Georg Ivanovas From Autism to Humanism - systems theory in medicine

5.2 Systemic psychotherapy

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b) strategic psychotherapy

Strategic family therapist believe that families tend to organise themselves according to particular sequences of interaction (Hayes 1991). The therapists are concerned with the relational pattern that serves as paradigm. They expect that whatever arises, will bring the family to react according to this typical pattern. In periods of stress this pattern might become more expressive leading to wrong solutions, because it is so rigid. In cybernetic terms it can be assumed that the family enters a positive feedback loop or a vicious cycle when under stress (heated up). The problem may even be intensified by the family’s attempt to interrupt it. Then the solution becomes the problem (Hayes 1991).

Strategic therapy looks at the organisation of the symptom. The symptom is absolutely central and has to be investigated profoundly in regard to relational patterns and the themes that are involved (Papp: 140). So a lot of time is spent in conceptualising the symptom. However, strategic psychotherapy is not so much concerned with the genesis of the repeating pattern in which the symptom is involved (Papp: 141). It is more interested in how it expresses itself and how it is maintained. The strategic therapist believes that the quest for a cause may delay or restrain the family from finding a new and more adequate pattern.

The symptom serves as a starting point for the therapeutic intervention. As all behaviour has a meaning in the context of the family, the signification of the symptom has an importance, as well. When interventions are not aimed at the issue that is most central in maintaining the problem, change, if occurs at all, tends to be peripheral or temporary (Papp: 154). This is comparable to the trigger point of the viscero-neuro-muscular system (chap. 4.8.c).

If a change is introduced through the intervention in one, the others will inevitably change as well (Papp: 145). If a couple has a typical feedback pattern and one partner abstains from participating in this game, the other has to react. He might slow down or, what is more probable in the beginning, will grow wild in order to provoke the other to participate in the usual pattern. This is often seen in quarrelling couples. When one partner does not participate in the usual pattern the other will become extremely offensive such that the former gets furious and only after an intensive fight both partners are able to calm down.

The necessity of a reaction has been illustrated with a sailing boat where both partners sit on opposite sides on the edge, the typical schismogenetic balance. If one of the two goes back into the boat, the other has to react. He will also go back into the boat or will fall over board or the boat will capsize.

This is, in fact, a critical point. Every ill-considered intervention from outside might provoke enormous harm. Probably many situations had worsened and families had unnecessarily been dissolved through therapeutic interventions that violently disturbed a fragile balance, even if, or especially if a symptomatic or ill person is involved. (Comparable developments can be observed in any other regulative network of the human, concerning all sorts of physiological processes, including initial deterioration, chap. 6.11).

The therapy has therefore to disrupt the self-reinforcement cycles carefully. Then the family might find a more adequate behaviour on its own. Finally, the symptom ceases as there is no supporting structure anymore. The therapist does not introduce the behaviour. He even might not understand what all this means. Actually he will never understand as “there are as many causes of x as there are explanations of x“ (Hanson 1972: 54), and in behaviour explanations are numerous.

The strategic psychotherapist tries alter the rules by

  • altering the families perceived reality,
  • provoking a counter-reaction,
  • bringing the family in a dilemma,
  • challenging the family’s belief or to construct a new reality

These techniques (and this is also true for the strategic therapies in general medicine) use the symptom to destabilize the whole situation in order to attain a more sustainable effect. They aim to change the frame producing the symptom.

Some typical strategic techniques are:

a) Reframing

This is the actual attempt to alter how a certain situation is perceived leading to a process of change. Reframing has an immense power as it induces change just by altering the semantic structure of behaviour. It does not change the behaviour as such. It influences the operator of a recursive process.

b) Paradox intervention (prescribing the symptom)

Supporting the existent behaviour and symptoms is the basis of the paradox interventions. They are based on the reflection that any attempt to intervene in a homeostatic process provokes a reaction against this intervention. The best possibility to avoid this is to go with the symptom.

Another paradox intervention is to stress the danger of a too quick change (Papp: 145). All difficulties and implications that might arise through a change (as referred above with the asthmatic child) can be discussed extensively. Interestingly, in this frame such predictions do not work as self-fulfilling prophecies. Practically, they have the opposite effect. Prohibiting change because a certain danger is seen is more beneficial than helping to avoid the present situation because the same danger is seen. This is supported by basic cybernetic models.


c) Pretending

Pretending is a kind of subspecies of a paradox intervention. It is used when a family is governed by a symptom absorbing all attention (the regular asthmatic attack of a child, the vertigo of the wife, the oppression in the chest of the husband). Then the symptomatic patient can be instructed to pretend the symptom regularly. He is obliged to simulate the symptom according to a time table which the other members of the family do not know.

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The question why and how paradox interventions work is controversially discussed. The question is, in a way, an invasion of linear thinking into systemic concepts. My favourite explanation is that in order to fulfil a task the family has to find a consensus and a cooperation on a meta-level that serves as starting point for an improvement of inner balance. This concept of ‘meta-level harmony’ is in line with other methods of naturopathy. But this is only one of many attempts to explain the observed effect. Paritsis counted about 20 possibilities to explain the effectiveness of paradox interventions (personal communication).

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Based on these principles different therapeutic approaches have been developed. Quite known became the Milan school. “They rejected the notions of hierarchy and examined how different levels of meaning were related to one another. They focused on pattern and information, rather than on structure or form” (Hayes 1991). Although it was mainly a strategic approach, the Milan school saw itself in the tradition of second order therapy, where a family’s reality is based on the circular construction of truth. (Selvini Pallazoli et al 1995). As a consequence, “the therapist will not make the stance of arguing for change nor imposing therapeutic goals onto the family. Problems are believed to arise when the therapist loses neutrality” (Hayes 1991).

Later, however, the Milan school split up und the main proponents followed a quite rigid structural approach (Selvini Pallazoli et al, 1989).

It has been said that the structural therapy uses negative feedback mechanisms, strategic therapy positive feedback mechanisms and the school of Milan both. (Hayes 1991). But such descriptions have more to do with the theory of the early proponents of systemic psychotherapy, positions that have been abandoned towards a more empirical stance.

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Many objections have been made, especially concerning the therapist’s ability to judge the structure of a family, stressing the lost coherence of modern family and the current inability to communicate (Anderson 1999). The ‘postmodern’ approach, therefore, rejects all conceptual techniques and is mainly organized around narratives. However, by that, systemic thinking is abandoned. This is highlighted by the fact that the family as such is no longer the centre of interest (Minuchin 1998).


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