Strategic Therapy

Strategic Therapy

Haley" has defined the strategic approach as one in which the clinician initiates what happens during treatment and designs a particular approach for each problem. Strategic therapists take re-sponsibility for directly influencing people. They want to enhance, at least temporarily, their influence over the interpersonal system at hand in order to bring about beneficial change. In fact, they are not as concerned about family theory as they are with the theory and means for inducing change.

The strategic approach has been used with innumerable kinds of problems and several outcome studies attest to its efficacy.'" '5" A number of people and groups are considered representative of this school, such as Milton Erickson, Jay Haley, the Mental Research Institute (MRP group, Gerald Zuk, the Institute for Family Study group in Milan, Italy, Lynn Hoffman, Richard Rabkin, Peggy Papp, Olga Silverstein, Cloe Madanes, and others. All of these therapists do not operate in exactly the same way, but rather than devote space to their individual contributions, styles, and differences, we will instead present some of the concepts, principles, and practices that apply to

most of them, and conclude with an overview of Haley's particular approach.*

Strategic therapists see symptoms as the resultants or con-comitants of misguided attempts to changing an existing difficulty. IS(' However, such symptoms usually succeed only in making things worse, while attempts by the family to alleviate the problem often 

exacerbate it. A symptom is regarded as a communicative act, with message qualities, which serves as a sort of contract between two or more members and has a function within the interpersonal network.'" It is a label for a nonlinear or -recursive- sequence of behaviors within a social organization.' ' '5 A symptom usually appears when a person is -in an impossible situation and is trying to break out of it.-6' P " He is locked into a sequence or pattern with his significant other( s) and cannot see a way to alter it through nonsymptomatic means. The symptom is thus a homeostatic mechanism regulating marital or family transactions:1

A basic tenet of strategic therapy is that therapeutic change comes about through the -interactional processes set off when a therapist intervenes actively and directively in particular ways'' in a family or marital system.6'• P The therapist works to substitute new behavior patterns or sequences for the vicious, positive feedback circles already existing.188 In other words, his goal is to change the dysfunctional sequence of behaviors shown by the family appearing for treatment. Some primary techniques are listed.

1.   The main therapeutic tools are tasks and directives. In fact, this emphasis on directives is the cornerstone of the approach.

2.   The problem must be put in solvable form. It should be something that can be objectively agreed upon, that is, counted, observed, or measured, so that one can assess if it has actually been influenced.

3.   Considerable emphasis is placed in extrasession change—altering the processes occurring outside of the session.

4.   Power struggles with the family are generally avoided, the tendency being to take the path of least resistance and use implicit or indirect ways of turning the family's investment to positive use.'" In fact, the development of techniques for dealing with resistance constitutes one of the foremost contributions of the strategic approach.

-Paradoxical- interventions are common and may be directed toward the whole family or to certain members. This category encompasses more than simply -prescribing the symp-tom,- and may also include strategies outlined by Rohrbaugh et al.121 such as -restraining- (discouraging or denying the possi-bility of change), and -positioning- (i.e., exaggerating a family's position, for instance by becoming more pessimistic than they

are). In a sense, the therapist becomes more homeostatic than

the family and -turns their resistance back on itself. -1".

The strategic approach developed by Jay Haley is the one most germane to our work with addicts. It was originally developed with families of young schizophrenics. However, we felt that of the various symptom groups, schizophrenics' families came closest to addicts' families (but not necessarily families of adolescent drug abusers) in the ways that they functioned and in the skill that they applied in resisting change. Thus, in scanning the approaches that were in use

when we began our work, Haley's model came closer to meeting our needs than most others.

Of the various strategic approaches, Haley's model shares the greatest number of common elements with structural therapy. This is not surprising, since Haley worked with Minuchin and they influenced each other in the development of structural family therapy. In parti-cular, both approaches place considerable emphasis on hierarchical family organization, noting that aberrant hierarchies (such as cross-generational coalitions) are frequently diagnostic of family dysfunction.

In an earlier publication'', PP 58-6" we presented a synopsis, by Haley, of his approach with disturbed young people. It is condensed

 There are certain assumptions that improve the chance of success with young adults who exhibit mad and bizarre behavior, or continually take illegal drugs, or who waste their lives and cause community concern. For therapy, it is best to assume that the problem is not the young person but a problem of a family and young person disengaging from one another. Ordinarily, an offspring leaves home by succeeding in work or school and forming intimate relationships outside the family. In some families, when a son or daughter begins to leave home, the family becomes unstable and in distress. If at that point the young person fails by becoming incapacitated, the family stablizes as if the offspring has not left home. This can happen even if the young person is living away from home, as long as he or she regularly lets the family know that failure continues. It can also exist even if the family is angry at the offspring and appears to have rejected him. Family stability continues as long as the young person is involved with the family by behaving in some abnormal way. A therapist should assume that, if the family organization does not change, the young person will continue to fail year after year, despite therapy efforts. The unit with the problem is not the young person, but at least two other people: these might be two parents, or a mother and boyfriend or sibling, or a mother and grandmother. It is assumed that two adults in a family communicate with each other by way of the young person and they enter severe conflict if the young person is not available to be that communication vehicle. The therapy goal is to free the young adult from that triangle so that he or she lives like other normal young people and the family is stable without the problem child.

This therapy and its premises have no relation to a therapy based on the theory of repression where an individual is the problem. Therefore, there is no concern with insight or awareness and there is no encouragement of people to express their feelings with the idea that this will cause change. Therapists accustomed to experiential groups or psychodynamic therapy have difficulty with this approach.

The therapy should occur in the following stages.

I. When the young person comes to community attention, the experts must organize themselves in such a way that one therapist takes responsibility for the case. It is better not to have a team or a number of separate therapists or modes of therapy. The one therapist must be in charge of whether the young person is to be in or out of an institution and what medication is to be given, and when. Only if the therapist is in charge of the case can he put the parents in charge within the family.

2. The therapist needs to gather the family for a first inter-view. If the young person is living separately, even with a wife, he should be brought together with the family of origin so that everyone significant to him is there. The goal is to move the young person to more independence, either alone or with a wife, but the first step to that end is to take him back to his family.

There should be no blame of the parents, but instead, the parents (or parent and grandmother, or whomever it might be) should be put in charge of solving the problem of the young person. They must be persuaded that they are really the best therapists for the problem offspring (despite past failures in trying to help him). It is assumed that the members of the family are in conflict and the problem offspring is expressing that. By re-quiring the family to take charge and set the rules for the young person, they are communicating about the young person, as usual, but in a positive way. Certain issues need to be clear.

a. The focus should be on the problem person and his The Therapy Model 119 behavior, not on a discussion of family relations. If the offspring is an addict, the family should focus on what is to happen if he ever takes drugs again; if mad and misbehaving, what they will do if he acts bizarrely in the way that got him in the hospital before. If anorectic, how much weight she is to gain per day, and how that is to be accomplished.

b. The past, and past causes of the problem, are ignored

and not explored. The focus is what to do now.

c.  The therapist should join the parents against the prob‑

lem young person, even if this seems to be depriving him of individual choices and rights, and even if he seems too olcl to be made that dependent. After the person is behaving norm-ally, his rights can be considered. It is assumed that the hierarchy of the family is in confusion. Should the therapist step down from his status a S expert and join the problem young person against the parents, there will be worse con‑

fusion and the therapy will fail.

d.    Conflicts between the parents or other family members

are ignored and minimized even if they bring them up, until the young person is back to normal. If the parents say they have problems and need help too, the therapist should say the first problem is the son, and their problems can be dealt

with after the son is back to normal.

e.         Everyone should expect the problem person to become

normal, with no suggestion that the goal is a handicapped person. Therefore, the young person should not be in a halfway house, a day hospital, kept on medication or on maintenance methadone. Normal work or school should be expected immediately, not later. Work should be self-support‑

ing and real, not volunteer.

3. As the problem young person becomes normal (by 'achiev‑

ing self-support, or successfully going to school, or by making close friends) the family will become unstable. This is an impor-tant stage in the therapy and the reason for pushing the young person toward normality. The parents will threaten separation or divorce or one or both will be disturbed. At that point, a relapse of the young person is part of the usual pattern, since that will stabilize the family. If the therapist has sided with the parents earlier, they will lean upon him at this stage and the young adult will not need to relapse to save them. The therapist must either resolve the parental conflict, or move the problem young person out of it while it continues more directly. At that point, the young

person can continue to be normal.

4. The therapy should be an intense involvement and a rapid disengagement, not regular interviews over years. As soon 
as positive change occurs, the therapist can begin to recess and plan termination. The task is not to resolve all family problems but the ones around the problem young person, unless the family wants to make a new contract for other problems.

5. Regular follow-ups should be done to ensure that positive change continues.