Psychotherapeutic Methods - The Milan School of Family Therapy

The Milan School of Family Therapy

Point of Reflection

• How has your thinking about families been influenced by systemic theory?
• How has your thinking about therapy been influenced by systemic theory?

Historical Background – The First Phase

• Selvini Palazzoli and her colleagues became increasingly dissatisfied with the psychodynamic model in treating persons with anorexia.
• This led them to look elsewhere for other therapeutic modalities.
• They spent a year at the MRI institute, focusing on developing ways to intervene strategically with family patterns of behavior that were repetitive and redundant.
• Families were treated by male-female therapists and observed by other members of the team.
• They published the book ‘Paradox and Counterparadox’ to illustrate the work that they had been doing.

The Milan School's Approach

• The Milan team adopted the term ‘systemic family therapy’ for their approach.
• The Milan School firmly established themselves as the systemic model.
• Quote from Paradox and Counter paradox: ‘the family is self-regulating system which controls itself according to rules formed over a period of time … (which)… come to exist … through a series of transactions and corrective feedbacks… (which determine) what is permitted in the relationship… these rules have the quality of communication.

Standard Session Format (First Phase)

• The standard format of a session had five parts: pre-session, session, inter-session break, inter-session intervention, and post-session discussion.
• During the session, the team formulated an initial hypothesis about the family’s presenting problem, validating, modifying, or changing it as the session progressed.
• After about forty minutes, the entire team would meet alone to discuss the hypothesis and arrive at an intervention.
• The treating therapist would then deliver that intervention to the family, either by positively connoting the problem situation or by assigning a ritual to be done by the family that commented on the problem situation and was designed to introduce change.
• Finally, the team would meet for a post-session discussion to analyze the family reactions and to plan for the next session.

The Five-Phase Session

• The Milan School divided the therapeutic encounter into 5 phases:
  • Pre-session: The team prepares for meeting with the family, reviewing referral information or previous session details to elaborate on directions for the session.
  • Session: Typically involves a male and female therapist with the team observing from behind a one-way mirror.
  • Intersession Break: 45 minutes into the session, the therapists leave to confer with the consulting team behind the one-way mirror to propose interventions.
  • Final intervention: The interviewing therapists give a message to the family, usually asking them to behave in a certain way until the next session.
  • Post-session: After the family leaves, the team reviews the impact of the message and plans for the next session.

Techniques - Positive Connotation

• It was the most distinctive innovation to emerge from the Milan model.
• Derived from the MRI technique of reframing symptoms as serving a protective function. Example: an adolescent needs to continue feeling depressed to distract the parents from their own marital issues.
• The Milan team believed that people did not change when they are being criticised so they tried to find a positive explanation for whatever behavior was exhibited.
• The team would hypothesize how the patient’s symptom would fit into the family system and deliver this during the final intervention with the injunction that it should not change.

Positive Connotation Details

• The Positive connotation must include the entire family system and confirm that the behaviour of all family members is maintaining the stability and cohesion of the group.
• Example: Carlo (son) should continue to sacrifice himself by remaining depressed as a way to reassure the family that he will not become an abusive man like his grandfather. Mother should continue her over-involvement with Carlo as a way to make him feel valued for his sacrifice. Father should continue criticizing the mother and son relationship so that the mother will not be tempted to abandon Carlo and become a wife to her husband.

Rituals

• Rituals were used to engage the family in a series of actions that ran counter to or exaggerated rigid family rules and myths.
• Example: A family that was enmeshed with their large extended family was told to hold family discussions behind closed doors every other night where each member had 15 minutes to speak about the family. Meanwhile they were to redouble their courtesy to the other members of the clan.
• Rituals were also used to dramatize positive connotations. Example: Each family member were to express his or her gratitude each night to the patient for having the problem.

Odd-and-Even-Days Format

• The Milan group also devised a set of rituals based on an odd-and-even-days format to break the family’s rigid stances and get them to react differently to each other.
• Example: a family in which the parents were disputing parental control were told that on odd days of the week the father should be in charge of the patients behaviour and without the mother interfering, and on even days of the week, the mother would be in charge.

Historical Background – The Second Phase

• The Milan team then took in Bateson’s ideas on difference, and this introduced a change in their style of work.
• They worked on the principle that therapists need to start looking at the families belief systems.
• Family beliefs that do not fit reality introduce difference in the belief system of the family.
• Therapy is seen as a means of introducing change and difference in the family by introducing new meanings.
• Shift of responsibility from the therapist breaking patterns to the family creating new patterns.

Hypothesizing, Circularity, and Neutrality

• They published a new paper to describe their work ‘Hypothesising, Circularity and Neutrality: 3 guidelines for the conductor of a session’ (1980).
• Hypothesizing is the start of the therapeutic journey. Each hypothesis must be similar to but slightly different from that of the family.
• Circularity is the executive part of hypothesizing. The aim of the therapist is to clarify patterns of interaction.
• Neutrality is the sense of respect and acceptance that has towards the family system. Neutrality could be towards persons, beliefs/ideas, and change.

Case Study: Stan’s Family

• A systemic therapist would understand Stan’s problems in the context of his family of origin.
• What hypothesis can we develop from the information we have from the genogram?
• A circular hypothesis is one that connotes the behaviour of each family member together.

Circular Questioning

• It elicits information that will create ‘the difference that will make the difference’ (Bateson,1972).
• It is the act of conducting an investigation on the basis of feedback from the family, in response to the information the therapist solicits about difference and change from different members.
• The aim is to activate the ability of the family to observe itself and its dynamics to create new understanding about the way they interact.

Types of Circular Questions

Triadic Questions

• Questions addressed to a 3rd person about a relationship between another two.
• Helps family members develop a better understanding of their family as a system.
• Enables family’s ability to become observers of their own system.
• Explores different perspectives of the same relationship.

Spatial Difference Questions

• Difference in relationship: who is closer?
• Difference in ideas/beliefs: what is the meaning?

Temporal Difference Questions

• Difference in time frame: who was closest before/during/after?
• Past-Past: was there more fighting before or after..?
• Past-Present: was father closer to X now or when younger?
• Past-Future: if you had less children, would it be more less likely that you will be together?
• Present-future: if instead of father always leaving, mother left, what would happen?
• Future-future: if mother left, would father be more likely to get closer to family – or less likely?

Clarification Questions

• Therapist might ask around a series of differences to generate a classification around a certain dimension: Who is the most worried about issue X – how does he/she show it? Who is the second most worried about the issue?

Behavior Effect Questions

• Therapist clarifies behaviour sequences: When does Sally refuse to eat? What does mother/father do? What does father do when mother…?

Developing Circular Questions

• Develop circular questions that might help you understand more about Stan and his family.
• Circular questions are structured so that one has to give a relational description in answer.

The Last Phase

• In the early 80’s the team split around the nature of therapy.
• Selvini Palazzoli maintained the model’s strategic and adversarial stance although she stopped using paradoxical interventions.
• Together with Prata, they started using the invariant prescription which they assigned to each family they treated.
• In the invariant prescription the parent were asked to go out together without telling anyone else in the family of their whereabouts and to be mysterious about where they went. The goal was to strengthen the parental alliance and reinforce the boundary between generations. They believed that anorexic and psychotic patients were caught in power game that originally was of the parents and into which they were pulled using their symptoms to defeat one parent for the sake of the other.

Post-Milan Techniques

• Boscolo and Cecchin moved away from strategic intervening but moved toward a collaborative style of therapy. This came from their belief that the power of intervention was in the interviewing process itself.
• Cecchin and Bosscolo established a new version of the Millan school called the ‘Post-Milan’.
• Cecchin believed that the therapist should take a stance of curiosity and join the family in a research expedition regarding their problem.
• According to him, curiosity was the most useful therapeutic stance as he said ‘Curiosity leads to exploration and invention of alternative views’ (1987, pg. 406).

Post-Milan Techniques Continued

• The post-Milan therapists did away with the final ‘message’ and sought to help the family re-think their lives throughout the course of the session.
• Another important idea coming from this new era Is the idea of ‘second order cybernetics’ i.e. it is impossible to describe a human system without taking into account what the observer thinks she or he sees.
• Another important contribution is the increased emphasis on reflexivity through reflexive questions. Through these questions, the family is helped to reach its own understanding of the family functioning.
• Lastly Tom Anderson (1991) introduced ‘reflecting teams’ a practice whereby the consulting team moves from behind the one-way mirror and talks about their ideas in front of the family to allow the family to hear more ‘news of difference’.

Key Points

• The ideas from the original Milan associates underlie much of the contemporary family therapy practice.
• They established a model for conducting a family therapy session and designed ways of encouraging a systemic perspective to emerge in family thinking.
• The main focus in this approach is on the rules of behaviour within relationships and the meaning of this behaviour within family life.
• The Milan associates first used the one-way mirror as a technique in therapy because it provided the team with a different perspective.
• Many postmodern or social constructionist practices developed out of the Milan approach.