N/A Hi! This is Dr. Diane Gehart and this is my online lecture on systemic therapies. It's the first part and it covers the MRI Institute and Milan therapy. In part two I cover strategic therapy and you can also find lectures on more contemporary systemic approaches such as EFT, emotionally focused therapy, as well as functional family therapy. This particular lecture goes with two of my textbooks. One is Mastering Competencies in Family Therapy and also Theory and Treatment Planning in Family Therapy. Both are published by Cengage and you can get either the chapter or the entire book directly from the publisher at cengage.com. You can get hard copies at your typical book retailers such as Amazon or Barnes and Noble. N/A Systemic family therapy includes several approaches, many of which were developed around the same time in the 1960’s, primarily by three groups of mental health practitioners. The first was the Mental Research Institute, also referred to as the Palo Alto group as it's associated with Gregory Bateson. There's also the Milan systemic approach which is based in Milan, Italy. Then there's also strategic therapy which is closely associated with the work of Jay Haley and Chloe Madonnas. These three approaches are distinct and especially were developed with distinct approaches. Yet they use very very similar processes in other ways and so I'm going to present all three of these separately and yet I will also highlight some of the similarities and differences as we go along. I'm going to begin by talking about the Mental Research Institute, the MRI is what I'll call it, and how you most frequently hear it referred to. This is actually one of the first groups to develop systemic therapy, arguably. Both the milan and strategic are kind of branched off from this particular group that began studying, originally communication patterns in schizophrenic families, and they developed this therapeutic model; one of the first family models based on this research. So, as one of the first systemic approaches, the MRI approach, one of the unique things N/A that they do (and then all later systemic approaches, really the heart of any systemic approach, kind of the defining characteristic), is they look at individual symptoms and they conceptualize them within the broader family and social networks - looking at how that symptom functions within the broader system. And when therapists think about change in these contexts and how to help families change, they focus on introducing small yet meaningful changes to the family patterns. So, a truly systemic therapist is not going to try to go in and correct a family interaction pattern, or educate people, or try to just go “you're doing it wrong” and “do it this way,” because if you've noticed humans at all, they don't tend to take that advice and change their behaviors really easily. So what family system systemic therapists have done is they've looked at the natural patterns and try to find ways that allow families to more easily change those patterns, because if you've ever tried to change a habit you'll notice it's not easy for humans to do that. Especially when you look at groups, systems of people where you've got four, five, six, eight people who have a set of patterns and behaviors - intervening and changing all that is much more complex. So they look at how that works and they try to introduce small meaningful changes that allow the family to naturally reorganize. So, they're not correcting dysfunctional patterns and if you hear someone talking like that, they're not thinking truly systemically in what that word means. It's not about fixing things, it's introducing small bits of meaningful change to that particular system. You study the system, you learn what's meaningful and you make a shift there and you allow the family to naturally reorganize. That's one of the hallmarks that we're going to see across all the different systemic approaches. Let's talk about one of their most significant contributions to the field. What I like to call “the juice.” Systemic reframing, now this is a real art. N/A You'll hear the term reframing used across various different therapeutic models but systemic family therapists do a very specific form of reframing. What they do instead of looking at an individual’s symptoms and focusing on an individual’s pathology, maybe reframing it in terms of history, what systemic family therapists do is they reframe the problem in terms of the family dynamic. So they're looking for alternative yet equally plausible explanations for the same set of facts that may exist in this family system. And so they really look at the symptom and consider what kind of role it may play in maintaining the family homeostasis, or the family norm, or the family’s sense that everything is ok, the normal range of family behaviors. So, you're trying to look at finding an explanation for what's going on and proposing a new way to look at things in terms of news that makes a difference. And so this reframe has to be something that will make a difference in this particular family system. For example, a common actual reframe in systemic approaches is when you have a child who is maybe acting out - and after assessing the system and watching dynamics, the therapist may come to develop the hypothesis that the reason this kid is acting out is because it unifies two parents who otherwise do have some discord. And so this acting out child can distract a couple from their own issues so they can focus on the child. Now I want to be real clear here, no one is getting blamed in systemic family therapy and I think that's also something that's very unique. There is no blaming the child for doing this or blaming the parents for this, instead, they step back and say this is just how the family has negotiated and kind of evolved over time to maintain its sense of integrity. Because there is - a system wants to hang together. Couples want to stay together. There is this natural kind of pull together in terms of the systemic dynamics and systemic dynamics or how do we keep this family connected, and so it's not like the child sat down talked to an aunt or uncle and tried to devise “how do I keep my parents together.” But what happens is through interactional patterns it becomes clear that when the kid is acting out, there's less stress between the couple and that creates a sense of balance and things feel okay and so it's none of it… typically it's not conscious at all. It's not that they don't conceptualize being subconscious or unconscious as you would in a psychodynamic way, instead it's an interactional pattern that's developed between people and there's no blame. But the idea is, what kind of - and this is where we're going to see the difference whether it's a reframe, whether we'll see some more behavioral directives at times - what kind of way of talking or what kind of things can we do to shift the meanings in this system? So the systemic reframe is a real classic, in terms of proposing that the child's tantrums, or acting out, or even sometimes certain physical symptoms, can be reframed as a way of the child, or the system unifying the parents to get them on the same page by focusing on the child. And so this child could be seen as sacrificing him or herself in order to keep the marriage together. And this can be a very powerful intervention especially if a couple knows that they have tension and they know that the one time they are on the same page is when they're having difficulty with one of their children. I didn't believe this when I first started, um, as a family therapist, but often you will see there's the presenting identified patient, the child with the problem, we’ll just call them the “problem child,” “bad child” and then often you'll have the angel, “problem-free child.” And often, more often than I care to ah, that I would believe would happened when I first started in this field - when problems subside with one child, the formerly “perfect child” all of a sudden is starting to act out. And that's when you know you've got systemic dynamics going on and there is something to the kid’s level of symptoms, and something else in the family system, often pulling and keeping the couple together and unified. There were a lot of amazing therapists who trained at the MRI Institute. N/A And here we have a list of some of the primary people who are associated with the MRI and throughout all my various lectures on systemic therapy, we will be referring back to MRI as many great family therapists who have their own approaches like Jay Haley, Virginia Satir, the Milan team including Steve DeShazer who developed solution-focused therapy, all of them studied at the MRI. Don Jackson was one of the original thinkers, and therapists, and developers of MRI approach. Um, he did pass away relatively early and Paul Watzlawick, John Weakland, and Richard Fisch, Art Bodin and William Fry also carried on some of that ah early development of the work. Probably the most prolific author of this group is Paul Walzlawick. And more recently, Wendel Ray has been an archivist of any, he has archived all the original tapes from the MRI and so if you are wanting to do advanced doctoral research in this area he's a great contact at the University of Louisiana at Monroe. And more recently, Barbara Anger-Diaz and Karin Schlanger have been working at the MRI Institute with more contemporary programs. Giorgio Nardone works closely, but in Italy, with the MRI developing these ideas. But there's a long history of many thinkers who have gone through the MRI developing very unique systemic approaches, having trained many of the people in family therapy. So next we're going to move on to the big picture, the overview of treatment, at the MRI. And it is the briefest of brief therapies and so it's an interesting one. It's one of, its really I would say, the original brief therapy method. N/A So in terms of the process of MRI systemic therapy, they begin very much focusing on present interactional patterns and they're going to track that interactional sequence. And we're going to talk a lot about that and all the systemic approaches it's really a hallmark of systemic approaches. And they look at the problem, whatever the presenting symptom is, usually, it's the individual symptom, they look at as part of a broader interactional behavior sequence. And they focus on first identifying what is the attempted solution, what is the family or couple trying to do, or even the individual trying to do that has unsuccessfully solved the problem. And so they look at the logic of that type of solution. For example, a lot of parents will bring in their kids saying that the kid has tantrums, or is acting out, or is defiant and that we've tried everything and nothing has worked. And so the MRI therapists say, well what would what have you tried? And they might say they tried timeout, so we tried putting in his room, we tried taking away the TV, we tried this. And as you listen, those are variations of punishment. Different ways and often they start with - they get more and more harsher and harsher punishments and they, you know, they're not working. So that's the class of attempted solutions and typically what they're going to do is look for a 180, what would be the opposite of the former attempted solutions, the failed attempted solutions, And so the opposite of punishment is going to be some kind of relationship-building typically. And so you're gonna have to look at what makes sense for that particular system. And so then they look at interruptions that are used to interrupt these patterns. Not necessarily correct them or fix them. And if you, one of the images that helps me with this is if you think of a school of fish which is a type of system, and you imagine they've - there's a school fish maybe swimming in a circle and someone throws in a rock and the whole, all the fish scatter, and if you watch them they will regroup in a different pattern and reorganize themselves. And that's the image that's most helpful, I think, for understanding um the interventions in the systemic approaches. They are not fixing them, no one's telling the fish where to swim. And that's kind of what it's like trying to micromanage family interactions, trying to get all let's say four-foot people changing their behaviors is really hard. But if you throw a monkey wrench into their typical pattern, then you're going to - everyone has to change. Another good example is, if you've got a dance floor, you've got a couple dancing, they've got their pattern. This is the dance that they do you do. You do something like put a few pieces of furniture in the middle of that and they have to dance around it, well you know what, the dance is going to change. Both - they have to change because the situation is changing and so um this is where you can get some pretty outlandish and sometimes not even logical ways to interrupt the problem sequence. A classic MRI intervention for couples who bicker is to um, that Paul Walzlawick wrote about is - ok next time you guys start an argument here's what I want you to do. I want one of you - both of you guys to be fully clothed, I want you to go into the bathroom, I want one of you to sit in the bathtub and the other one of you to sit on the toilet fully clothed and I want you to have your arguments there. And just by changing the context, interrupting it there, they're just throwing a monkey wrench into the typical interaction sequence, that something different is going to shift. And the truth is, most of us know what we should be doing and we would choose better behaviors and interactions with others if we're not in our pattern, in a rut. And so what they do is they give the couple this opportunity, and one or both of them is going to change what they typically do. But just because you interrupted their pattern and so that is the magic of the MRI approach. And you allow them to self-organize and the truth is, I guess I've never seen anyone reorganize in a more negative way - if that helps, um, I guess it's theoretically possible. But most people, when you interrupt them, you kind of get them out of their negative interactional sequence. And when people get to consciously choose their behaviors, they almost always choose a better behavior. Making connections a therapeutic relationship and MRI therapy. N/A The therapeutic relationship in MRI therapy. Now the therapeutic relationship, especially by traditional systemic family therapists is a little hard to get used to because it's not about empathy necessarily. It's not about being harsh and cold, but it is more in some ways detached because it is considered a brief therapy. It is not about getting clients to project and the rule is a little more technical, but there is this very profound trust and respect of the individuals in the system. The systemic therapists really do believe that the family is - with a little assistance and some reorganize in a healthier way, and they're going to be fine healthy normal functioning couples and families. There really is this belief and trust and hope and a very positive view. Um, they very much adapt their language and viewpoint to, they kind of get in sync with the family system. And they practice something called maneuverability and basically, the therapists will take whatever role is going to be most useful in promoting the family to change. And so they may be a more soft empathetic style, it may be a more technical kind of detached clinical style. They will take whatever position they feel like it going to be most helpful to that particular couple or family or even individual to make change. And so they're very flexible in whatever position they take based on the particular family system and its needs. The viewing: Case conceptualization in MRI strategic...MRI therapy. I keep throwing strategic in there because strategic is closely aligned. But the case conceptualization in MRI is probably the hardest part and it's really something difficult to not learn in a clinical environment with a supervisor and a team and you learn to begin to see systems. I'm going to do the best I can to introduce you to it, but learning to see systems is probably one of the most difficult shifts a therapist can make. And learning to view things systematically - it is not a natural way to look at or think of the world. We tend to look at, you know, A causes B, and to focus on how B effects A and how A effects B and that it's interrelated and they're all interconnected - that's much more complex, it's not intuitive for any human being I know. Even Gregory Bateson said it takes effort, more effort than we're used to in terms of conceptualizing and so I think it certainly is one of the most difficult approaches in terms of conceptualization. That said I'm trying to break it down so that it's easier to learn, in this particular lecture. N/A So when MRI therapists conceptualize what's going on they're focusing on the interaction patterns, the patterns between people. They're not trying to analyze a psychopathology within the individual. And so when they conceptualize what's going on, they begin - I'm looking at, what does normal look like, what is the homeostasis, what is a normal range of acceptable behaviors within this relational system. And then they begin to track how the tension rises. And this is what's called, early positive feedback in systems thinking. And so positive feedback, in a sense, is feedback that “uh oh,” something, the behaviors are going outside the normal acceptable range. And then there's the symptom, typically the positive feedback “oh no something is out of acceptable range,” and the system is then going to take corrective action in order to bring the system back to homeostasis. So if homeostasis is, we’re all getting along we're joking we're having a fine time, then the symptom rises, maybe um in a family, this might be someone or people are getting cranky, then there may be the symptom, it might be a large conflict, it may be a child's tantrum, it may be a cutting episode with a teen, any type of symptom behavior. And then you look at the self-correction. So after this explosion, who's doing what to try to either make up, or pretend like nothing happened. But somehow someone in the system can - because it becomes so uncomfortable, people are going to start doing different things to bring it back to homeostasis. And so you want to look at what those patterns are. Is it the same person who apologizes every time? Is it the same peacemaker who makes peace no matter who is fighting in the family? Do people just all go to bed pretending like nothing happened in the morning? It's very important, this is probably the most important of diagnostic things, is to understand how they self-correct to get back to normal “homeostasis.” And then you keep tracking um, this interactional pattern. And all the systemic approaches are going to do this in some way. And so for the MRI, it's a very behavioral approach, looking at what people are doing and they're also focusing less on the content - not what the temper tantrum is about - but looking and asking and learning about more, about what's called meta-communication. Or um, what, what is the communication about the communication. So for example when a child throws a temper tantrum, what is that about? It is - you want to ask - often it is the child expecting that his desires should be ruling the family or whatever. It might be, “I'm in control you're not in control of me, parent.” And so you would look for what is the parents’ response - typically it’s, “no I'm the one in control.” So looking at those type of interactional sequences and what they mean and tracking those in terms of the messages about their relationships and interrelationships in the family system. So MRI systemic family therapist and the whole approach is based on the assumption that one N/A cannot not communicate. You're always communicating. So when a family comes in or a couple comes in or an individual comes in and says, “I just can't communicate with my spouse” or “my kids” or “my partner” or whatever it is, systemic therapists know that that's not accurate. They are communicating but they just don't like what's being communicated and how it's being communicated. Stone-cold silence communicates a lot actually. Um and so, the MRI therapist, when someone says that, they start becoming curious about what is being communicated and how; why they have any sense that they're not communicating and they also look specifically at the symptoms as a form of communication. You know, a child throwing a temper tantrum is a form of communication. A child cutting is a form of communication. You know, a partner nagging is a form of communication. A partner withdrawing is another form of communication. They're trying to say something to their partner, child or significant others. And so the … the systemic therapist is going to look at, what's, what is being communicated, what is actually being communicated and why and what are the patterns there and what are they. Usually from an MRI perspective, all those communications there, is each person trying to define the relationship on their own terms. Who's in control? Who's got the most power influence? Um, and those sorts of things, you know, who - where - who's loving who and what's that all about. So they're looking at what each communication, which can be verbal or nonverbal, behavioral. What each form of communication and how it is trying to define the various relationships. N/A So as mentioned earlier, one of the hallmarks of the MRI approach is assessing for these, more of the same solutions, or the attempted solution. And these are the solutions the family has tried and did not work and instead they're perpetuating the actual problem. And so there are some common forms of these, more of the same solutions, you can look for. One is what they call terrible simplifications, and that is when action is necessary but none is being taken. And so this common with addictions, marital conflict, or family problems where somebody does need to address an alcohol or drug abuse type of problem and no one is doing it. Or there's definitely trouble in the marriage and everyone's pretending like it's not there. There's also something called the utopian syndrome, and this is when action is being taken when none is actually necessary. So this can be seen with a parent having very perfectionistic expectations of a child, and you can see the symptoms that you typically see here might be depression or anxiety and procrastination and those sorts of things. And so here people are trying to um, they're taking action to change something that's either unchangeable or it's not developmentally appropriate to be changed. And then finally we have paradox, and that is when action is taken, but at the wrong level. And so in this case um you're looking at a first-order solution to a second-order problem or a second-order solution to what is a first order problem. What does first and second order mean? It's described in another chapter, but I'll summarize it here. With first-order solutions, you're changing, um the change, is not…... Second-order change is when you're changing the actual structure of the system. Where first-order, you're just changing the organization of the specific parts but the basic dynamics and homeostasis are the same. And so an example of this is when a person is demanding an attitude or personality change in their partner or child when the correct solution is actually a behavioral change. So they're wanting their partner or child to either do something and be something that they're not which would be a second-order change. When what they - what's a reasonable change or a solution here is a first-order change. Rather than getting your child to love having a clean room you're just going to get them to clean their room. Asking for that attitude shift is unrealistic. Another common one is wanting your partner to be romantic and, you know, bring flowers and dates and romance and magic and mystery, like we did when we first met to the relationship, into a 20 year old or 10 year old relationship would be a second-order shift. When a first-order shift of, organizing a date, doing what the person is asking it's more a behavioral shift is more realistic, and what's possible at this developmental stage of the marriage. So these are some ways what they mean by the paradoxical levels. So the original communication theory developed at the MRI, which is the foundation of most systemic approaches, talks about the concept of meta communication, this is communication about communication. And this is often, in communications theory, referred to as the command aspect of communication. So you have the report aspect, which is the content, and then there is the command aspect, which defines the relationship, and that's really where all of our conflict tends to arrive from. The command aspect is typically nonverbal um, and it's typically a comment on the relationship. So um both parents, and children, and partners complain about everybody's tone and that's what they're complaining about - typically the tone is saying “hey I'm in charge of you,” and that's often where the conflict erupts because no one, very few of us, like to hear that the other person is in control. And then there's also adjusting that based on parental hierarchy and such. So, some of the forms of metacommunication are voice, tone, gesture, eyes. And so what you're looking for is whether or not that this metacommunication reinforces the verbal message which would be congruent, whether it's satirizing the verbal message to where it's openly contradicting. Or creating a double bind - so on one hand there's a verbal um the verbal element, the report element is, saying one thing and the command uh the command element, the nonverbal, is contradicting that and that cannot be directly commented on or successfully commented on. And a classic example of that is when a mother, when the son goes to hug his mother and her response to that is, “how come you never show me affection.” And so, and in that system, there's no way to successfully comment on that and that's where the contradiction is. So she freezes up when he goes to hug her, there's this freeze up and then it's like, “you never show me affection,” but it's like, “you won't let me hug you, and yet you're saying I don't show you affection.” And so the kid feels totally caught in being able to comment on that. Another one I've seen is the parent says “no I do trust you, I really do trust you, but,” and then they go on to the reasons why they don't trust them. And so the kids trying to say “but you don't trust me” and the parents like “no no, I do,” and then they have their long list of exceptions and reasons and there's no way for the kid to successfully communicate with the parent about this contradiction. So if you find yourself struggling with, sensing in a systemic approach, I do think one of N/A the most useful and easiest elements of systemic dynamics to conceptualize is what they call complementary or symmetrical patterns. So complementary is when two people in the system have um opposite kind of roles and they get exaggerated. It's not problematic to have complementary roles if no one's having symptoms in the system and they don't get exaggerated. Symmetrical patterns are where people are actually taking similar roles. So the more frequent ones that need to be assessed or thought about through or some examples of these complementary patterns include the pursuer distancer. So one person is pursuing for intimacy, and the other is distancing. And there's, there's typically, in couple relationships there's typically a pursuer and a distancer and this should have been flow across time and ideally flip back and forth and that can be a relatively healthy system, healthy couple system, and over time it can go back and forth. The more exaggerated it becomes, and then the more lopsided that it becomes, the more problems you're going to typically experience in the relationship. There's also the criticize and defend pattern. One that is similar is controlling and resisting control patterns. Sometimes with couples in particular, sometimes with siblings, you can see the logical one and the emotional one. She’s the one who has all the emotions and he's all logic and ideally those should actually be within the same person and that should - but sometimes you'll see with couples especially the ones who've been together for a long time, that they become so polarized on this, that she only does emotions, he only does logic and they drive each other crazy. And it begins to feel like he's logical and she's emotional and he doesn't have emotions and she can't be logical, and that is one of the pieces of real insight and wisdom that comes from beginning to see things systematically. It's like, that reality has only been created because of the dynamics of this system. And that's where the systemic therapists are able to see that and not believe that this is attributed to one person or another. These are not personality characteristics, these are dynamics of the system. Same with the helpless one and the rescuer, you can certainly see, especially between couples, you can see the one who's rescuing and that one's sick or helpless in some way. Again, you will frequently see that with what I call the over function or under function pattern, and that's where one is doing all the work and the more that one functions the more the other one under functions. They begin to believe that one's incompetent and ones super neurotically competent. And they begin to believe that those are personality characteristics. Each person believes it and so they don't even question it. Similarly you can get the good parent, bad parent dynamic or the social recluse or the oversexed, undersexed. As you get these very exaggerated patterns, people really do begin to believe that these are in the individuals, rather than a dynamic part of the systemic dynamics that have evolved over time. Another distinction that MRI therapists make when conceptualizing the family system is N/A first and second order change. Now first-order change, as I mentioned earlier, involves changing the roles within the system and this feels really different when you're in the system. And so this is like, for example, when the pursuer becomes a withdrawer or the withdrawer becomes the pursuer. So if you've been in a relationship with, you know, a partner where you've been pursuing for a long time and not feeling responded to, when the person who's been withdrawing becomes the pursuer and you're the one withdrawing, it feels like there's been a major shift in the relationship. That's what it's going to feel like those in the system. Um, but that is still considered first-order change because in that shift they've kind of maintained the same level of intimacy, there's a certain - only so much intimacy that this couple can handle. Whereas second-order change would be a fundamental restructuring of the system. Um, in this case it would typically look like the couples actually has more intimacy there's a fundamental change - the roles have not flipped, instead the roles are, both roles are totally different. Now when we describe this conceptually it does sound like both first and second order change and I say often in life, in therapy it feels like there's more of a 1.5 order change. There's been some things that do seem really different than some parts are similar. And from an MRI perspective not every problem needs a second order change. Sometimes first order change is acceptable. Um, I can - what comes to my mind here is when the parent-child hierarchy is reversed, when the child's been calling the shots rather than the parents. Just shifting that around can sometimes be the change that needed to happen, don’t need to reorganize the whole system. But typically therapy focuses on second-order change but it's not always necessary. Also typically, not always you will have first order change before you have second order change. So often there will be some shifting in the roles or the system might flip before you have the true kind of reorganization of the basic homeostatic, you know, patterns within a system. So another key element to case conceptualization in MRI systemic therapy is they were if not N/A the first, then one of the first therapeutic approaches that use an observational team. Because they really did start off as a research team and they were observing families in communication and noticing the pattern and discussing them like researchers and that research approach is what evolved into the systemic family therapy approach. And typically a team was behind the mirror and there was a person in the session, the therapist, talking to the family. Typically halfway through, the therapist would come out consult with the team. The reason for that is that typically the team - because they're not in the room, they're not in the conversation, they're not becoming part of this system - that they can see the systemic dynamics before the person in the room. And if you get the opportunity to train or work in a systematic way where you can do observational teams of clients, you will notice that you're always much smarter and wiser behind the mirror than you are in front of it. And so and this is a very useful way to train when working with couples and families because it's much harder when you're in it and you're part of the dynamic, you become part of the dynamics. Um, it's much harder to see those patterns when you're in the conversation, in the room with them, rather than sitting back and watching the show unfold. And so that is why they use those observation teams and they're frequently used in the training of couple and family therapists. And like I said. if you get an opportunity to do this, it's one of the fastest and best ways to train, to learn how to work with couples and families and think systemically. Targeting change setting goals in MRI therapy. N/A So when it comes to goal setting, MRI systemic therapists are extremely minimalistic. They just want symptom free interaction patterns. And so they, you know, how can we get this individual, couple, family, to not have symptoms. That's all they're here to fix. They don't have underlying theories of health and normalcy or “ you've got to have a family that looks like this” before I'm going to terminate treatment. That's not how they think. They're like “how do we get the presenting symptoms to go away nd for them to have a sustained interaction patterns without the symptoms?” They do not have theories of health. They look at the problem as the attempted solution. So they look at, they define what the problem is in very behavioral terms, they identify the attempted solutions and then they describe the behavioral change and they develop a plan to target the attempted solution. And so, this is how they work and in terms of the target of change, it is the attempted solution, that's what they're going to focus on changing. Getting a different class and type of solution, typically what they call a 180 degree shift, the opposite type of solution. And then the tactic of change is usually using the clients own language and we'll be talking about that in interventions. Interventions in MRI systemic therapy. N/A So as we mentioned in the “the juice” section, a significant contribution to the field is this concept of systemic reframing. It’s one of the key interventions used in MRI approach, where they take the symptom and they reframe it in the broader context of the family dynamic. So for example, a child tantrum, or symptom, or behaviors, are they are sacrificing themselves in order to unify the couple and keep the marriage together. So that's a type of systemic reframe. Then they also look at what they've uh - tried to identified less of the same behavior prescriptions. And so then this is where they identify, what is the attempted solution. So for example, more and more punishments and then they try to identify an alternative behavior that will alter that pattern. And then they give the client these prescription behaviors, so when they leave sessions - they have to do this whatever the prescribed behavior is. And so um, in terms of for example, with the punishments - and that could - a 180 shift from that could be building the family relationship, the parent-child bond and relationship. You could also have a 180 shift - could be rewarding that behavior with something. And so depending on the family, and the system, and the meanings that are being made they would develop an intervention, a behavioral prescription, send them home with it, and when they come back the next week they see what happens. They say “how did that work out for you?” And based on however that happened they would shift or adjust their reframe and/or the behavior prescription for the next week. And they just basically keep doing that untill those symptoms go away. I mean that's, that's all - and that's what makes it so brief and how they intervene. N/A So the therapeutic double bind is sometimes considered a paradoxical intervention. And often people become concerned when they hear about these paradoxical interventions. The more you work with couples and families the more they begin to make sense because when there is a double bind it seems like there's no way, you know, no matter what you suggest someone is like, “no that won't work, no that won't work,” there's all these excuses and rationalizations going on. So I will - don't try using the therapeutic double binds or paradox until it makes perfect sense and you'll know the moment when it's time for therapeutic double-blind. So this is when you do more of this - what you're doing here instead of doing less of the same, you're going to do more of the same behavior prescription. And this is, um, there are certain families and certain systems or individuals where direct interventions to interrupt this, the um, problem behavior just seem, they just don't work. No one follows through on it, no one can do it, no one will do it. So this is when you move on to the therapeutic double-blind and this is when you're going to prescribe more of the same but in a slightly different way. And again what you're doing here is you're interrupting that symptom. You're putting a couple pieces of furniture into the living room so they have to move differently around in their little dance. And so they cannot not do something different, something cannot not change, somethings going to change. So um, and what the purpose of this is, and these are carefully constructed (this is where it's really helpful to have that team behind the mirror helping you design one of these things, it takes a pretty good therapist to do this on the cuff or off the cuff) is to undo the double-blind message in the family. And so with the therapeutic double-blind no matter what you do, it's going to be different. Even if you do the same old behavior, it now has a new meaning. So a common example of a double bind is a wife who wants more romance from her partner, her husband and um - but if he does what she asks then she complains that he only did it because “you're only, you know, because I asked you, you're only buying me flowers because I asked so it doesn't count, you're only taking me on a romantic date because I asked and so it doesn't count” and so no matter what he does it's never good enough because she's demanding, she's demanding a spontaneous behavior which is a double-blind. You cannot, you know, demand that somebody feel a certain way. That is actually, it makes no logical sense, and yet human beings do it all the time to each other especially in couples and families. So the therapeutic double bind would be uh, the directive would be he needs to do, initiate a new behavior, but he cannot, he cannot do what she's asking so that's the double-blind. So he needs to do something different, anything, but the one thing he cannot do is what she's asking for. So this puts him in a double-blind where if he does come up with a new romantic behavior that she didn't ask for he can win, and then if he does do what she asks for then it's very possible that it can be interpreted as “well you were told not to do it but you did it anyway” and so then it's of his own volition. And so it's less of a command because you've undone - you've kind of undermined her specific command. So by changing the context and what your command is - you put him, you create this therapeutic double-blind where no matter what he does it is something different that can have a new meaning in the system. So therapeutic double blinds are a little tricky to figure out when and how to use them, but to be clear, when nothing else seems to be working this will begin to make sense. And um, and like I said in the beginning, it's something that's harder to do in the moment but with more practice it becomes easier to understand how these work. And again it's another behavioral experiment. They go home you see how it works and you see what new meanings, new interactional patterns develop out of this. And then you adjust the following week if necessary. Another intervention that is sometimes used - it has again a paradoxical flavor, is what N/A they call, the dangers of improvement. So as couples, and families, or individuals start to get better um - beginning to have clients identify the potential problems that might arise as the problem is getting resolved or if the problem gets resolved. For example, when you're working with someone who has typically had a lot of drama and excitement in terms of their relational patterns and if they're coming and saying “we don't want to have conflict and drama.” Danger of improvement - so if you guys really have no conflict in this relationship might you become bored with that? Is that a possibility? What other things might happen if there's really no conflict? May the sex end, you know you're going to have the hot passionate make up sex. How might ending conflict in this relationship affect you guys and potentially in other ways? And this can have a very helpful way of helping a couple reframe what's going on, think about things differently and re-experience things differently. Another paradoxical technique that’s sometimes used in the MRI approach is called, restraining N/A or going slow. And so this is a directive that might be - as the changes start to happen - to restrain them you may want to take them - to slow down with all this, “you guys are making some big changes really fast.” And so what might be some of the dangers of this? This can work in several different ways. It can help them um, deal with setbacks in a more positive way. Again it can help them develop more realistic expectations. Again the family's going to make the meaning that they need to be making from that intervention, they're going to use that to reorganize and set their homeostasis or redefine homeostasis in more helpful ways. And again it helps them refrain the progress that they're having. And so now we're going to move on to talking about Milan's systemic therapy. And Milan's systemic therapy was developed by a team of four therapists in Milan who came and studied at the MRI Institute. And when they came back they really wanted to focus on implementing the cybernetic theories of Gregory Bateson as purely as possible. And so that was their mission. when they developed their systemic approach. So in a nutshell, the least you need to know about Milan. Um what you're going to notice about the Milan approach is that it's a much more language based approach, using a lot of reframing and circular questions. And they also refer to these interactional patterns as family games and we'll talk some more about that. And they use a lot of what's called, what they call positive connotation to reframe the symptoms. So they're very focused on looking for what is the positive spin on this. And they really focus on shifting family interactions by shifting what they call the family's epistemology and view of the problem. So epistemology is how do we know what we know? And so what they're trying to shift is the family's way of making meaning, and how they punctuate reality, what they focus on, and how they label things. So there's a lot of attention to the use of language. The Milan therapist actually became very closely aligned with some of the more postmodern social constructionist approaches. Which again are very focused on how we construct meaning and how we construct a reality through language. Juice. The juice. Significant contributions of the MRI approach. Circular questions. I think circular questions are some of the most wonderful systemic interventions. No matter what approach you work with, when working with couples, and families, or especially actually when working with individuals, and you're trying to understand their systemic dynamics that surround their symptoms, circular questions are just beautiful, simple, elegant. They're elegant because what you do is through this series a very non-confrontational, gentle, curious, open questions, you work with clients to explore the interactional dynamics, and also the meanings around those, and how people are interpreting and making sense - kind of identifying the underlying epistemology as they would say. And so, and again whenever I work with an individual I need to assess that interactional sequence of behaviors and so these types of circular questions are just invaluable. I use them very frequently. Oh it's beautiful though, not only are they assessment but they are also intervention. So as you have the family, or couple, or individual start answering these questions about the interactional sequences, and behaviors, and meanings, you don't need to confront anybody. Um, as you ask questions like, you know, “who do you think is the most depressed in the family,” each person talks and explores that. It becomes very clear that there are a lot of different realities and every - there's like multiple levels of reframing and recontextualizing things. And you're just simply asking curious questions and they're doing all the work for you. And so it is a very elegant, non-threatening, more simple than some of the other interventions you hear about such as directives and stuff. When we get to Jay Haley in part 2 of this lecture, some of his kind of outlandish directives you sometimes hear about for systemic therapies. This circular question is the very gentle and elegant um way to intervene and address these - as both assess and intervene at the same time - with these interactional, problem interactional dynamics. There are numerous different types of circular questions and so we're to go through some N/A of them here. One of the most basic is the behavioral sequence questions. So this is um, tracing the entire interactional sequence around whatever the presenting problem might be. So, when little Johnny gets mad what does dad do? And if the primary presenting issue is dad and little Johnny are fighting, one of the things that any good systemic therapist is going to do is ask “but what is mom and sister doing in the background?” “Is there anyone else who has got an opinion about what's going on?” “And so when little Johnny and daddy are arguing, what's mom doing, what's sister doing, what's going on, how do things get back to normal?” And you just ask all these different behavioral interactions sequence questions. Then there's behavioral difference. So for example, if a kid says “my mom's a nag.” You would ask “so what does it what does she do that makes you want to call her a nag?” And when you get the description - “and so how does your dad ask you to do things?” and “how how do you ask your mom to do things?” “How would your sister ask your mom?” “How does your sister ask your dad?” And so you just start asking all these questions. You're not sure what's gonna unfold, you're still kind of assessing but you're comparing. So um “how do you make a behavioral request?” “How does your dad make behavior requests of you?” How do you make a request of your dad, and your mom, and your sister and how's everyone doing it? And just by having these different descript - and everyone can even have a different opinion and it's totally fine. And as they start describing these things, the reframes, and the patterns - the family begins to see this. Or even if you're working with an individual, as you ask them to start comparing these different - you know, compare every left, right, center, in every which direction - even an individual begins to the patterns. And you're not having to confront them and that's what I love about these. Um there's also comparison and ranking questions and these can be incredibly enlightening. So comparing anything - so we're talking about depression -”who gets depressed the most often, or who's the most depressed, or who's who's the best listener, or who's the worst, least compliant with the parent?” And which situation - then you might want to change it. Some situations, so, regarding homework, “who is the most cooperative?” And regarding the house, helping around the house “who's the most cooperative at the holidays or whatever?” And then um, so those are really fun. And you can also have hypothetical circular questions. So, “if your mom ended up in the hospital who do you think would be the most helpful, who do you think would be most worried about her, who do you think would be the least worried, who do you think would be helping the most out around the house, who do you think would be doing the cooking, who do you think…?” Yeah so you would start asking these hypothetical questions where you begin to understand the logic of the system. Similar with before-and-after questions. So before - let's say dad goes on an alcoholic binge, “what's going on and what happens after, how is mom different, how is sister different, how are grandparents, how is dad before, how is dad after?” You ask all these before and after questions to begin to understand the logic and the meanings of the system. And of course you can do rankings in there and comparison. So you can just have tons of fun with this. But what you're doing is you're trying to track that interactional sequence and also the different meanings within the system and how they understand things and the logics of the system. And just depending on the client's presenting problem, you would ask whatever type of question. These are, as you can see endless and a ton of fun and extremely useful because while you're assessing they're simultaneously, there's an intervention usually going on, and the reframing - they're doing it for you. So the Millan team. The original Millan team began with Mara Palazzoli, Gianfranco Cecchin, Luigi Boscolo, and Guiliana Prata. And eventually the team kind of said - divided into the two females and the two males, with a Palazzoli Prata focusing a lot on the invariant prescription - we'll talk about that shortly - working with anorexic and schizophrenic families and doing more research. Where Cecchin and Boscolo developed more of the training element, focusing on developing a model and training folks in the model. I once had a conversation with a Gianfranco Cecchin about his work and one of the comments he said - “you know, we were really divided on economic lines because the men had to support families and the women didn't, and so we had to create an institute and do training to support our families and and the ladies got to stay and just focus on research because they didn't have to make money.” I always thought that was a very interesting comment. The big picture: an overview of treatment in Milan systemic therapy. Milan systemic therapy is frequently referred to as long-term brief therapy. N/A And basically they were working with people from all over Italy, and so typically the families would only come in once a month. And they were fine with this because their thought was that they're doing very complex interventions into systems and it can take a month for the changes, and for the interventions to have some effect. So once a month they would meet with the family. And the basic structure of the session was there'd be a pre session where they would hypothesize about what might be going on. They're very - Gianfranco and Luigi, were very famous for saying “we never want to marry our hypotheses.” Meaning, “we don't want to believe ourselves too much.” And they - they would develop these hypotheses and - but they would let go them as soon as they proved not to be correct. But they used this to help generate their interventions. They'd have a session. Then there'd be the intersession where they go meet with the team behind the mirror. They call the person in the session the conductor. And then they go in and deliver the intervention and then the team would have a discussion about how it went. And so typically it would take a year, and they would meet once a month. And so typically too - they were dealing with families with a child as a presenting problem and so they would typically spend the first couple of sessions kind of reframing the symptom. And and then typically by session three they would have the sessions only with the with the parents and they would typically shift this to focusing on the parents either as a couple, or for the parenting issues. And so that's typically the pattern that they had. Making connections: the therapeutic relationship in Milan therapy. N/A Two concepts that the Milan team really introduced to the field were the concepts of neutrality and multipartiality. And so they originally introduced the concept of neutrality, meaning that you're not taking sides with any of the family members on the problem, certainly not blaming they were very neutral. And they later redefined this as some people saw this as being non-emotional, not attached - which probably in the context of Italy - is not what was going on. Um, so they reframe this is multipartiality. So they're willing to take and honor all perspectives. So they were famous for saying, they're “hoping at the end of therapy everyone thought that each member of the family thought that the therapist was on their side” because they were able to show empathy for each person's perspective and understanding of and respect for each person's perspective. Which is a very important and difficult skill in couple and family therapy. And so, some other concepts they use to conceptualize their relationship. One was what they called therapeutic curiosity, and this is the sincere interest in hearing each person's perspective within the system. And so there was this kind of enthusiastic embrace and curiosity about how each person saw it. The other piece that they used is this concept of an aesthetic curiosity. And so they didn't believe that there was a singular truth about anyone or about what was going on. Instead they were curious about the emerging patterns. And so they were curious about the patterns, the aesthetics of the system, and how they morphed, and changed, and how the family, everyone, made meanings and interacted, and there was this curiosity for how the system emerged. Another concept that use they use to describe their later work is the concept of irreverence. And you can see this often in earlier tapes of Milan and other systemic therapists and a lot of people find this somewhat offensive in some ways. But I think there is a real art to what they were doing and to understanding what's going on here. Because irreverence really captures a therapist relationship to the problem not to the client. So no matter how horrific or terrible the family might think a particular situation is, the therapist - and this is true of all of the MRI strategic and Milan - one of the things, it's so hard to be able to do this therapeutic approach right, is they never buy into the fear that many people have around whatever the presenting problem is. There's a sort of like irreverence to it in a way that allows them to be creative. And so they don't see that, that there's a personality flaw or illness or unresolved childhood issues, but they really do believe that systems can be self-correcting and that there's this openness, this creativity, this willingness to play and be flexible that really is noteworthy. And so if you feel like, “oh my god this is terrible, this is horrible, no one can ever overcome this problem” - if a therapist comes to the situation like that there's not a lot hope let me tell you. And so this irreverence is this willingness to be creative, think outside the box, think outside the system, is really what that means here. And so the therapist never feels hopeless. And that's about the problems. You're not being rude to your clients but you aren't feeling prisoner to the problem which is a very common experience. Another thing that the Milan therapist emphasized, and this comes from their focus on trying to embody Bateson's work, is this unavoidable influence of the therapist. And so they really saw the role of the therapist as inherently affecting the system. And so they really tried to monitor and notice how they are affecting the family and the expression of the symptoms. And so they never saw themselves as the expert. Whatever hypothesis or interventions, they saw themselves as - if whatever they were doing was unhelpful um, then they were wrong not the family. And so they were very quick to - even when developing their own theories, to abandon any concept that didn't seem to be helpful or useful. So again, they're not the experts, but they're part of this system and what they're doing and seeing is - everything from a systemic perspective, everything you notice is a reflection of your epistemology not theirs. You're drawing the distinction that's coming from your constructions of the world, not necessarily theirs. And so it's understanding that all these descriptions, this hypothesis you've created, these theories you're coming up with, they're all about you and if they're not working or making the change that needs to happen, you need to change you before you can be helpful to them. The viewing: case conceptualization. So in terms of interactional sequences, the Milan team called these family games, and again this term doesn't really translate well into English because a game can have a connotation of manipulation. The intent is these are just the interactional patterns that create the homeostasis. And it's maybe, think of more playful games than manipulative games. But really, just maybe this is better translated into interactional sequences. And so these are, again, these are relational rules for how the family interacts, but they're not consciously created. They emerge naturally from family interaction patterns. So when you watch couples come together they - even from their very first interactions they begin to create their own micro little culture, and it is both influenced by their families of origins, but the two of them create their own thing. And so a lot of what those circular questions are designed to do is to help identify this interactional sequence or gain. So another thing that Millan therapist really focus on is how language is used, particularly descriptions of self and others, and how this shapes their reality, particularly their experience of the presenting problem. So they're very famous for turning all these adjectives like I am depressed, he's an angry person, and they change those into verbs - the person is doing depression, the person is doing anger - to highlight that there is choice in their behaviors and to make it less of a label and more of an action which is actually easier to shift. So much more subtle a concept here is what they call the family epistemology and epistemological errors. So this again comes out of the work of Gregory Bateson and they talk about family epistemology. And so epistemology is how we know what we know and when it's applied practically in family systems work it's looking at how the family quote/unquote punctuates events. So do you focus on, you know for example, a wife may come in and say he withdraws he doesn't show any attention to me, and the husband may say oh but she nags. And so that's how each one is - but I only nag because you withdraw, and I only withdraw because you nag, and the chicken and the egg. And so this is where the family therapist reframes and put those two dynamics, which each person is only describing half of it, into the larger system, kind of reframing it. So looking at that, those those epistemologies and how they frame things um is how one of the things that family therapists, Milan's systemic therapists, are how they're assessing what's going on in the family, and how they're making meaning, how are they interpreting a child's depression or tantrums. Are they defining it, you know, as “oh my god maybe my kids had his ADHD,” or “the kids having tantrums because his mother's not strict enough with him,” or them some others might say “he's having tantrums because you're too strict with him.” What kind of meanings are they making from all of this and how are they interpreting it? And so this is what they mean by the families epistemology. They're looking for epistemological errors which is where they're getting stuck. A common one is only focusing on how the other person's doing something wrong rather than on your half of the interactional sequence. Targeting change: goal setting in Milan therapy. So when developing goals, conceptualizing where this treatment is going to go, Milan systemic therapies really focus on making new meaning. So achieving some kind of new meaning so that the symptoms are no longer necessary. So they're looking at generating new meanings, new ways of punctuating things that are going on that changes the get “games” or interactional sequences within the family. So again, just like the MRI, they're not trying to literally fix or educate the family on how to behave and communicate better. And again, instead they're perturbing the system with new interpretations, new ways of framing things, and allowing the system to self correct itself. Again, from systemic - having a systemic assumption that the system will reorganize in a better way if you interrupt it. That those kind of default, you know, patterns - when you interrupt them people choose better interactions. And that's just what they trust, that dynamic, and that's what they're trying to do. Again similar to the MRI approach, there are no predefined goals based on health or ideas of family, or normal family functioning. The goals are just simply to reduce the symptoms by creating new international patterns. So the families can integrate new information, change its rules and the idea is for the family to be able to maintain stability and cohesion as a family system without having the problem symptoms. Again, very similar to the MRI approach and again, there's no norm there, so again this is going to allow it to be a little more flexible across cultures. The doing: Interventions in Milan systemic therapy. So in terms of intervening, a lot of the intervention process is built around the hypothesizing process. And they're really two phases. One is hypothesizing for conceptualization, and this is typically done behind the mirror with the team talking to one another to come up with a hypothesis in that pre session we talked about earlier. Then there's hypothesizing as an intervention and so from - as they have this hypothesis, they interview the family using circular questions, and then they can deliver a hypotheses as an intervention. And typically - we're going to talk about this in the next slide I believe - they're going to hypothesise upon it with a positive connotation. But there are three types of hypotheses typically. One is about alliances, who's on whose team. Another hypothesis is about myths, family myths, and premises that - so I believe you're working with the myth that fathers knows best and they may hypothesize around that. Or they may have a hypothesis that's analyzing communication patterns. And so these are the things they're going to focus on when they deliver that intervention as to what's going on, what's the role of the symptom, um in this family. So positive connotation. It's the Milan style reframe. So again this is very similar, it is a form of systemic reframing but the Milan team always used a positive. So that's interpreting the behavior of each member of the family positively. And they're really focusing and emphasizing the benevolent motivation of each person. So reframing a child's problematic behavior is a way to keep the parents um is one way that they would reframe that. They would similarly reframe the parents behavior as an expression of their love and caring for the child. And so this is - the emphasis is that the therapist is always viewing the family members with less judgment and with greater hope. Reframing the wife's nagging as her way of trying to connect with her husband, and the husband's withdrawal as his way - he's trying to establish his independence within the relationship or whatever it might be. And so you would find ways to - whatever is going on, you're going to find a positive reframe for each person's role as much as possible. So as we talked about earlier, circular questions are like the bread and butter of Milan therapy. They are used to both assess and do intervention because it naturally, and in a very gentle way, and very organically reframes and puts everything in the broader systemic context for the individual, couple, or family. Counter paradox is very much like the therapeutic double bind or what's called symptom prescription, where you're telling the family not to change. And so you might tell a child in a particular family - it might be - “maybe you need to keep being very depressed, because if you're not depressed and your parents - your mom might become depressed, or your parents might argue more, or their marriage might be - maybe it's just better if you stay a little bit depressed because it's better for the whole family, we really appreciate the personal sacrifice you're making to do this.” And again this is done thoughtfully, carefully. You don't do this with every symptom or every client. With certain problems and family dynamics, this is the type of intervention, again, that begins to make sense. And so this is frequently used when families are uncooperative with more direct interventions. And you will know, I promise you. You will have a moment if you work with couples, and families, or even individuals when paradox is the only logical solution and that's when you do it. So don't randomly try to just - you know, maybe I'll go try paradox today - you will know when the system is so resistant to change that prescribing the symptom - and that automatically recontextualizes. So when you prescribed the symptom, the context changes. You cannot do the symptom in the same way again, and no longer has the same meaning and something is going to change. And so there are times where this is the most effective intervention and the only one that's going to help people get help and get people unstuck. So rituals are a type of behavioral prescription used in Milan. These are assignments that would address double binds and these are used to help shift meaning. So things like, the rituals are used to create conflicting directives in the sequence. Um, a good example here is a woman who was caught between her husband and a child. They asked her to act as a wife on odd days of the week and as a mother on even days and then be spontaneous on your seventh day. And again this little experiment and directive, highlights those family dynamics that no one, that people, that's not being acknowledged within the system. And there's no way you cannot not behave differently and it becomes much clearer what the dynamics are - kind of wakes people up out of their patterns and allows them to choose a different behavior. And however the family responds to this, it doesn't really matter from one perspective, that information is taken in and they use that to refine their understanding of the family epistemology, the family interactional sequences, and they will refine their hypothesis, and with that develop another intervention. And again, just like MRI, each week you take the feedback back from the system, you use that to refine your hypotheses, and then you deliver another intervention and see what happens. And so it's very much, a very organic process, until the symptoms are no longer necessary or part of the family homeostasis. The invariant prescription is a classic Milan intervention that is specifically designed to sever covert coalition's between a parent and a child. And so this is when you see that there's an alliance between a parent and a child. They called it invariant because you could use this with virtually every family and it seemed to work. Basically what the idea here is, is that you create a secret between the parents and you let the kids know that there is a secret. And this ends any inappropriate coalition's where one child feels - “oh yeah i’m mom's confidant.” When that child learns that she and dad now have secrets that she's not part of it, it severs that and allows the subsystems to - the parents and the children to have more healthy boundaries and alliances. And so this is a very quick way to seperate. So you can have the couple go on secret outings. The kids - “we just can't tell you why we need to be gone for the next two to four hours.” It actually doesn't matter what they're doing. They could be shopping for furniture or going on a hot date. Doesn't matter, as long as the kids - as long as there is a secret between the two parents. And so the emphasis is on creating secrets between the parents and a very clear division between the parents and the child. This often helps with, in situations where the children are having - where there's a coalition or children acting out and there's an alliance between the two parents, I mean between a parent and a child. Tapestry weaving: applications of systemic approaches with diverse populations. So then systemic approaches as you may have noticed, don't have theories of health or normalcy. This makes it easier to apply across cultures because you're not trying to say - this is a family structure, a healthy family structure, and everyone needs to look like this. So it can be much more adaptable because it works very much from within the client's worldview. It uses their language, I mean it's not imposing a theory of health or an appropriate way to be a family. So systemic approaches have been used also with adolescents coming out to their families. It's important to know that gay, and lesbian, bisexual, and transgendered, youth have much higher rates of suicidal ideation, substance abuse, self-harm, depression, and anxiety. I mean it's very important to consider these safety issues with them. It's also interesting that most adolescents are actually able to accurately predict their parents' response to their coming out. And so it's important to discuss this and prepare for this. There's several models for how to work systematically with adolescents in the coming-out process with their families. Systemic approaches actually have a growing research base on the effectiveness. Specifically there are several evidence-based systemic models that are particularly good for working with conduct disorder, teen substance abuse. In fact all of the evidence-based models that address conduct disorder, substance abuse, and teen substance abuse are based on systemic therapies. So it's exciting to see the research coming out and there's definitely a lot of systemic research even for adults and substance abuse. In terms of severe mental illness, there are many systemic based approaches that do have a strong evidence base. Some of the models are listed here. So to sum up part 1 of this systemic online lecture. The MRI approach and the Milan systemic approach. They are both distinct and yet share a lot of overlapping characteristics. They both are focusing on how to perturb or interrupt the interactional sequence. In MRI they're really focusing on the attempted solution. Where in Milan they're focusing more on the meanings that are being made, the family epistemological error. Their interventions are much more language based where in the MRI they're more behavioral based. And yet the underlying fundamental conceptualizations are quite similar. And so in part 2 we're going to discuss strategic family therapy.