices of the community. (Coatsworth, et al). Coatsworth, et al uses the Strategic Structural Systems Engagement, which was developed by Coatsworth, et al. This approach included theoretically based strategies that BSFT therapist could be used to engage resisting families. “Results from two randomized studies demonstrated that BSFT’s specialized strategies were superior at engaging and retaining families than was an engagement condition designed to represent common engagement practices in the community” (Coatsworth, et al, p. 4, 2001). (Results indicate that families assigned to BSFT had significantly higher rates of engagement (81% vs. 61%), and retention (71% vs. 42%). BSFT was also more effective than CC in retaining more severe cases. Post hoc analyses of treatment effectiveness suggest that BSFT was able to achieve comparable treatment effects despite retaining more difficult cases. We discuss these results from a public health perspective, and highlight the study’s contribution to a small but growing body of literature that suggests the benefits of a family-systems paradigm for engagement and retention in treatment.”(Family Process, Vol. 40, No. 3, 2001) This statistic was one of the first pieces of research that caught my attention. From the few case studies that I read the numbers seem to suggest that the Strategic Model of Family Therapy is an effective intervention tool. I will step backwards some to explain some of the different tools used to bring about change in the family system. In MRI Interactional Family Therapy the focus is placed on family interaction and the faulty communication patterns that lead to family dysfunction. This form of therapy addresses the fact there is always communication within the family network no matter how the message is received and how these messages can be used to change negative behavior to positive behavior. There are some axioms that pertain to interpersonal communication. At some level all behavior is communication. At many levels communication may occur simultaneously. All communication has a content and a relationship aspect. Command messages define relationships. Relationships may be of a symmetrical or complementary nature. Symmetrical relationships can become competitive.(Page263-264) When the use of Brief Family Therapy is found to be appropriate the clinician using this approach should remember that BFT is exactly what it claims to be, which is brief in nature, around ten sessions, and attempting to resolve a previously unresolved problem in the family network. Some rules of thumb for Brief Family Therapy are the following. Define the problem, identify the attempted solutions, determine the position of the client, design an intervention, sell the intervention to the client, assign homework to the client, do a homework follow-up, terminate sessions. The practitioner using this approach should see the client’s complaint as the problem, not a symptom of any underlying disorder.(Page265-270) The development and refinement of Strategic Family Therapy can be attributed to the work Jay Haley and Cloe Madanes. “According to Jay Haley therapy can be called strategic if the clinician initiates what happens during therapy and designs a particular approach for each problem. When a therapist and a person with a problem encounter each other, the action that takes place is determined by both of them, but in strategic therapy the initiative is largely taken by the therapist. He must identify solvable problems, set goals, design interventions to achieve those goals, examine the response he receives to correct his approach, and ultimately examine the outcome of his therapy to see if it has been effective. The therapist must be acutely sensitive and responsive to the patient and his social field, but how he proceeds must be determined by himself.(1973, p. 17)” (Journal of Systemic Therapies, Vol. 23, No. 4, 2004 p. 29-30) “Haley, a student of Erickson’s and codeveloper of the Mental Research Institute model of strategic family therapy, was influenced by the structural work of Minuchin (Minuchin, Montalvo, Guerney, Rosman,& Schumer, 1967). Haley (1976) changed his focus from the individual as the primary change agent in the family (a la MRI) to a view of problem solving that focused on the interactional sequences of behaviors as metaphors for unsolved problems in the family. For example, a child’s problems with bed-wetting might be a metaphor for his or her parent’s sexual (bed) problems. Because the family presented with one problem, it must have reasons for not mentioning the other, according to Haley. Assuming that the sequences of problem-solving behavior in the family are similar from situation to situation, changing the sequences around one interaction (bed-wetting) should be accompanied by corresponding changes in other problem-solving behaviors (the sexual problem). Madanes (1981) added to the evolving model of strategic family therapy by focusing on positive interactions and benevolent intent behind seemingly maladaptive behavior. Madanes refined the art of prescribing symptoms and dysfunctional sequences by focusing on the paradoxical perspective that one cannot pretend to do a thing while one is actually doing it. This focus propels the family into simultaneous changes at many different levels so that symptoms are no longer necessary.”(Journal of Family Psychology, Vol. 4 No. 1 September 1990 p.50) I will give some highlights of a case study actually done at the Mental Research Institute (MRI), now known as the Strategic Family Therapy and Training Center (SFTTC). “In the state of California, and throughout the United States, children who experience behavioral and/or emotional difficulties that teachers and other school officials deem severe are sent to special schools, both residential and nonresidential. The mental health aspects of most of these children’s difficulties are served by the county juvenile mental health system. In addition, protective services also turn to the county juvenile mental health system for mental health assistance for cases where a child is involved in an abusive situation. An overview is presented of a recently completed training project conducted in which the strategic model was the primary treatment methodology used by clinicians working in the juvenile mental health division of a large metropolitan county health and hospital system. Although the approach used is not new, the voluntary application of the strategic family therapy model in a large, complex social service system of this magnitude is fairly unique. The strategic model of family therapy has been demonstrated to be among the most influential and widely used therapeutic approaches in use today (Haley, 1963; Haley & Richport, 2003; Madanes, 1990). In 1999 the Strategic Family Therapy and Training Center (SFTTC) was set up at the MRI for the specific purpose of re-establishing a therapy and training program at the institute where the strategic model was first introduced. The director of staff development at a large metropolitan county health and hospital system was aware that strategic/structural family therapy had been demonstrated to be an effective model when applied in a large system as his own (Keim, 2000, 2000b, 2000c; Szapocznick & Robbins, 2000) and contacted us. The procedures and model used and taught were essentially the same as are outlined in many classic texts on strategic family therapy (Haley & Richport, 2003; Madanes, 1990; Madane, Keim, & Smelser, 1995). In this county-wide juvenile system where a variety of modalities and beliefs about therapy predominated, and where family therapy was hardly ever used or tried, change was not forced on any therapist or agency. Training began with inviting at least one licensed clinician with some supervisory experience from each agency to participate in the training, as well as having administrators from each agency, attend a three day intensive seminar in strategic therapy. The 14 supervising therapist, one from each agency, then participated in behind the mirror supervision of their cases once a week in an eight hour day, for 30 contiguous weeks. In addition, over the same period of eight months, the supervising therapists attended a monthly three-hour didactic meeting focused on improving supervision skills using the methods and protocols of the strategic approach. One hundred and fifty clinicians, including interns when feasible, were invited to attend a separate three day strategic intensive seminar. In addition, approximately 75 of the 150 therapists, meeting in four groups of 15-20, not including interns, participated in training once a month for three hours for the duration of the eight month training. In summary, the supervising therapists received a total of 282 hours of training. A second group of 75 clinicians received a total of 42 hours of training. A third group of clinical administrators and 75 other clinicians received 18 hours of training. There were no special challenges to working with the lead clinicians. They were experienced, open, and intelligent, with a keen interest and enthusiasm for learning the strategic family therapy model. Coming from different agencies provided a special group experience with no subgroups. We think this facilitated group camaraderie, and therefore enhanced group learning. The team found that the average clinician in the social service system needed several months to master the skill of achieving a therapeutic contract with clients. Mastery of this fundamental skill took longer than we had anticipated. The main reason seemed to be that clinicians, while sympathetic and caring, had been shaped by work context and environment to assume positions of authority. In this system especially, taking an authoritative stance, unless done as intentional tactic to fit a particular situation, often has the effect of keeping the therapist powerless. Most social service clients assume a role of passivity. Actual cases seen by staff therapists and supervisors in live supervision during the training demonstrated a success rate of greater than 75%. By success we mean that the presenting problem was resolved and the contract that each member of the family had asked for, and the therapist agreed to help them solve, was achieved according to the clients and the therapist. Supervisors trained in the model continue to voluntarily use and supervise others in using this model.”(Journal of Systemic Therapies, Vol. 23, No. 4, 2004 p.28-36) In summary I would like to quote an obituary written about Jay Haley. “Haley was a controversial figure in family therapy circles. Haley proposed that therapists should be accountable for their work long before the days of managed care and evidence based therapy. He said the success of therapy depended on actually solving the problem that the client and family presented. He thought that therapists who felt solving a problem was superficial usually didn’t know how to resolve problems. He believed in giving good service for a client’s time and money.(Rick Whiteside)