Family and couples therapy

Strategic family therapy: the Problem- solving approach

By: Dr. Najah M. Al-Khatib

Strategic therapy grew out of the communication theory developed in Bateson's

schizophrenia project which evolved into three distinct models:

1. MRI's brief therapy model (Mental Research Institute)

2. Jay Haley and Cole Madanes's strategic therapy
3. Milan group systemic model

These therapies started in the Mental Research Institute where strategic therapy was
inspired by Gregory Bateson, Milton Erickson, Don Jackson, Jay Haley, John
Weakland, Paul Watzlawick .

This approach builds its premises on two main approaches:

a. Cybernetics theory ‫علم االتصاالت و نظم نقل المعلومات‬
b. Systems theory

Main concepts:
 Communication
 Feedback loops
 Positive feedback
 Negative feedback
 Family rules
 double bind communication
 redundancy principles
 family homeostasis
 Hierarchical structure

Theoretical formulation:
Watzlawick, Beavin and Jackson developed conceptualization about interpersonal
implications of conversation. These are:
 People are always communicating; there is no such situation where people are '
not communicating" even if they are silent.

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 All messages have content, command (definition of the relationship), and
functions. These are translated in families in a form of rules or dialogues.
Command messages are patterned into rules which are deduced from observed
redundancy (repetitions) in interaction. Family rules serve as directing ‫موجهه‬
‫ لألفراد‬members rather than instruction ‫تعليمات واوامر‬. Family rules aim to preserve
family homeostasis. Homeostasis mechanisms bring families to equilibrium in
the face of any disruption, thus serve to resist change. Families operate as goal-
directed, rule-governed systems.
 Usually the problem is not in the content of communication, but in the process
and way of interaction among family members. Therefore, the therapist needs to
analyze the inner dynamics of each individual to study their persistent pattern of
interaction and communication. Example:” I nag because you disobey me”. “No
Mom, it’s the other way around. I disobey you because you nag”. In therapy the
attention is directed to what is occurring rather than why it is occurring among
and between family members, and the way they interact, define and redefine
their relationship, and not to draw inferences about each participant’s
intrapsychic conflicts. There is a focus on communication pattern within the
family, its style, clarity or ambiguity, behavioral effect of communication, as
much as content of the communication.
 Family problems are viewed as interactional and situational (specific to a
particular time and place). Strategic family therapy shifted the attention from
the individual to the social context and the interchange between individuals. The
therapist’s primary way of viewing problems is to attend to the family’s
sequence of interactions and its hierarchy of interactions.
 Feedback loops (circular pattern of communication): communication theories
did not look for underlying motives. Instead, they assumed circular causality
and analyzed patterns of communications linked together in additive chains of
stimulus and response as feedback loops. In the above example, there is no use
to discuss who the cause of the problem is. The mother is not the cause neither
the daughter’s behavior. Both are caught up in an echoing system, a chain of
reactions that feeds back on itself. This circular interaction continues between
family members because each one of them imposes his/ her punctuation. Each
one says that his behavior is due to what the other’s said or did.
‫يشبه هذا الوضع عندما يتشاجر طفالن وكل واحد منهما يتهم االخر انه هو السبب او انه قام بعمل شيء‬
":‫سيئ واالخر رد عليه" انت السبب" " ال انت السبب مش انا" او "انت بديت بالمكشلة" " والثاني يرد‬
‫ال انا رديت على اللي انت عملته معي‬

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  Feedback has two forms (positive and negative). Positive feedback, which leads
to a response in family that exacerbates the problem.

‫عادة في العائالت تستمر المشكلة بسبب طريقة و أسلوب العائلة في التعامل معها‬
،‫ بعد والدة الطفلة صار الولد يتصرف بطريقة غريبة‬-‫ سنوات‬3 ‫ أسرة أنجبت طفلة جديدة و لها أخ عمره‬:‫مثال‬
‫ األب صار يضرب ابنه ليتصرف بطريقة أفضل و‬.‫يحاول لفت االنتباه له من خالل مسالك عدوانية ناحية أخته‬
‫ لكن الولد زاد سلوكه سوءا و تطور إلى تبول ليلي و اضطراب في الشهية و محاولة شد‬,‫يعدل مسالكه الصعبة‬
‫ سلوك األب العدواني و عدم تفهمه لما يجري عند ابنه و ضربه أدى إلى زيادة‬.‫شعر الوليدة عدة مرات و عضها‬
‫حدة المشكلة‬.

‫ أن يتم توضيح أن االبن يحتاج إلى رعاية وحب واهتمام و إشعاره بأنه ليس مهمل وأن أخته لم تحل محله‬:‫البديل‬
‫ كذلك من الممكن إهمال سلوك لفت االنتباه واالستمرار في إظهار الحب‬، ‫مما يؤدي الى توقف السلوك العدواني‬
.‫للولد وهو ما يعرف باالمحاء او االطفاء في المدرسة السلوكية‬

However, positive feedback loops is a central concept in strategic therapy. For the
MRI group, this is translated into a simple yet powerful principle of problem
formation in the family. Whether a situation becomes a problem or not, is dependent
on the family members' perception and response to the situation. For example: if a
family encountered a situation that they are unable to solve, they tend to repeat using
the same ineffective solution over and over. This makes the problem persistent and
even can become chronic. The vicious cycle continues. In such situation there is a
need for change. Change in families takes two forms:

1. First order change of family rules: when there is a change of problematic

behavior only. ‫تعديل السلوك الخاطئ‬

2. Second order change: when family change the rule itself because it no more is
useful or applicable.
‫من المهم تعديل القانون العائلي ألنه غير مالئم وال يحل المشكالت‬

Reframing is a technique used to change family rules. It means: reinterpreting the

behavior in a more acceptable way or logical way. For instance, the behavior of a
disturbed child is reframed as being " fearful" or "displacing anger".

Jay Haley added a functional emphasis to the cybernetic interpretation with his interest
in the interpersonal payoff of behavior. Later, he added structural concepts picked up
in the years he spent working with Minuchin. According to Haley, rules have

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hierarchical structure. Inadequate parental hierarchies lie behind most problems. Haley
borrowed the technique of prescribing ordeals from Milton Erickson. This means
that the price of keeping a symptom or a problem outweighed that of leaving it or
giving it up. A person may make the effort of trying to stop an aggressive behavior
instead of being accused by others of being crazy or sick.

Cole Madanes emphasized the functional aspect of problems in families, particularly

rescuing operations involved when children use their symptoms to engage their
parents. There is a protective function of symptoms for the whole family. Usually, one
member in the family develops symptoms to rescue his or her family from dissolution
or breaking. For instance, a girl may through a temper tantrum after observing her
parents fighting. Thus, the parents stop fighting and pay attention to her tantrum or
problem.

In strategic model there are three basic explanations of how problems develop:

1- Cybernetic: difficulties are turned into chronic problems by misguided

solutions, forming positive feedback escalations. Symptomatic families
are trapped in dysfunctional, homeostatic patterns of communication.
They cling to their rigid ways and respond to signs of change in a
negative way. Change is treated as a threat rather than as a chance for
growth.
2- structural: problems are the result of incongruous (inappropriate)
hierarchies (order)
3- Functional: problems result when people try to protect or control one
another covertly, so their symptoms serve a function for the system. The
symptoms maintain system’s homeostasis.

Problems are maintained by self- defeating patterns of behavior. In addition, there is

a structural dysfunctional organization of behavior whereby the family has problem in
their hierarchy. If parents are not in charge, and the family is unable to modify its
structure to adapt to change or problems, this family will be stuck in dysfunction and
pathology. Family problems increase and symptoms of dysfunction appear if the
family could not make adaptation to every life cycle it goes through.

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The use of paradox: Paradox ‫ التناقض‬/ ‫المفارقات‬- is inconsistency that follows correct
assumption from logical evidences. ‫عبارات متناقضة ظاهريا وتتعارض مع المنطق والواقع‬
‫والبديهيات‬

In families, paradox in communication takes the form of paradoxical injunction ‫القصد‬

‫ التناقضي‬. Paradoxical injunction is to demand a behavior or something that only can be
done spontaneously. For instance, love is not obligatory or comes out of demand; it is
spontaneous. We cannot force others to love us. Example: “you should love your
father”; “tell me that you love me”; “ you should be a good boy” . The choice for such
a person is either to comply with the request of the mother or father, or oppose them
and be different than what they are asking. Example: “the boy is telling Mom that he
does not love her or does not stand his father” or “behaving as a bad boy and making
more problems to his family inside and outside the home.

Continual exposure to paradoxical communication is like the dilemma of being in a

nightmare but you cannot wake up from it. Nothing the dreamer does can help him/
her unless he waked up. In families where they have a continuous problematic
behavior such as fighting a lot, increasing the fighting maybe suggested in extreme
cases by the therapist. Then, the family will either resist the therapist and stop the
fighting, or fight more as the therapist requested. In both situations, they have control
which means that they can change their behaviors and find solutions for the fighting
through better communication and interactions.

Double- bind communication:

The family members give contradictory messages to each other. They are not aware of
the discrepancy in messages thus the other members get confused and do not know
how to respond or what to do. Example: “the husband says he is democratic and fair
with his wife; however, he treats her badly and sometimes hits her or humiliates her”.
Another example: the mother asks her son to stop smoking, but she smokes Shisha/
Nargila. Such a situation would confuse the family members because the rules are
not clear; the right- wrong behavior is ambiguous.

The MRI approach to problem solving:

First: identify the positive feedback loop that maintain problems

Second: determine the rules that support those interactions
Third: find ways to change the rules

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The MRI group believe that their work ends when the family move from the stage of
being stuck to the stage of moving. No further work is done with the family unless
they ask for specific things. A great emphasis is placed on establishing goals for the
family. These goals should be realistic and behavioral in nature. Changing behavior of
family members is an important approach of strategic family therapy.

For the MRI group, the way to resolve problems is to change behavior associated with
them. It is believed that through seeing the results of altering rigid behavioral
responses, clients will become more flexible in their problem-solving strategies. When
this happens, clients achieve a second-order change- a change in the rules governing
their response to problems.

Milan’s systemic therapist would not focus so much on attempted solutions but,
instead would ask about past and present relationships in the family. In doing so, the
therapist is uncovering a network of power alliance and coalitions between family
members that constituted the family’s “games”. The sick person or the one with the
psychological problems uses his/her illness or problems to protect other family
members. For instance, if Omar is having enuresis and his parents focus on his
problem and forget their conflicts and stopped fighting, then if he stopped having
enuresis, his parents will go back to fighting and may get divorced or his mother may
leave the house. Another example: Mariam is having conflicts with her parents and
she stopped visiting them. She claims that she does not have time because she is busy
with her daughter who had behavioral problems and poor achievement in school.
Mariam keeps saying that her daughter’s problems make her unable to socialize with
people including friends and her family of origin. Mariam’s daughter acting dependent
and as a problem- maker to protect her mother from shame and guilt toward her family
of origin. The daughter is saving the face of the mother, thus if she behaved nicely and
started to get high grades, Mariam would be forced to go back to conflicts with her
family and has to let go with “games” of being busy and should resolve conflicts with
her family of origin, maybe blamed by them, or get hassled by them.

Haley's approach is behavioral with an ultimate goal of reorganization of the family,

particularly its hierarchy and generational boundaries. It is the therapist's
responsibility to motivate clients to make change through using various techniques.

In Haley’s approach, the therapist focuses on family problematic communication

patterns that maintained the problems. He/she will ask family members to alter their
behavior through pointing at the problematic behavior (build insight) or simply by

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manipulating them (beat families at their own games) to create therapeutic change. He
asks family members to change their behavior through building insight with them and
focusing on problematic behaviors and how are they created in the family.

Haley used to provoke the client to rebel and become in charge of his behavior or
action. For instance, he used to ask a schizophrenic client to hear voices. The client
would either follow the request and starts to hear voices thus he is responsible of the
hallucinations (which is usually uncontrollable), or he refuses to hear voices and
resists them, thus he is in control of his hallucination. This is known as paradoxical
injunction. In the 1980s the Milan group stopped using paradoxical interventions

Haley believed that telling people what to do is wrong because this only mobilizes
resistance. The alternative is to show them how behavior changes perception rather
than the other way around (behavioral approach).

Strategic Family Therapy Goals

• Great emphasis is placed on establishing goals for the family. These goals
should be realistic and behavioral in nature.
• Changing behavior of family members is an important approach of strategic
family therapy.
• Resolve presenting problems by focusing on behavioral sequences
• Get people to behave differently
• Shift the family organization so that the presenting problem is no longer
functional. For example: enuresis of the daughter did not rescue the marriage
and her parents continue to fight
• Move the family toward the appropriate stage of family development. Problems
often arise during the transition from one developmental stage to the next

Strategic Family Therapist’s Function

• Therapist: consultant, expert, stage director
• change is the therapist’s responsibility

Treatment approach
1. Assessment: this includes trying to understand and analyze the problems and their
origin; deciding what are the main problems. The therapist asks questions about
couple’s relationship and how did they meet and get married. The therapist also

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 observes in the session the pattern of interaction and communication of family
members. As well, the family will discuss the problems and decide what things
are being done in a faulty way, and roles of each member in causing and
maintaining the problems.
2. Giving directives: asking families to do certain actions outside the sessions. For
example, the therapist asks the family or the couple to go out together or do
something inside the home together; something new or a task that will be done
differently. Example: the husband who never cooked will make lunch; a son will
clean his room every day; a child will make a behavioral chart for his enuresis.
3. Pretending techniques: acting or doing the behavior or the problems as it usually
happens in home, and asking parents to pretend that they are helping their child to
get over the problem. The therapist learns about the way the families usually
solve their problems and what they routinely do. Thus, the symptomatic member
of the family will give up the behavior as he/she learns that the others around
him/her are aware of the purpose this behavior is serving. Thus, there is no need
to continue repeating the inappropriate behavior or playing the “games” . This
approach is like drama games and role playing where the parents and the
symptomatic child does things in the same way as usually and the parents act the
same way they usually do. The play should be acted several times by the family
outside the session till they understand that the bad behavior can be controlled
and changed.
4. Creating ordeals: the therapist prescribes actions or things that make the
symptoms more troublesome rather than being useful or worthy. The therapist
complicates the situation by asking the clients and families to feel bad about their
problems and that they are losing more through continuation of the pathology.
When the family realize that it is more difficult to have symptoms than to give
them up, the person will give up the bad behavior alone. One example is to ask a
client who has obsessive- compulsive hand - washing to wake up at night during
sleeping and to wash hands many times. Another example is to ask a daughter to
give a gift for her mother every time the girl attacks or fights with her mother, or
the opposite. The therapist may ask a child who is disorganized to burry all his
toys or put them in a barrel every time he misses up with them or leave them on
the floor with the participation of the father or mother. When the child wants to
play again, he has to dig into the sand or the barrel to find his toys. Then, no more
he will leave the toys in the house.
5. Reframing : rephrasing the meaning of certain behavior or action in a positive or
new way. The members will have a new perspective about the behavior of each

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 other. For instance, an adolescent with anorexia nervosa, is caught up in a power
struggle with her parents, and use the symptoms in an attempt to defeat one
parent for the sake of the other.
6. Rituals: asking family members to do things in a certain way every day, or every
other day. Rituals are used to engage families in a series of actions that ran
against rigid family rules and myths. Rituals may also be used to dramatize
connotations. For example, each family member will thank the client for having
the symptoms to maintain the family bonds or ties. Another example: the
therapist may ask the father of an enuretic child to clean the child on odd days
while the mother stays away, while the mother cleans for the child in even days
without any interference of the father. A third example: Rami is four years old
who through a temper tantrum when he wants something and the mother says no
to anything Rami wants. The mother gives Rami things to stop his shouting and
swearing. The new ritual will be to use timeout with Rami every time he goes
into temper tantrum. Like this, the family members create new rituals for
themselves while older rituals start to fade away.
7. Positive connotation: symptoms serve a protective function in families. This
could be for preserving the family overall harmony or protecting certain members
in the family. The child starts crying to divert attention of parents from a fight
that could threatens the family continuity. The therapist builds his hypothesis
about the purposes of the maladaptive behavior or feeling of the child then shares
it with the family. They discuss the hypothesis and try to build insight into how
their actions perpetuate the pathology inside the family but without their
awareness. This is done usually unconsciously.
8. Asking circular questions: developed by Boscolo and Cecchin away of the Milan
group. Circular questions help the family members to see themselves in a
relational context and seeing that context from the perspective of other family
members. The therapist asks the client to think about relationships inside the
family and see how pathology is developed as a reaction and outcome of
interpersonal relationships that take certain pattern.

For example, a therapist may ask a girl to explore how her father could make a
difference in her life if her mother steps out and gives more freedom to the father to
speak or make decisions.
‫المعالج يطلب من الفتاة ان تفحص مع نفسها ماذا سيحصل لو قامت والدتها باحترام والدها بشكل أفضل‬
‫وإعطاءه فرصة للتعبير عن نفسه واتخاذ قرارات في األسرة‬
‫المعالج يطلب من الزوج ان يفكر فيما لو قامت زوجته بإنهاء دراستها ثم بدأت العمل لتساعد في مصروف‬
‫البيت ماذا من الممكن ان يتغير في األسرة‬

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The therapist asks circular questions out of genuine curiosity as a way of joining the
family in a research journey regarding their problem. Then, the family can arrive to a
better comprehending of their problems.

9. The therapist is actively involved in therapy with the family. Neutral therapists
are viewed as cold and distant from the family, which may make the family leave
therapy.

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