socw 674 social work and families lecture no. twelve

1. SOCW 674 Social Work and Families Lecture No. Twelve The Milan Systemic Model

3. Milan Group Families thus were helped not only to become aware of the repetitive patterns in which they are caught, but also see themselves within a relational context (i.e. from the perspective of fellow family members). Moving beyond their earlier, typically linear perceptions of family interactions, each family member was now in a stringer position to examine a variety of perspectives that provide more alternatives for solving problems.

4. The notion that the therapist The notion that the therapist as observer as part of what is being observed- and thus inescapably part of the system to which he or she is offering therapy-redefines the therapist as someone who, like the other participants, has a particular perspective but not a truly objective view of the family or what�s best for them. One consequence of this thinking is to take �truth �away from the therapist and make goal setting a participatory process that therapist and family members engage in together.

5. The Therapist Doing so empowers the family to make changes (or not to make them) as they see fit. The therapist is a nonhierarchical collaborator (although hopefully a knowledgeable and inventive one who is both curious and impartial) allows the family to investigate and decide about its future in its own way and at its own pace.

6. The Milan approach The Milan approach, as it continued to evolve, remained focused on information, such as Bateson ( 1972) did- as exemplified in his famous definition of information as � a difference which makes a difference. � Characterized by a systemic search for differences- in behavior, in relationships, in how various family members perceive and construe an event- and by efforts to uncover the connections that link family members and keep the system in homeostatic balance, the approach has come to be known as systemic family therapy.

7. The Milan Group The Milan Group was formed by Maria Selvini-Palazzoli, a child psychoanalyst, who in the late 1960�s , organized a team of fellow psychiatrists- including Luigi Boscolo, Gianfranco Cecchin And Guiliana Prata- to treat families of severely disturbed children, many of whom were suffering from anorexia nervosa.. In 1971 the Milan Center for the Study of The Family was founded. They introduced a team approach as well as developing their own theory and set of powerful and innovative intervention techniques such as positive connotation and rituals designed to over come therapeutic impasses and change stalemated family interactive sequences.

8. The Early Milan Model : Paradoxes, Counter paradoxes, Rituals and Positive Connotations

9. The Milan Group The Milan Group initially began to focus � on the rules of the game � in psychotic families- tactics by which family members struggle against one another together, they act To perpetuate unacknowledged family � games � in order to control each other�s behavior. They conceptualized the family as 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 and Prata, 1978 ) The therapist�s task, then, was to disrupt, expose and ultimately interrupt the destructive � games � in which all family members participate together.

10. Selvini-Palazzoli and colleagues Selvini-Palazzoli and colleagues asserted that the schizophrenic family, tapped by the rules of the game, is powerless to effect change. That is, the rules of the family�s game, rather than the individual input, define and sustain the member�s relationships. What remained paradoxical was that all family members, presumably seeking therapy in order to change, nevertheless continued to behave in ways that prevented any change from taking place. As Tomm ( 1984a) observed, it was as though the family were asking the therapist to change its symptomatic member, at the same time insisting that the rest of the family was fine and had no intention of changing.

11. Assuming that symptomatic behavior Assuming that symptomatic behavior in a family member helped maintain the system�s homeostatic balance through an unacknowledged network of coalitions and alliances, developed over generations, the team began by prescribing no change in the at behavior. In this way, they were adapting to the MRI technique of paradoxical intervention to their own systemic formulations that all of the family�s attitudinal and behavioral patterns were mere moves designed to perpetuate the family game, and thus could not be confronted and challenged head on.

12. Through the subsequent use of therapeutic counter paradoxes Through the subsequent use of therapeutic counter paradoxes-especially therapeutic double binds- the family was warned against premature change, allowing the members to feel more acceptable and unblamed for how they were, as a team attempting to discover and counter the family�s paradoxical patterns, thus interrupting repetitive, unproductive games.

13. In the language of the Milan Group In the language of the Milan Group, the family�s behavior was given a positive connotation-positive motives were ascribed to all family transactions, which were reframed to appear to be carried out in the name of family cohesion and thus functioning as purposefully to maintain family homeostasis. At the same time, each family member�s behavior was connoted as related to the identified patient�s symptoms, thereby tacitly getting their acknowledgement of the over-all implication in the �family game. � Subsequent interventions typically prescribed assigned rituals that were aimed at forcing behavior change in the system.

14. Originally the Milan Group Originally the Milan Group believed in actually spacing the therapeutic sessions and also used a team of therapists working with the family. Typically, the therapists a man and woman, saw the family together while the remainder of the team watched the family from behind a one-way mirror to gain a different perspective. From time to time during the session, the observers summoned one of the therapists outside the room in order to change therapeutic direction. Conferring with the therapist, the observers would offer suggestions, opinions and observations, often issuing directives that the returning therapist could then share with the family.

15. Following the strategy conference Following the strategy conference, the therapist rejoined the family group, discussed what had transpired with the other team members, and assigned the family members a task, usually a paradoxical prescription. Sometimes, the intervention took the form of a paradoxical letter, a copy of which was given to every family member. If a key member missed a session, a copy of the latter would be sent by mail, frequently with comments (again, often paradoxically stated ), regarding his or her absence.

16. Prescriptions . Prescriptions too the form of opinions (� We believe Father and Mother, by working hard to be good parents, are nevertheless�� ) Or requests that certain behavioral changes be attempted by means of rituals carried out between sessions. ( � The intermediate family, without any further relatives or outsiders, should meet weekly for one hour, with each person allowed fifteen minutes to � � ) By addressing the behavior of all of the members, the therapist underscored the connections in the family patterns.

17. The classic Milan therapeutic interview The classic Milan therapeutic interview format thus was divided into five segments: the presession, the session, the intersession, the intervention, and the postsession discussion. Family therapy began with the initial telephone call from the family. The team member who took the call talked to the caller at length, recording the information on a fact sheet. Who called? Who referred the family? What is the problem? How disturbed is the caller�s communication? What tone of voice is used ? What is the caller�s attitude regarding the upcoming treatment ?. What special conditions, if any, does the caller attempt to impose ( specific date or time ) ?

18. These intake issues These intake issues were then taken up with the entire team in the presession, prior to the first interview, in a lengthy and detailed way, and various team members proposed tentative hypotheses regarding the family�s presenting problem. All of these tactics affirmed the Milan therapists� belief that the family and the therapist(s) are part of one system.

19. In an earlier version of the Milan model In an earlier version of the Milan model, there was more concern with family processes than with family structure. Members of dysfunctional families were seen as engaging in unacknowledged destructive, repetitive sequences of interaction. No one seemed able to extricate himself or herself from the family�s self-perpetuating � games � in which members tried to control each other�s behavior.

20. . The identified problem The identified problem is seen as serving the system in the best way possible at the moment,. Why, then, can the family not find a better way to survive and function, one that does not involve sacrificing one of its (symptomatic ) members ? Perhaps the rules governing the system are too rigid, tolerating an extremely narrow range of behavior.

21. . Since the family members Since the family members, through their communication patterns, maintain the system�s rules and thus perpetuate the transactions in which the symptomatic behavior is embedded, the therapist must try and change the rules in order to change that behavior ( Selvini-Palazzoli, Boscolo, Cecchin & Prata, 1978 ). Systemic therapy tried to discover, interrupt and thus change the rules of the game before the behavior of the players ( the symptomatic member as well as the other family members ) could change.

22. Selvini-Palazzoli and her colleagues Selvini-Palazzoli and her colleagues in their early formulations contended that a family double-bind message, a paradox, could be undone only by a therapeutic double bind, which they call a counterpaaradox. Positive Connotations and Ritual Prescriptions Positive connotations is a way of reframing the family�s problem-maintaining behavior in which symptoms are seen as positive or good because they help maintain the system�s balance and thus facilitate family cohesion and well being. By suggesting a good motive for behavior previously viewed as negatively motivating ( � The reason your child refuses to go to school is that he wants to provide companionship for his lonely mother � ), the systemic therapist is indicating to the family that the symptomatic behavior formerly looked upon negatively may actually be desirable.

23. All members All members are considered to be motivated by the same positive desire for family cohesion, and thus all are linked as participants in the family system. Because the positive connotation is presented by the therapist as an approval rather than a reproach, the family does not resist such explicit confirmation and accepts the statement. As a result of reframing, then symptomatic behavior is now viewed by the family as voluntary, greatly enhancing the possibilities for change. However, the positive connotation has implicitly put the family in a paradox. Why must such a good thing as family cohesion require the presence of symptomatic behavior in a member?

24. Positive Connotations Positive Connotations also prepare the family for forthcoming paradoxical prescriptions. When all view their behavior as positive, all view one another as cooperative and thus are willing to join in complying with any tasks that may be assigned by the therapist, reducing family resistance to future change.

25. If the therapist If the therapist adds a no change prescription-� And because you have decided to help the way in this way, we think you should continue to work for the time being � ( Tomm, 1984b, )- an additional paradox of � no change in the context of change � further increases the impact of the intervention. The phrase � for the time being � implies that the current family pattern need not always occur in the current manner, leaving open the possibility of future spontaneous change. The family ids left to resolve the paradoxical absurdities on its own.

26. Family Rituals Family Rituals such as weddings, birthday parties, baptisms, bar mitzvahs, graduations, funerals, etc. often play a central role in a family�s life. Such transitions are designed to mark and facilitate family developmental transitions and changes. Therapeutically, they may be designed to intervene in established family patterns, promoting new ways of doing things, which in turn may alter thoughts, beliefs and relationship options ( Imber-Black, Roberts & Whiting, 1989 ).

27. Ritualizing the behavior Ritualizing the behavior offers a new context and is thus more likely to be carried out by the family. Rituals are usually assigned in paradoxical prescriptions describing in detail what act is to be done, by whom, when, and in what sequence. Typically carrying out the ritual calls for the performance of a task that challenges some rigid, covert family rule.

28. Generally speaking Generally speaking, the purpose of the ritual is to provided clarity where there might be confusion in family relationships; the clarity is gained by the family�s Enactment of the directive ( Tomm,1984b) . Take the case of parents who are inconsistent or competitive with one another in attempting to maintain behavioral control of a disruptive child. An alternating day ritual may be suggested in which Mother takers full charge of discipline on odd days ( with father observing and taking exact notes on the ensuing mother-child interaction ) and Father takes charge on even days ( with Mother playing the counter role ).

29. Each parent Each parent is directed to carry out the assigned roles for a certain number of days, and to behave �spontaneously �for the remaining days of the week. Carrying out the ritual clarifies differences in approach for the parents and provides greater awareness of how their differences can cause confusion in their child. It thus highlights the importance of two-parent consistency as a goal if the child is to achieve the comfort level necessary to abandon the disruptive behavior.

30. An Evolving Model: Hypothesizing, Neutrality and Circular Questioning When systemic therapists speak of circularity they are referring both to interactional sequences within the family and ,because the therapist is a part of the system., the therapist�s interactional relationship with the family

31. Milan systemicists Milan systemicists contend that hypothesizing, a continual interactive process of speculating and making assumptions about the family situation provides a guide for conducting a systemic interview. The technique allows the therapist to search for new information, identifying the connecting patterns that sustain behavior, and speculate on how each participant in the family contributes to systemic functioning. Beginning with the family�s first telephone contact, and continuing throughout the therapeutic process, hypothesizing represents therapeutic formulations regarding family functioning

32. Systemicists Systemicists believe that unless the therapist comes to the family session prepared with hypothesis to be checked out, there is the risk that the family may impose its own definition of the problem and its resolution, which is likely to be faulty and to perpetuate the presenting problem. Hypothesizing involves the active efforts the team makes during the presession to formulate in advance of the family session what they believe might be responsible for maintaining the family�s presenting symptoms.

33. Hypotheses Hypotheses formulated by the team typically take the form of systemic or relational statements, linking all family members, and thus offer a circular structure regarding family rules and interactive behaviors. Hypotheses are carefully constructed to elicit a picture of how the family is organized around a symptom or presenting problem

34. As Burbatti and Formenti ( 1988) As Burbatti and Formenti ( 1988) contend, the goal of therapeutic hypotheses is change, not truth. In the Batesonian tradition, hypothesizing offers information, allowing the family members to choose or reject the therapeutic message from an active therapeutic partner. Hypothezing offers a structured viewpoint, organizing data provided by the family, encouraging family members to rethink their lives and together begin to form new hypotheses (for example, regarding previously denied coalitions 0about themselves and their � games. �

35. Neutrality Neutrality means the therapist is interested in, and accepts without challenge, each member�s unique perspective of the problem ( if not necessarily accepting the problem itself ). No one family member�s view is seen as more correct than that of any other. All perceptions by family members are considered to be legitimate and accepted without judgment by the therapist. By hearing all views, the family is in better position to pinpoint the problem affecting all its members and to begin to develop a range of alternative solutions ( Prevatt,19999 ).

36. To Milan therapists To Milan therapists, neutrality refers to efforts to remain allied with all family members, avoiding getting caught up in family coalitions and alliances. Such a position, typically low key and nonreactive, gives the therapist maximum leverage in achieving change by not being drawn into family �games� or appearing to side with one family member against another. More concerned with curiosity about how the family system works than with attempting to change it, the neutral therapist assumes that the system the family has constructed makes no sense; the family members could not be any other way than they are at the moment.

37. Selvini Palazzoli Selvini Palazzoli has observed, �if you wish to be a good therapist it is dangerous to have too much of a desire to help other people�. Rather, the therapist�s goal should be to help the family achieve change in its ability to change. They also have the right not to change. Neutrality precludes taking a position for or against any specific behavioral goals from therapy or assuming that the therapist must somehow be the one to effect change.

38. Circular questioning Circular questioning involves asking each family member questions that help address a difference or define a relationship between two other members of the family. These differences are intended to reveal the multiple perspectives of different family members and to expose recursive family patterns. Here the therapist is trying to construct a map of the interconnections between family members, and is assuming that asking questions about differences in perception- and questions derived from the feedback from previous questions about differences-is the most effective way of creating such a map ( Campbell, Draper & Crutchley, 1991 ). One main gain is that each family member is continually exposed to feedback from the others throughout the therapy.

39. Underscoring the notion of feedback loops Underscoring the notion of feedback loops, the team developed guidelines for asking questions that led to the construction of a map of the interconnections between family members. Boscolo, Cecchin, Hoffman and Penn ( 1987) insisted on questions that ( a) probed perceptions about relationships ( Who is closer to Father, your daughter or your son ? ) (b) investigated degrees of difference ( On a scale of one to ten, how bad do you think the fighting is this week ? ), (c) studied now and then differences ( Did she start loosing weight before or after her sister went off to college ? ); and ( d ) sought views of family members on hypothetical or future differences ( If she had not been born, how would your marriage be different today ? )

40. By asking several people By asking several people the same question about their attitude toward the same relationship , the therapist is able to probe deeper and deeper without being directly confrontational or interrogating the participants in the relationship ( Selvoni_Palazzoli, Boscolo, Cecchin & Prata, 1980. )

41. Circular questioning Circular questioning aims at eliciting and clarifying confused ideas about family relationships and introducing information about such differences back to the family in the form of new questions.

42. Questioning Family Belief Systems Questioning family members, hypothesizing about the family game, and constantly feeding back information to the family have remained the key methods of achieving these goals.

43. The Milan Group The Milan Group began to develop counter paradoxes directed at breaking up contradictory patterns, thus freeing up the family to change. One common counter paradox was to declare that although there were change agents, they did not wish to upset what appeared to be a workable family homeostatic balance and therefore would prescribe no change for now ( Selvini-Palazzoli, Boscolo, Cecchin & Prata, 1978 ).

44. Not long afterward Not long afterward, the Milan Group began to think of systems as evolving and unfolding rather than seeking a return to a previous homeostatic level. Relying now on circular questioning to present differences for the family to consider, the team attempted to activate a process in which the family creates new belief patterns and new patterns of behavior consistent with those beliefs ( Tomm,1984a). New information was given the family explicitly through reframing or implicitly through the prescription of family rituals.

45. By uncovering connecting patterns By uncovering connecting patterns, by revealing � family � games by introducing new information in the system through opinions or requests that certain family rituals be carried out between sessions, Milan therapists were trying to bring about a transformation in family relationship patterns.

46. Milan therapeutic procedures Milan therapeutic procedures also changed over time. The � classic � method-male and female co-therapists, two team members behind the one-way mirror- was amended so that a single therapist was likely to work with the family while the rest of the team ( often students learning the technique ) observed. The observers were free to call the therapist out of the room to share ideas and offer hypotheses. The fixed month-long interval between sessions became more flexible, depending upon feedback from the family and consultants. Generally speaking, the 10 session limit extended over an indeterminate period of time still qualifies the approach as long brief therapy Jones, 1993)

47. Prevatt ( 1999 ) Prevatt ( 1999 ) outlines the following steps in her work with a family where acting-out children provide a shield for marital difficulties. Constructing a working hypothesis. Exhibiting a therapeutic stance of neutrality Using circular questioning as both an assessment and therapeutic technique Working with a team to monitor the process Identifying the labels used by the family Identifying openings or themes to be explored Using positive connotation for problematic behaviors Using end-of-session intervention.

48. The Invariant Prescription The invariant prescription is based on a six-stage model of psychotic family games. Selvini-Palazzoli contends that a single process takes place in all schizophrenic and anorectic families, beginning with a stalemated marriage (stage one ) in which the child attempts to take sides ( stage two). Eventually drawn into the family game, the child erroneously considers the actively provoked parent to be the winner over the passive parent, and sides with the �loser �. The subsequent development of disturbed behavior or symptomatology in the child (stage three), requiring parental attention, represents a demonstration of the passive parent of how to defeat the �winner.�

49. Instead of joining the child Instead of joining the child, however, the passive parent or � loser � sides with the � winner � parent ( stage four ) in disapproving of the child�s behavior. The child in the scenario feels betrayed and abandoned and responds by escalating the disturbed behavior determined to bring down the � winning � parent and show the �loser� what can be done ( stage five ). Ultimately the family system stabilizes around the symptomatic behavior (stage six ), with all participants resorting to � psychotic family games � as each tries to turn the situation to his or her advantage ( Selvini-Palazzoli, 1986 ). An invariant prescription is a fixed sequence of directives they must follow if the therapist is to help them interrupt the family game.

50. A Post-Milan Systemic Epistemology Boscolo and Cecchin�s efforts emphasize neutrality as a more effective device for quietly challenging an entire family to reexamine its epistemology. In effect, they temporarily join the family, becoming part of the whole system from which they begin to offer information and perspectives on reality. In essence the therapists and family members influence one another, producing the opportunity for change as a by-product. Expanding on earlier cybernetic ideas, Boscolo and Cecchin argue that by becoming part of the observing system, the observer loses all objectivity, and there no longer exists a separate (observed) family system.

51. For Boscolo and Cecchin For Boscolo and Cecchin, any intervention then should not be directed at a particular outcome, but rather should be seen as jarring the system that then will react based on its own structure. For Boscolo and Cecchin, the system does not create the problem. Rather, the problem creates the system; it does not exist apart from the �observing Systems �that reciprocally and collectively define the problem. Thus, therapists cannot change families through therapeutic interventions but can merely coexist in a therapeutic domain in which they may perturb the system through interaction but that will only lead to therapeutic change if the structure of the family system allows the perturbations to have an effect on its organization ( Campbell, Draper & Crutchley, 1991 ).

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

53. Eight Reflexive Questions Future oriented questions ( designed to open up consideration of alternative behavior in the future ) ( � If the two of you got along better in the future, what would happen that isn�t happening now ? ) Observer-perspective questions (intended to help people become self-observers) (�How do you feel when your wife and your teenage son get into an argument? � ) Unexpected counterchange questions (opening up possibilities of choices not previously considered by altering the context in which the behavior is viewed) (�(�What does it feel like when the two of you are not fighting? �) Embedded suggestion questions (allowing the therapist to point to a useful direction) (�What would happen if you told her when you felt hurt or angry instead of withdrawing? � )

54. Eight Reflexive Questions Normative-comparison questions (suggesting the problem is not abnormal) (�Have any of your friends recently dealt with the last child leaving home, so that they would understand what you are going through now? � ) Distinction-clarifying questions (separating the components of a behavior pattern) (�Which would be more important to you-showing up your boss�s ignorance or helping him so that the project can be successfully completed ? � ) 7. Questions introducing hypotheses (using tentative therapeutic hypotheses to generalize to outside behavior with others) (You know how to become silent when you think your husband is angry with you? What would happen next time if you told him how you felt?�) Process-interrupting questions (creating a sudden shift in the therapeutic session) (�You just seemed to get quiet and upset, and I wonder if you thought I was siding with your wife? �

55. As Tomm As Tomm has moved in the direction of a social constructivist/narrative view ( McCormack,& Tomm, 1998 ), he has concentrated his efforts on helping individuals and families bring forth their healthy interpersonal patterns ( HIPS) and replace pathological interpersonal patterns ( PIPS ) ( Hoyt, 2001b). This simple typology refers to the interactive patterns that generate or promote healing between people as opposed to pathology. To Tomm, it is the interaction pattern (e.g. domination and control vs. submission and compliance) that is contaminated in PIP, not the persons who have drifted into the habitual pattern. If HIPS open up space( welcoming others into one�s life and nurturing the relationship ), then PIPS close off growth, promote defensiveness, and cut off relatedness ).