Strategic Therapy: Systemic Therapies Part II

Hi. This is Dr. Diane Gehart, and this is my lecture on Systemic Therapies, part 2. This lecture covers strategic therapy, and the first lecture covered the MRI and Milan systemic approaches. These lectures go with my textbooks-- Mastering Competencies in Family Therapy as well as Theory and Treatment Planning in Family Therapy. Strategic therapy was developed by Jay Haley and Cloe Madanes. And Jay Haley actually started and was one of the original researchers at the MRI Institute. So his approach is-- you'll see many similarities between the strategic and the MRI approach, but there are some notable differences. And we're not going to get into a lot of history here. But if you're curious, I will let you know he actually carpooled with Salvador Minuchin for a while. And Minuchin, as you probably know or will soon know if you're reading the book, is the person who developed structural family therapy. And so the exchange between these two in their daily carpooling-- it's amazing how life shapes us and the synchronicity sometimes-- influenced a lot of Haley's work. And then also, Jay Haley had a significant disagreement with Gregory Bateson about the concept of power. And I could probably do a six-hour lecture on those theories. But if you're curious, you can certainly research that more. And we will talk some about power. I guess in a nutshell, Gregory Bateson felt like that was an epistemological error to talk about power, and that distinction blurs the systemic interactions and understanding of that, where Haley thought it was a useful concept. And he did use the concept of power in conceptualizing clients. So these are some of the similarities between the strategic and MRI. They are both grounded in general systems theories, similar to the Milan, also. That's why all three of these are very similar. They are all relatively brief therapy approaches. And some of the unique things about strategic is the conceptualization pieces, and we'll go into detail, as well as his particular way he delivered behavioral prescriptions that he called directives. And we'll talk a lot about that today. And so those are some of the main differences we're going to see when we look at these different approaches. But fundamentally, primarily focusing on the systemic interaction pattern, finding a way to intervene in that systemic interaction pattern, you can see that across all three of these different systemic approaches. And we'll also see them in the newer contemporary family therapy approaches, such as emotionally-focused therapy as well as functional family therapy. We'll also see it in cognitive behavioral therapy. Family therapists do it also. So it's really fundamental. And for the MRI, strategic, and Milan approaches, it's really the heart of what they're doing. The juice of strategic therapy-- significant contributions to the field. One of the most distinctive features of strategic therapy are the strategic directives. And these are actually much harder to understand than they maybe appear like at the beginning. Because basically, directives are directions for the family to complete a very specific task. But these tasks are not linear, logical corrections to the presenting problem. That would be closer to what cognitive behavioral family therapists do. So a kid comes in with tantrums. Typically, in strategic therapy, the directive would not be to go home and use some behavioral consequences to manage those tantrums. That's not what a directive is in strategic therapy. And that's a really hard concept, I think, to get, and it is a very complex theory in many ways. Because it's not necessarily surface level, linear logic. . It's systemic logic. And that's much more subtle and less intuitive. So if you listen to the first part of the lecture-- hopefully, you did-- if you didn't, we're going to do a quick crash course here on systemic interaction cycles. But basically, systemic therapists conceptualize the problem not as an individual is having tantrums or depression or even conflict. But instead, they look at the international behavior sequences around the behavior. And they look not just at the main players, but all the other players who may be withdrawing or not involved or quietly disappearing while the parents erupt into arguments. That look at everyone who's in the family system's behavior related to whatever that presenting problem is. So for example, if the presenting problem is that the father and son are constantly arguing, the therapist will be equally curious about what's the mother's role in all that arguing and what are the roles of the other siblings in that argument. And again, a strategic directive is not logical generally. Because what they're doing is they are interrupting that problem interactional sequence. Because generally-- Haley was very direct about this-- generally, if good advice would solve the problem, then most people wouldn't actually come to therapy for that. So if he believes that if he can just sit down and try to tell the father, if you just speak this way, your son will not have tantrums and will obey you-- if the problem was that simple, two-dimensional, they would have figured that out and they would not be dragging themselves to a therapist's office. Most people, by the time they get to a therapist's office, it's a much more complex problem. And he does say if straightforward, simple advice-giving directives-- I would call them more the cognitive behavioral, educate them on a better way to do things-- if that works, do it. But he says that for him in his, practice, he said that 95% of the time, they need a more systemic directive. Because if you think about it, it's very hard for all of us to change patterns, and especially with how we behave in our families and in our relationships. Those are much more difficult patterns to change. And so what systemic therapists do-- because they know rarely does good advice and simply educate them and tell them what to do-- most people actually know what to do. If you ask your clients, often they will be able to describe the logical situation, but they can't get themselves to do it on a regular enough basis to manage the problem. So what systemic family therapists do is they interrupt that negative interactional sequence in some way. And it's often not a logical way or could seem silly. One of the classic interventions to interrupt the problem interactional sequence is to-- for a couple that's arguing, you would have them sit fully clothed in the bathtub and then have another one sit fully clothed on the toilet and have their argument there. That comes out of the MRI literature. Haley talked about doing things that would be very symbolic. So for example, if one child is colluding with another parent, every time that child colludes with the parent in an argument, the parent would be given the task to give that child a dime for taking their side against the other one. Very symbolic metaphor there in terms of pointing out that dynamic to interrupt the behavioral sequence. Another thing that Haley did was for couples arguing a lot-- and this was a couple he was working with that had a very-- how should we say this-- lawyer-like approach to how they would debate-- he would have them set up-- you can have your argument, but you're going to set up your room as a court room, and set up the room up that way. And/or to use hats to symbolize different roles, and/or hats just to be silly and get people out of their rut. So directives are not logical solutions to the problem. They are things that are going to interrupt the family. They might have the reserve to do one little thing different that's not really a solution, but to just trip them up. Because what happens is when you interrupt those negative interactional sequences that we have, most people wake up, and they have to do something different. And in doing that something different, almost every time, we choose a better behavior than our rut bad habit choices. And so what you're doing is you're waking people up out of their habitual interactional patterns. You're finding some place in that cycle that you can interrupt what's going on and that the system is going to reorganize. Each person is going to have to do something different because of this slight interruption into the pattern. And so these are often much more doable than educating parents on a whole new way of parenting or couples in a whole new way of relating. Instead, what you're going to do is interrupt their pattern and allow them to self- organize in a way that makes sense for them that's going to be much more easily sustainable. And this is why it's so brief, the therapy, because you're not trying to get the couple to communicate in a new and different way. You're not trying to get parents to parent in a totally new and different way according to your own theory. Instead, you're just going to interrupt what they're doing and know that that system is going to reorganize in a new way that allows them to find a family homeostasis and balance that doesn't require the symptom or problem. The big picture-- an overview of treatment. So strategic therapy is a brief therapy that has five formal stages. The first stage, the social stage, is an interesting one, because it's an important one. And what Jay Haley talks about for the social stage is that you need to make the clients feel comfortable. And Jay Haley was one of the first therapists to actually advocate for normal, chit-chat conversation, such as, did you have trouble finding the place, how are you doing today. But in a much more-- engaging them like they are normal people, not in a more traditional psychodynamic or even humanistic way, which is directly getting into emotional processing. If you've ever been to therapy, this probably makes sense, but it's pretty overwhelming to see a therapist for the first time-- I would think especially Jay Haley. So he did spend some time just getting to know the people as people using social courtesy, using everyday conversation. Then you move into what brings you here today, and you get into the problem stage, where you begin to have them describe the problem. And next, you get to the interaction stage, where you have them describe the interactional patterns. So you're tracing the interactional sequences. And sometimes, you would even have them demonstrate this in session. Then you get to the goal-setting stage. What are they hoping for? And then you do the task stage. So even at the end of the first intake session, the family is given a directive or some sort of task to go home and work with. And so in each week, then, when they come back, you begin with how did your homework go. And based on that, they'll develop a new task and revise their hypothesis, similar to what they do in the Milan approach, and send them home with another task. Haley also emphasized that the first phone contact is actually a very important beginning point of therapy, and that the initial interview actually begins with that first phone contact. Again, this was a novel idea at the time that he presented it. And I guess for some, it still is novel. But you gather information in a matter-of-fact way and ask about all the members of the household. And you do invite them to all come for the initial appointment, whether or not they are directly part of the presenting problem. And so this very first contact sets the stage for working interactionally, working systemically, and also begins the assessment process. The therapeutic relationship in strategic family therapy. The role of the therapist in strategic family therapy can be very difficult to understand. I even admit-- when I first saw Haley work, I was a little bit horrified, in some ways, to be quite honest. He seemed kind of abrupt and harsh compared to what I expected a therapist to be in my mind. And I'll be honest-- I really didn't get him until I started working with a difficult family. And I remember going, oh, this is why he did what he did. And there probably will be a day where you're sitting with a family, and maybe you'll remember this lecture. If you do get to see any of the original interviews with Jay Haley and some of his early work, you may not be overwhelmed or impressed. But I promise you at a certain point in your career, you will be sitting with a family, and all of a sudden, this will not seem-- I guess for me, he was very manipulative, actually, instead of harsh and gruff. The truth is, the strategic part and the manipulative part was upsetting to me when I first started thinking about working with clients. And I probably had a very idealistic view of what that might be like. I think the more you work with various families, his concepts make more sense. So one of his main concepts is this concept of strategic positioning. And he basically maintains that the therapist's role shifts depending on the client's need. Haley was very famous for saying, if I do something that upsets the family, if I become the bad guy to the family, and they unite and solve their problems, I don't need them to like me. I need to be helpful to them. And I'm willing to sacrifice being the good guy and the hero and having that sense of accomplishment in order for the family to address whatever they came to therapy for. And so a strategic therapist is always thinking about what type of response from me is going to be most likely to promote change for this family. And so some of the commonly used positions is social courtesy, which I mentioned a little earlier. It's being a very courteous and social in very common, everyday social ways-- how's the weather, talking about sports, those sorts of things. Haley would use that if it's going to make the family feel comfortable and do the task that they need to do. He's good with that. Another position he would take is a one down position-- like wow, this is such a serious problem. I don't know if I can help you. Or maybe this isn't something that can be changed. If he felt that taking that type of role would stimulate in the family this, oh no, no, we can try harder. We'll do the assignment next week. Or no, I'm not giving up on my son. You can't give up on my son. And they become the one who's more hopeful than the therapist. He would take whatever position it would take to be useful to the client. And again, the more complex and difficult your cases are, the more this type of positioning makes sense. Case conceptualisation in strategic family therapy. So similar to the MRI and Milan, strategic family therapy really focuses on the international sequence of behaviors between all members of the family system. So again, not just the main players, like it might be one parent and one child, or sometimes it's one child and the rest of the family, or it could be the couple. But they would look at the interactional sequence with everyone who's involved, even the quiet members of the team, or sometimes the in-laws or parents for a couple, or friends can have significant roles in the international sequence. The couple has an argument, and the people that the couple are confiding in are actually making the problem worse. So these are things that systemic family therapists would assess. But what's unique and strategic is how they make sense of this. They have five basic ways they like to think about a problem. One is involuntary versus voluntary. So is the symptom voluntary or involuntary or some of both? Looking at helplessness versus power-- who might be helpless, who has power? Looking at metaphorical versus literal meanings of symptoms, looking at hierarchy versus equality, and also looking at hostility versus love. For example, when we're looking at parent-child interaction sequences in terms of making sense of what's going on, often you can frame it as one person is trying to establish a hierarchy or seeing the relationship as more hierarchical where another person is wanting more equality or seeing it is a more equal relationship. And so you can frame each person's behaviors based on one of these ways. So you could see a parent with a child conflict. They parent may be trying to establish a certain amount of hierarchy where the child is trying to establish more equality. So looking at that, you can also look at dynamics of helplessness versus power within a problematic family and couple interactions, and even for individuals and their whole interactional sequences. And especially later on, they will frame a lot of what they are seeing in a family in terms of each person trying to love the other in some way or another. And so you can frame a parent's harsh punishments or consequences as their way of trying to show love in terms of teaching the child to make good decisions. And you can frame the dynamics that way. And you can frame even the child's refusal to do that as trying to focus more on connecting with the parents or by reframing it in this way. Again, using a systemic reframing, you can help the family or couple to see the interactions in a new and different way, and therefore inform new ways of relating to each other. As I mentioned, Jay Haley and Salvador Minuchin carpooled for a while, and there was some sharing of ideas. And one of the places we see that is in case conceptualization in strategic therapy brings in some elements that are used frequently, also in structural. And so like Minuchin, Haley uses stages of the family life cycle to conceptualize why a family might be stuck. And so the basic stages of the family life cycle-- and there are several different models with variations on this-- there is birth in infancy, early childhood, school age children, adolescence, leaving home and launching. There's also the process of becoming a parent, a grandparent, old age. And you can, of course, have divorce and remarriage as part of that. And so when conceptualizing the interactional problems and the relational problems going on in a family system, strategic therapists think a lot about how the family might be struggling with a transition to a new stage. Because with each stage of the family life cycle, there is a renegotiation of independence and interdependence. So for example, when children transition to school age, children become more independent. And so the whole family pattern of interdependence gets shifted a little bit. And so the parents have to allow the children to have more independence to successfully transition to school age to allow those kids to experiment with various degrees of independence. For example, when I work with families, one of my goals is always by the time a kid is in eighth grade, they should be able to do their homework, turn it in, manage all their school life without any intervention on the part of the parent. Now, of course, in kindergarten, the parent is going to likely need to help them. But if the parent keeps being as involved with homework all the way through eighth grade, that eighth grader is not going to be able to manage their own homework. And so to make that happen, to have that transition happen, the parent has to let the child experiment with deciding when they're going to do their homework and experiment with keeping track of what homework needs to be turned in when, experiment with how to study for exams. And so the parent has to mentor the child into that independence. And if that doesn't happen, you will definitely see problems in the family organization. And so similarly, the parents need to become a little more independent from those early childhood years where almost every moment is focused on taking care of the children. The parents have to get a life, too. And that's very important. They're not going to be ready for that kid to launch if the parent's entire life is organized around the child and their activities and their friends and their needs. And so conversely, with the birth of a child-- I've worked with a lot of people who weren't quite ready to understand how you lose so much of your independence that you had as a single adult, as a couple. Radical transition. And so that's another major transition that families can get stuck there, too. And so Haley uses this to conceptualize what might be going on and where they maybe didn't reorganize the family norms and homeostasis for the developmental needs. And of course, when you throw in things like divorce and remarriage, it becomes much more complex. Because that depends on a whole range of factors as to what's a healthy way to go through a divorce and/or to reorganize a family after remarriage. So as I mentioned earlier, one of the main concepts that Haley used to conceptualize family interactions is the concept of power and hierarchy. And we'll hear the term of hierarchy when we go to the lecture on Minuchin also. And so family hierarchy looks at who has influence and in what arenas. And what's healthy and normal depends very much on the family. Cultural norms, very much influence what a healthy family hierarchy should look like. And of course, based on the family life cycle, as we're just talking about, it changes frequently what that should look like based on the ages of the children. And so when observing a family and observing family interactions, Haley is looking at who has influence and how is power moving through the system. And so he looks both at who's pretending or seems to have power and then who actually has power. Because you can have family members who seem to be having a lot of influence by the way they're talking, but when you watch at who actually listens to whom and when and how, you may be surprised to learn that the person who looks like they have the most power actually has less. And so when working with couples and families, what you're looking for is typically-- especially with parents and children-- you're looking at the effectiveness of the parent to set consequences, limits, and influence on their children. And again, this totally varies by culture as well as age, what's healthy, normal, and appropriate. And I like to joke that about 90% compliance is somewhere in the healthy range. Because it's also possible for a parent to have too much power, too much influence. I actually worry a little bit if a child is listening and never defies a single request the parent makes ever, then I worry that there is too much parental hierarchy. The child isn't learning to become independent enough and isn't stretching and growing. And so it's important to really assess what's going on. Again, cultural norms play a huge role here. And so across different cultures, various forms of hierarchy can be appropriate and normal. There's a range. It's not like your child is 6, and so because your child is 6, they should be obeying you this much. You should have this much control over your child. Obviously, it's a much more flexible and fluid process. And so what family therapists are looking for is, is there sufficient hierarchy so that there isn't some kind of symptom-- whether it be depression, anxiety, conflict-- in that family system for any of its members. And so it's very subtle. Another thing that's really important to remember is that the therapist's own gender and cultural background and socioeconomic class background play a huge role as to whether or not when we're watching another family, our family in our session, whether we judge it to be a sufficient hierarchy or not. And so we have a lot of our own cultural norms that we have grown up with that are in our head as to what it should look like. And so it's very important to step back and ask, is the current family structure causing symptoms in the family? Then it's a problem. And to avoid using as much as possible our own social cultural gender norms. And so it's a very subtle thing, but that's how Haley conceptualized the interactions in families, is very much through how is power moving and flowing. Sometimes, especially in traditional families, you will see that even though they may talk about the father being the head of the house, the mother, the homemaker, can have significant power about certain realms within the house. And within certain cultures, this is very standard. It's well recognized that the wife, the mother is going to make decisions around x, y, and z, and the husband and the father are going to make decisions around a, b, and c. That's how it works here. And so it's not like one person has control of everything. You want to look at where people have power and how they use it. And so more recent developments in strategic therapy are focused on what they call strategic humanism. And strategic therapists, especially in the early days, were known for being a little bit out there, not necessarily the warmest, fuzziest. And more recently, though, later developments, there is really an emphasis on emphasizing the family's ability to love and nurture rather than focusing on the domination and control. So when they're conceptualizing, especially when they may be delivering the hypothesis to the family, they will talk about how each person in the family is trying to love and nurture the other, and that these attempts aren't working. And how can we find ways to interrupt these problematic cycles rather than focusing on and describing people's behavior in terms of a desire to control, dominate, or have power? And so again, the case conceptualization is framed more in terms of the family's unsuccessful attempts to show love rather than their unsuccessful attempts to control one another. And so they've softened up over the years. You'll see the same from many of the other traditional family therapists. And I think it's just a reflection of the development of even American culture-- that the therapy models are changing, too. And so if you do see some of the earlier videos and you're like, oh my god, I can't believe he just said that-- it's true. As our culture has shifted and you can see some of these changes, the therapy models are changing, too, to be a little bit softer in their delivery. So next, we're going to talk about goal setting, targeting change in strategic family therapy. So like the other two systemic theories we've covered-- MRI and Milan-- there is no predefined set of long-term goals, normal family functioning in strategic therapy either. And so the focus really is to have the family develop a new set of normal behaviors, homeostatic behaviors, that do not require any member of the system to have symptoms. And so this makes it much more culturally friendly, especially if the therapist can refrain from putting on their own social culture class norms onto the family, that it's very much about how do we get the family to redefine their homeostasis. And again, the therapist is not redefining them or teaching them how to have a healthier family structure. That is not strategic therapy whatsoever. That's much more in line with what would happen in CBT or even a Satir approach, which there are other lectures on that. Instead, what we're trying to do is interrupt the family-- homeostasis-- perturb the system, shake it up, so they have to do something different, knowing that each time you interrupt the rut that they're inn, they're almost inevitably going to choose better behaviors and organically from within redefine a healthy norm for them. So some of the common ways that strategic goals are achieved-- one would be to correct the hierarchy, rebalance the hierarchy, either within the couple or within the family. One other way is to reduce the intrusiveness of one person or to increase engagement between two people who are too distant. In strategic therapy, reuniting family members, even outside the nuclear family, can be very important in one of the goals. Another way to approach change is to change who is helpful and/or how a person is helpful to others. So very often-- for example, if you have a parent who has been, for lack of a better term, micromanaging their kids' homework, let's say, in middle school-- so changing how the parent becomes helpful and shifting that to more mentoring them to learn how to be independent with their homework would be an example of how to put together that strategic goal. They also do address repenting an injustice and forgiveness within a family when there have been serious transgressions between members. And also, another type of goal could be increasing the expression of compassion or unity within the family. So now we're going to talk about the doing-- the interventions in strategic family therapy. And again, these are a very subtle set of interventions. I think they don't make a whole lot of sense until you work with a family that doesn't respond well to just direct, linear instructions on, hey, you can improve your parenting or your couple relationship in this way, and they don't respond to that. And these interventions I think, make more sense after you've spent some time with some more challenging couples or families. So we talked a little bit about directives in the beginning. We're going to talk more, because it really is, in many ways, the primary intervention. So again, directives are behavioral tasks given to clients, usually between session, to alter their interaction patterns. And so you have more straightforward directives. When the therapist does have more power to influence people and to get them to do what is asked, you can use more straightforward directives, where indirect directives are used wen the therapist has less authority with the client. And so these may be more paradoxical and/or metaphorical tasks. And so in this case, it's a way for dealing with clients who are not wanting to do or not responding well to the straightforward directives. You generally would start out with the straightforward and move to interact typically, unless it's really clear that the client is pretty resistant from the beginning. So straightforward directives would be used with a family or couple or even an individual where the therapist thinks that they will try to follow through on what is asked. So this is the process. First, you assess the situation. You don't come up with these things without really assessing the systemic dynamics of what's going on. And then you target a small sequence to change. And so for example, let's say you have a mother who seems to be micromanaging her seventh grader on homework. Let's just have that be our little case scenario here. So you're going to look at this interaction-- the mother asked her son to do homework. He keeps playing a video game. He ignores her the first two or three times. Then she asks him again. He gives back now a snarky remark, so she gets more angry-- so you're assessing this whole sequence-- until she gets into a tirade, and then she takes his iPad away. And then he gets angry. She sends him to his room. And then after whatever, 10 minute timeout, he finally comes down and he start his homework. And then they micromanage that all night. And so that's how it goes. And then he might forget to turn it into the teacher. And then you come in and see, what's dad's role in watching all this, and what's the sister's role. And so you would track all of this. So maybe Dad comes home and adds to the lecture, but really looks like he's supporting mom, but really doesn't do anything to back her up practically. Never really enforces. Meanwhile, the younger sister is the perfect child, because she's sitting there doing her homework the whole time the brother and the mother are arguing. So that's a little sequence. Let's say that's it. So maybe in all of this, what is one small thing in this sequence they can do better? So one small thing the mother can do differently is to instead of maybe virtually give her son the reminder, she can text it since he's on that iPad. She can send him a message. So you're not telling her how to repair it and set new consequences. So you're going to let them do most of what they naturally do, but you're just going to tweak it. So you can try, why don't you text him a little message to remind him that it's time to do homework and see how that goes? You could do a more metaphorical thing where every time she comes to remind him, he needs to be sucking his thumb. This would highlight some of what's going on after if you've determined that the kid is capable of far more independence. The kid doesn't have enough independence for his age. So sucking his thumb could be a metaphorical way of reminding both him and his mother that he is acting younger than he should be for his age. So they're allowed to have the same interaction. The only difference is whenever she's telling him that he needs to do that, he needs to suck his thumb, or something else that reminds them of the roles that may symbolize that. You could also have the father come in and also do something where he responds in some kind of different way-- not to practically change things, but to also symbolize that he's kind of powerless and not supporting anyone in this. And so you come up with some very precise, doable instructions for the directive. And so you would take them to that whole little sequence and describe what piece is going to change and what exactly they need to do. And depending on the situation, you may need to go through weekday versions of this and weekend versions or whatever the problem might be. You review the task, you have them repeat it back to you, you get them agreed to do it. And then it's very critical that when they come to the next session, you ask for a report on how all that went. And based on whether or not they do it, you develop another intervention to see what happened. And again, when you ask for the task report, you just-- well, it worked or it didn't. That's not a task report. So you're like, so, Mom, did you send him the text message without using words? Son, is that true? And then what did the son do? Did he text back, Mom, I'll get to it in whatever, two minutes or five minutes, or he did nothing? And how did Mom respond to that? And so you track the whole new interactional sequence. How was dad? How was little Susie? Was anyone different? You track everyone. You reassess the entire interactional sequence. And based on that, you develop a hypothesis of shifted, what didn't, what worked, what didn't, and you've got to figure out. And that's one of the things tat strategic therapists-- you can fault them if you want to fault them for a lot of things. One thing they do do is they take full responsibility for promoting change. And so if they came up with a directive that didn't promote change, then it's their assessment that needs to be revised, not tat the family is bad. So it's the therapist's job to keep developing tasks that they will do and that will promote change. So indirect directives are typically a form of paradoxical intervention. And these are very classic and used frequently in family therapy. And if it seems a little cruel, as I said, when you work with certain families, you will quickly come to realize why this is always considered an option in systemic family therapy. Because the logic of certain family systems is so resistant to change, because the family homeostasis is keeping it stable. And so oftentimes, trying to change that is very destructive to multiple people in the system, often people who are not symptomatic in the moment. And so if you get, let's say, little Johnny to start doing his homework, you might actually create-- inadvertently, not intentionally, but within the system, there might be a lot more trouble that erupts in the marriage. And that, for most systems, is the worst thing and the most destabilizing thing. So you are very aware that that's why family systems don't often change so easily. And so when you work with families long enough, the paradox will one day make sense. And you'll be sitting there going, oh, this is why they weren't evil, cruel, bad people. They were working with really complex systems that had very complex homeostasis going on. And again, don't try this without knowing what you're doing under good supervision. Because again, it's not necessarily something-- you shouldn't be using this with suicidal clients, domestic violence. You're not prescribing the symptom in that case. But paradoxical interventions are when you prescribe the symptom to the family in a new context. So you're not just prescribing this symptom to be snarky and rude. You're doing it with a new context so they can no longer do the same old behavior. Even if they do the same old behavior-- like they can't, quote unquote, change-- because there's a new context, it all has new meaning. So they can no longer do the same old behavior, because you in therapy have shifted the meaning of what that means. And so what happens with symptom prescription is you're instructing the couple, family, or individual to do the symptom, but you're changing the meaning of it. So you've changed the context of the behavior. It can no longer be experienced in the exact same way again. For example, a common symptom prescription is to set a time for couples to argue. So on Tuesday, Thursdays, and Saturdays, we want you arguing between 7:00 and 7:30 PM, and please set a timer. And so by prescribing the arguing-- it's really actually hard. Most couples find this very difficult. OK, it's 7 o'clock. You need to start an argument. And so as the person sits there going, how do I start an argument, they will have this whole new internal dialogue and whole new level of awareness of how they are participating in this interaction and how they create it, how they sustain it. And so that insight changes the whole meaning. And it's very hard for them to engage in that same problem behavior in the same way. Something is going to have to shift. Similarly, you will see a lot of paradox used with clients who claim that they have uncontrollable symptoms. Jay Haley and Erickson, his mentor, worked a lot with people with a lot of uncontrollable anxiety and similar types of symptoms. So for example, worry, you'll see paradox used quite a bit with worry and anxiety symptoms or panic or whatever it is. You would prescribe the person to worry. I want you to worry every morning before you leave for work. I want you to set aside five minutes, and I want you to sit there and do your daily worry session. And again, when a person sits down to worry for their prescribed five minutes, there's this initial, OK, so how do I start my worrying process. And you watch your mind do that. And then you're like, well, how do I keep it going? I've got to keep going. I have two more minutes left of worrying. How can worry some more? So in that process, you're changing the context. They can no longer do the behavior that they claim they have no control over. It no longer has the same meaning, and they have to relate to it differently. Something is going to shift. And so you see how they do with this intervention. You follow up on the next week. And based on that, you would revise it until the symptom is no longer a problem. So indirect directives. There are some other forms of these two. Some are more metaphorical tasks, maybe when it's not appropriate to explicitly address a problem. For example, if a family of origin or a deceased person is having way too much influence over what's going on in the family, you could do something like even blow a huge picture and make it central, putting up a picture of someone who is deceased and maybe upsetting the family or the couple in a prominent place in the house to create this place to honor them, but also highlighting how it's inappropriate that they're taking up however much space they're taking up. Another interesting one that strategic therapists use is called pretend techniques, which is literally fake it till you make it, basically. And so sometimes, depending on the situation, a strategic therapist will prescribe that couple or family pretend to be more loving, more understanding, more whatever it might be in order to fake it till you make it. One of my favorite strategic concepts is what they call ordeal therapy. And ordeals are used when the client feels absolutely helpless in controlling symptoms. And so this is often used with anxiety or compulsive types of behaviors or with bad habits that a person wants to stop. And the ordeals don't actually even have to be logical. It doesn't have to be logical. OK, if you're trying to lose weight and you want to go have ice cream, break your diet, then you're going to go exercise for 30 minutes beforehand. That's not the idea here. The idea is to put something-- if you were going to go over eat to deal with your anxiety, that you're going to clean the house or balance your checkbook or just do something. Again, you're interrupting the pattern of behavior. That's what ordeals are doing. They're looking at what's the interactional sequence-- for example, someone who cuts. Ordeal therapy will be like, so you want to cut. If you're going to decide you really are going to cut yourself today, then you need to do something before you do that. And so it doesn't have to be a logical thing that's going to encourage them not to cut, like you're going to meditate for 15 minutes, practice mindfulness before you cut. That's going to be your ordeal. It doesn't have to be that. If a client wants to do that, that's an option. But this more strategic, systemic thing is, you're going to go reorganize your sock drawer before you cut. And each time you feel you need to cut, you've got to reorganize another drawer. And there isn't a logical connection there, and that's OK. Because all you're trying to do is interrupt the pattern by just doing something unexpected. It's possible by reorganizing their sock drawer that afterwards they don't feel like cutting. They may or may not, but you're interrupting. The whole thing is going to unfold differently. So no matter what the problem is, if you're going to cut, you're going to come up with there's some ordeal. And often, you want it to be a little more distasteful. It doesn't have to be horrific, but something. Every time you're going to cut, you're going to donate $20 to charity, whatever it might be. And for different clients, they may have some metaphoric meaning. They may just be crazy wisdom, no linear connection, just interrupting. And it may have a logical, linear trying to prevent. But that's the concept of ordeal therapy. And there are certain clients and certain types of problems where this concept works pretty well for some clients. So finally, we're going to wrap up by talking a little bit about diversity and the evidence base. We're going to begin here with tapestry weaving, working with diversity in strategic therapy. As we mentioned earlier, strategic therapy is readily applicable with a diverse range of clients if it's implemented the way it's been developed in the sense of the case conceptualization is not based on a set of behavioral norms, that this is what a normal, healthy family looks like. And instead, the therapist really focuses on, what's the interactional behavioral sequence, and how do we shift that, and how does the client shift that? And all I'm going to do is interrupt the pattern, and they're going to reorganize. And that allows the family to reorganize based on cultural, gender, social economic class norms that are congruent with their own beliefs. And there have been several forms of strategic-based evidence-based treatments developed specifically for Hispanic and African American. The particular approach is called brief strategic family therapy. It's an evidence- based treatment developed by Zapasnik and a team of therapists down in Florida. And so they've actually used different variations and developed different evidence-based treatment manuals for working with Hispanic adolescents as well as African American adolescents. And strategic systemic concepts have also been used widely working with transgender youth as well as gay, lesbian, and bisexual youth in facilitating the adjustment to the family wen working with these special populations. So because it doesn't have a theory of normalcy, a therapist doesn't add their own ideas about normal behavior. It can certainly be used in a relative sensitive way the way it's been developed to work with a wide range of diverse populations. So strategic therapy itself was developed very much from a qualitative research approach in terms of developing a hypothesis, doing an intervention, seeing how clients responded, watching families communicating naturally, and so they developed in that kind of orientation. There was less systemic, traditional, contemporary outcome-based assessment of the approach. However, several evidence-based treatments have been developed using strategic-- it's generally systemic-- interventions, particularly with adolescents who have conduct issues, substance abuse issues. And so many of the approaches that incorporate strategic therapy concepts are targeting that particular population. So just wrapping up here. Strategic therapy shares a lot in common with both the MRI and Milan approaches. With the strategic approach, integrating concepts earlier of power in terms of how they looked at the international sequence, more contemporary practitioners focusing more on how love and nurturance is expressed between family members and members of the couple. But fundamentally, they're all looking at that interactional sequence. And so the MRI is focusing on the attempted solution and finding a 180 shift. The Milan is looking at the positive connotation for developing a hypothesis and describing that international sequence. And in strategic, they're tracking power and later love in terms of how that sequence goes. All three of them, their basic premise is how do we perturb the system is the term they used or interrupt the sequence. They're never fixing it in a logical, linear way. They're not educating people how to communicate better. They are tripping people up. They are tripping them up somewhere in that negative interactional sequence. They find some point in that sequence to say, here, you're going to do this one little thing differently. You're going to text the message rather than speak it verbally, whatever it might be. But you're interrupting that sequence where the family can naturally reorganize from within. They're not telling you, mom, you're an overbearing mother, and you need to stop infantilizing your child or whatever it might be. They're not doing that. And so this is how you're going to set limits with your child from here forward. Instead, they're just identifying the sequence, interrupting it, and letting the family reorganize in a way that makes sense for them culturally, socially economic class wise, based on their personal values and beliefs. And they keep having the family interrupting the negative cycle until the family reorganizes in such a way that all members are symptom free. And that is the basis of it. They're all relatively brief, as you can tell. And they have been used especially in contemporary practice. They're used very widely when working with both children and adolescents who have acting out types of issues and behavioral types of issues, in particular is where the evidence base is pointing to these being particularly useful. In another lecture, you can listen to how emotionally focused couple in family therapy also uses very similar systemic ideas to help couples and families with conflict.