Lecture 5: Introduction to Social Constructionist Model: Milan School

Systemic ComparativeKevin Standish

Newham College University Centre

Learning Outcomes

1. Identify the background influences2. Describe the core concepts of Milan Family

Therapy (MFT)3. Conceptualisation of problems in MFT 4. Therapeutic goals in MFT 5. Therapist role in MFT 6. MFT interventions7. Evaluation of MFT

1. BACKGROUND

FoundersKey influences

Core systemic influences

• Gregory Bateson’s circular epistemology.• Greatly influenced by the works of the Mental

Research Institute (MRI) & brief therapy• Pragmatics of Human Communication by

Watzlawick, Beavin, and Jackson (1967). Strategic therapy

• Key publication: Paradox and Counterparadox (1978) : understanding the family over time and trying to determine how the family came to “need” the problem they were attempting to resolve.

Model based on complexity

• System theory – von Bertalanffy(1967)• ‘pattern which connects’ –Bateson (1979)• cybernetics• Double bind hypothesis – Bateson 1950s• Family homeostasis hypothesis – Jackson

( 1957) –> conjoint FT ( similarity to homeopathy) -> paradoxical intervention -> strategic approach.

Founders of Milan Family therapyMara Selvini Palazzoli

Gianfranco Cecchin

Luigi Boscolo

Lynn Hoffman

Peggy Penn

Guilana Prata

Major Theorist: Mara Selvini Palazzoli

• Specialized in eating disorders but became frustrated with lack of results

• Led group of psychiatrists who formed Center for the Study of the Family in Milan, Italy

• Described families as engaging in series of games– Families stabilize around disturbed behavior to try & benefit

from them– Therapists meet with families & then parents separately to

give invariant or variant prescription to produce firm boundary between generations

Team split in 1980• Cecchin and Boscolo have

evolved a non-interventionist style premised on social constructionism where the therapist’s use of circular questioning opens up space for the client and therapist to co-construct multiple new perspectives on the problem situation

• Selvini Palazzoli and Prata developed the strategic aspects of the original model further by outlining the development of particular types of problem maintaining interaction patterns that they referred to as family games.

• strategic therapy style-> highly directive)

2. CORE CONCEPTS

Core concepts/assumptions

• The principal assumption is that the presenting symptom serves a function of helping to maintain the family system’s homeostasis.

• “a self-regulating system which controls itself according to the rules formed over a period of time through a process of trial and error” (Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1978, p. 3)

Premises of the Theory: Systemic• Therapist will take systemic view of problem

maintenance & strategic orientation to change• Symptoms serve a purpose• Concentrate on consequences of family communication

patterns & conflict between competing hierarchies• Therapeutic neutrality — keeps therapist from being

drawn into coalitions & disputes & gives therapist time to assess family dynamics

PRINCIPLES

• Double bind - ability to communicate different, and often conflicting, messages simultaneously

• While all relationships are governed by ‘rules’ they frequently lack rules to change the rules about how members deal with each other

• Therapist takes charge of symptom and prescribes

• The person(s) no longer do(es) it because he ‘cannot help it’, but ‘because my therapist told me to’.

EARLY MILAN MODEL

• Paradoxes • Counter paradoxes• Positive connotation• Long brief therapies• Team of therapists

Milan school- salient features

• Five part therapy sessions.• The use of co-therapy and a team behind a screen.• Commitment to the guidelines of hypothesizing.• Circularity and neutrality & circular questioning.• End of session interventions involving positive

connotation and the prescription of rituals, some of which were apparently paradoxical.

• In second-order cybernetics, the therapist becomes part of the system being observed rather than being an outsider observing a family system.

3. CONCEPTUALISATION OF PROBLEMS IN MFT

Problem Conceptualisation

• symptom serves a function of helping to maintain the family system’s homeostasis

• entire system is caught up in “family games” whose purpose is to control individual family members’ behaviour in response to flaws within the family hierarchy

• The games are played through unacknowledged alliances and coalitions.

Problem Conceptualisation

• Family members become symptomatic in an attempt to either deal with isolation or retaliate against family members for the hurt they are experiencing (Campbell, 1999).

• The symptom or problem that developed within the family was not viewed as coincidental.

• the symptomatic family member has taken his or her attempt to control too far and the result is a symptom or diagnosis

The problem of the referring person

• Failure to examine the problem of the referring person resulted in unsuccessful therapies.

• The referring persons is suspected of being a homeostatic member of the family (eg., doctors who have been treating the family for years and have formed a friendship with them, young "supportive"-type psychiatrists or psychologists, or social workers acting as liaison between the patient and the family)

The problem of the referring person• They argued that taking information about, and

potentially from, the referring person was a key way to understand how the family presented for assistance, and how therapy might progress.

• Without this understanding, the referring person could become a 'grave problem' for the therapy, given that s/he may hold a pivotal role in stabilising the family or, in other ways, do some of the family's emotional work for them.

• Palazzoli, Mara S.; Boscolo, Luigi; Cecchin, Gianfranco; Prata, Guiliana The problem of the referring person. Journal of Marital and Family Therapy, Vol 6(1), Jan 1980, 3-9

4. THERAPEUTIC GOALS IN MFT

In the Milan approach, change occurs when the family is able to see their problems in a more systemic and healthy way (i.e., recognize that their problem may be serving a purpose).

Change• relationship-centered questions reveals new ways

of thinking.• the family must face the reality of the relationships

experienced by each individual family member. • There is a shift in how the family views their

problems: no longer ascribe blame individual family member—rather, see their problems as family problems

• every family member must change, as opposed to only the symptomatic family member, resulting in second-order change: purposefully changing the rules of their system.

Formulation…

1. Families in “problem saturated” transactions – games

2. Family members unilaterally try to control each others behaviour

3. Therapist to discover and interrupt these games

5. THERAPIST ROLE IN MFT

The therapist’s role, simply stated, is to be curious and creative

Role of the Therapist• observe the patterns of family interactions

and uses techniques for making therapeutic interventions

• Both expert & co-creator of evolving family system

• Is neutral – does not overtly challenge or change families; argues against change

• Takes a non-blaming stance, gives directives, uses circular questioning & other indirect forms of intervention

Role of the Therapist

• Stresses positive connotations of behavior• the therapist uses curiosity to help

navigate the questions, which allows the therapist to be observant for openings.

• The opening conceives a space for the therapist to help the family to see their problems in a new way.

6. MFT INTERVENTIONS

positive connotation,hypothesizingcircular questioning; neutrality.

Session Structure1. Presession- hypothesis from telephone call2. Phase 1: Joining and Building Rapport3. Phase 2: Understanding the Presenting Issue4. Phase 3: Assessment of Family Dynamics – validate, modify,

change hypothesis5. Intersession – discussion with reflecting team6. Phase 4: Goals generally are NOT set. Trust the system to

resolve itself7. Phase 5: Amplifying Change / Intervention: Positive

connotation and rituals8. Phase 6: Termination9. Post session discussion There is a reflecting team behind a one way mirror.

Positive connotation

• Similar to positive reframing; however, it includes a systemic component.

• reframe problem as one that preserves family homeostasis

• the therapist can help the family begin to realize the homeostatic need for the behaviours.

• The symptomatic family member is seen in a more favorable light, and the symptom may actually be welcomed

Treatment Techniques

• Hypothesizing — prepares team members to treat family

• Circular questioning — focuses attention on family connections by addressing differences in perception

• Neutrality- is an attempt for the therapist to see each person’s point of view. This later changed to curiosity (Cecchin 1987)

Hypothesizing

• Systemic hypothesizing is the Milan therapist’s way of confirming or disconfirming necessary information regarding how the family functions and how the therapist conceptualizes their functioning.

• Hypothesizing begins with the initial telephone call from the family.

• Prior to the first session, the Milan team exhausts all possible hypotheses about the family’s symp-toms and functioning based on the telephone conversation.

Hypothesizing• reflecting team members inform the therapist halfway through

the session of the new developed hypothesis. • A new therapeutic direction may develop based on the consensus

of the reflecting team• As the session comes to a close, the team arrives at a final neutral

hypothesis : the most systemic and powerful hypothesis for the family.

• The final hypothesis not ascribe blame to any single family member; often results in a prescription or ritual developed by the

• reflecting team. • Later, after the family leaves, the reflecting team and therapist

discuss how the family reacted to the intervention and plan for the next session.

• In some cases, a therapeutic letter is written

Circular Questioning

• Circular questioning is an interviewing method used to gain descriptive assessments and deliver interventions through questioning of the family members

• Circular questioning is to expand the family’s beliefs beyond the meanings that they currently hold.

• This is often done by asking questions to individuals that probe how others view the situation.

Circular Questioning

• Meaning formulation is an important component of this approach to develop context. “Without context, there is no meaning” (Campbell, 2003, p. 19).

• to examine their belief systems and the Meanings that they attached to their behaviours.

• based on inquiries about the differences within the relationships of family members and their perceptions

Circular Questioning

• The therapist continually searches for patterns, feedback loops, differences in beliefs among family members (called openings), and the covert rules that support family interactions.

• openings allow a place during the session to begin questioning, , and exploring differences

Karl Tomm 3 papers

1. (1987) Interventive Interviewing: Part 1. Strategizing as a Fourth Guideline for the Therapist

2. (1987) Interventive Interviewing: Part 11. Reflexive Questioning as a Means to Enable Self-Healing

3. (1988) Interventive Interviewing: Part 111. Intending to Ask Lineal, Circular, Strategic,or Reflexive Questions?

Neutrality/Curiosity• neutrality was that if every family member were

asked at the end of a session, ‘Whose side was the therapist on during the session?’ they would all say, ‘My side’”

• neutrality has been misunderstood and challenged as implying cold or aloof (Cecchin, 1987)

• A curious therapist allows all family members a voice• Therefore, adhering to neutrality, the curious

therapist is more likely to be open to numerous hypotheses about the system and invite the family members to explore those hypotheses, increasing the number of options for change

Treatment Techniques• Rituals:– Engage family in actions that run counter to, or exaggerate,

rigid family rules & myths – Occur daily at mealtime, bedtime & during chores– Include 5 components essential to family health:

• Membership; Belief expression; Identity; Healing; Celebration

– Purpose - change cognitions or meaning of behavior– Therapist should be specific in what is to be done, who is

to do it & how it is to be done

PARADOX

• " …the specific tactics and manoeuvres which are in apparent opposition to the goals of therapy, but are actually designed to achieve them

• “. . . paradox not only can invade interaction and affect our behaviour and our sanity, but also it challenges our belief in the consistency, and therefore the ultimate soundness of our universe”

PARADOX: When to prescribe?

1. Presupposes an intense complementary relationship, with a high degree of survival value for the family

2. Within this context an injunction is given which is structured so that it• (i) reinforces the behaviour that the patient expects to be

changed• (ii) implies that this reinforcement is a vehicle of change, and• (iii) creates a paradox by telling the patient to change by

remaining unchanged.

3. The therapeutic situation prevents the patient from withdrawing or revealing the paradox by commenting on it, by virtue of (i) and (ii).

Process & Outcome• Symptom resolution in 10 or fewer sessions• Family dynamics change– Systemic connection becomes clear– Member stops being scapegoat– Games change

• Old epistemology is discarded & more productive behaviors emerge

• Process of growth continues

Unique Aspects of Systemic Theory

• Flexibility makes it applicable to treating a variety of families

• Therapists work in teams– Some in room, some behind one-way mirror– Papp’s “Greek chorus”

• Concentration on one problem over short period of time

period Ten months, divided into ten sessions spaced at monthly intervals

Initial contact Usually telephonic Therapist ties to maintain neutrality in order not to be seen by other family members as being in a coalition with the whoever made the initial call Questions phrased in social terms

Calls between sessions Neutral stance of therapist maintained In case of emergency calls (e.g. suicide attempts) therapist assumes role of social control agent rather than that of therapis

Resources Therapist brings in other members of the therapeutic team Supervision Observatio

Therapy session – five components Team discusses the family Family interview with other team members observing Team discussion of the family and the session Conclusions of the team presented to the family with other team members observing Post-session where team sums up

Termination Mutual agreement by therapist and family Respect for family’s decision to terminate Warning of possibly of relapse or doubt

SUMMARY

• Circular questions asked from positions of curiosity and irreverence (neutrality) to bring forth the family’s construction of the problem.

• Challenging the family belief system that underpins problem maintaining interaction patterns.

• Circular questioning within sessions and end of session interventions are used to promote change.

7. EVALUATION OF MFT

Comparison with Other Theories: Systemic

• European bias toward nonintervention makes it not widely used anywhere besides Europe

• Controversial view of schizophrenia – Palazzoli believed it resulted from child’s attempt to take

sides in stalemated relationship between parents

• Tailor interventions to specifics of family– Therapists responsible for creating innovative treatment

plans– Limited generalisation of specific interventions

Evaluation• Post-Milan therapists also moved away from desiring

particular outcomes from therapy and instead saw their role as merely to “poke the system” (jar the system, perturb the system), which left families responsible for the outcome.

• Milan family therapy has been shown to be effective with families dealing with various childhood disorders, including oppositional defiant disorder, attention deficit disorder, autism, childhood depression, and anxiety.

• Additionally, couples with marital/relational issues find benefits, as do families with a member involved in drugs or alcohol.

Evaluation

• Families seeking answers to the past or desiring an analysis of why their problems have developed will not benefit as much because the Milan family therapist does not pathologize.

• Milan family therapy might not be as culturally sensitive as necessary: today you need to incorporate sensitivity to cultural, racial, and sexual orientation differences into a hypothesis formulation

Readings• Selvini et al (1998) Hypothesizing, Circularity, Neutrality, Three

guidelines for the conductor of the session. (Required reading)• Ceccin (1993) Hypothesizing, Circularity and Neutrality

Revisited an invitation to curiosity (required reading).• Dallos, R. & Draper, R. (2010) chap 1 & 2• Metcalf, L. (2011) Chap 9• Burnham & Harris (1992) Systemic family therapy the Milan

approach • Tomm (1995) Circular interviewing: A multifaceted clinical tool. • Tomm,K.(1987) Interventive_interviewing part 1. Strategizing as

a fourth guideline for the therapist• Advanced reading• Brown (2010) The Milan Principles extinction, evolution or

emergence