Milan Systemic Family Therapy

1. Lecture 5: Introduction to Social
Constructionist Model: Milan School
Systemic Comparative
Kevin Standish
Newham College University Centre

2. Learning Outcomes
1. Identify the background influences
2. Describe the core concepts of Milan Family
Therapy (MFT)
3. Conceptualisation of problems in MFT
4. Therapeutic goals in MFT
5. Therapist role in MFT
6. MFT interventions
7. Evaluation of MFT

3. Founders
Key influences
1. BACKGROUND

4. Core systemic influences
• Gregory Bateson’s circular epistemology.
• Greatly influenced by the works of the Mental
Research Institute (MRI) & brief therapy
• Pragmatics of Human Communication by
Watzlawick, Beavin, and Jackson (1967). Strategic
therapy
• Key publication: Paradox and Counterparadox
(1978) : understanding the family over time and
trying to determine how the family came to “need”
the problem they were attempting to resolve.

5. Model based on complexity
•
•
•
•
•
System theory – von Bertalanffy(1967)
‘pattern which connects’ –Bateson (1979)
cybernetics
Double bind hypothesis – Bateson 1950s
Family homeostasis hypothesis –
Jackson
( 1957) –> conjoint FT ( similarity to
homeopathy) -> paradoxical intervention ->
strategic approach.

6. Founders of Milan Family therapy
Mara Selvini Palazzoli
Gianfranco Cecchin
Lynn Hoffman
Guilana Prata
Luigi Boscolo
Peggy Penn

7. Major Theorist: Mara Selvini Palazzoli
• Specialized in eating disorders but became frustrated
with lack of results
• Led group of psychiatrists who formed Center for the
Study of the Family in Milan, Italy
• Described families as engaging in series of games
– Families stabilize around disturbed behavior to try & benefit
from them
– Therapists meet with families & then parents separately to
give invariant or variant prescription to produce firm
boundary between generations

8. Team split in 1980
• Selvini Palazzoli and Prata
developed
the
strategic
aspects of the original model
further by outlining the
development of particular
types of problem maintaining
interaction patterns that they
referred to as family games.
•
strategic therapy
highly directive)
style->
• Cecchin and Boscolo have
evolved
a
noninterventionist
style
premised
on
social
constructionism where the
therapist’s use of circular
questioning opens up space
for the client and therapist
to co-construct multiple
new perspectives on the
problem situation

9. 2. CORE CONCEPTS

10. Core concepts/assumptions
• The principal assumption is that the
presenting symptom serves a function of
helping to maintain the family system’s
homeostasis.
• “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, & Prata,
1978, p. 3)

11. Premises of the Theory: Systemic
• Therapist will take systemic view of problem
maintenance & strategic orientation to change
• Symptoms serve a purpose
• Concentrate on consequences of family
communication patterns & conflict between competing
hierarchies
• Therapeutic neutrality — keeps therapist from being
drawn into coalitions & disputes & gives therapist time
to assess family dynamics

12. PRINCIPLES
• Double bind - ability to communicate different, and often
conflicting, messages simultaneously
• While all relationships are governed by ‘rules’ they frequently
lack rules to change the rules about how members deal with
each other
• Therapist takes charge of symptom and prescribes
• The person(s) no longer do(es) it because he ‘cannot help it’,
but ‘because my therapist told me to’.

13. EARLY MILAN MODEL
•
•
•
•
•
Paradoxes
Counter paradoxes
Positive connotation
Long brief therapies
Team of therapists

14. Milan school- salient features
•
•
•
•
•
Five part therapy sessions.
The use of co-therapy and a team behind a screen.
Commitment to the guidelines of hypothesizing.
Circularity and neutrality & circular questioning.
End of session interventions involving positive
connotation and the prescription of rituals, some of
which were apparently paradoxical.
• In second-order cybernetics, the therapist becomes part
of the system being observed rather than being an
outsider observing a family system.

15. 3. CONCEPTUALISATION OF
PROBLEMS IN MFT

16. Problem Conceptualisation
• symptom serves a function of helping to
maintain the family system’s homeostasis
• entire system is caught up in “family games”
whose purpose is to control individual family
members’ behaviour in response to flaws
within the family hierarchy
• The games are played through
unacknowledged alliances and coalitions.

17. Problem Conceptualisation
• Family members become symptomatic in an
attempt to either deal with isolation or retaliate
against family members for the hurt they are
experiencing (Campbell, 1999).
• The symptom or problem that developed within
the family was not viewed as coincidental.
• the symptomatic family member has taken his or
her attempt to control too far and the result is a
symptom or diagnosis

18. The problem of the referring person
• Failure to examine the problem of the
referring person resulted in unsuccessful
therapies.
• The referring persons is suspected of being a
homeostatic member of the family (eg.,
doctors who have been treating the family for
years and have formed a friendship with
them, young "supportive"-type psychiatrists
or psychologists, or social workers acting as
liaison between the patient and the family)

19. The problem of the referring person
• They argued that taking information about, and
potentially from, the referring person was a key way
to understand how the family presented for
assistance, and how therapy might progress.
• Without this understanding, the referring person
could become a 'grave problem' for the therapy,
given that s/he may hold a pivotal role in stabilising
the family or, in other ways, do some of the family's
emotional work for them.
• Palazzoli, Mara S.; Boscolo, Luigi; Cecchin,
Gianfranco; Prata, Guiliana The problem of the
referring person. Journal of Marital and Family
Therapy, Vol 6(1), Jan 1980, 3-9

20. In the Milan approach, change occurs when the family
is able to see their problems in a more systemic and
healthy way (i.e., recognize that their problem may be
serving a purpose).
4. THERAPEUTIC GOALS IN MFT

21. Change
• relationship-centered questions reveals new ways
of thinking.
• the family must face the reality of the
relationships experienced by each individual
family member.
• There is a shift in how the family views their
problems: no longer ascribe blame individual
family member—rather, see their problems as
family problems
• every family member must change, as opposed to
only the symptomatic family member, resulting in
second-order change: purposefully changing the
rules of their system.

22. Formulation…
1. Families in “problem saturated” transactions
– games
2. Family members unilaterally try to control
each others behaviour
3. Therapist to discover and interrupt these
games

23. The therapist’s role, simply stated, is to be
curious and creative
5. THERAPIST ROLE IN MFT

24. Role of the Therapist
• observe the patterns of family interactions
and uses techniques for making therapeutic
interventions
• Both expert & co-creator of evolving family
system
• Is neutral – does not overtly challenge or
change families; argues against change
• Takes a non-blaming stance, gives directives,
uses circular questioning & other indirect
forms of intervention

25. Role of the Therapist
• Stresses positive connotations of behavior
• the therapist uses curiosity to help
navigate the questions, which allows the
therapist to be observant for openings.
• The opening conceives a space for the
therapist to help the family to see their
problems in a new way.

26. positive connotation,
hypothesizing
circular questioning;
neutrality.
6. MFT INTERVENTIONS

27. Session Structure
1.
2.
3.
4.
Presession- hypothesis from telephone call
Phase 1: Joining and Building Rapport
Phase 2: Understanding the Presenting Issue
Phase 3: Assessment of Family Dynamics – validate,
modify, change hypothesis
5. Intersession – discussion with reflecting team
6. Phase 4: Goals generally are NOT set. Trust the system
to resolve itself
7. Phase 5: Amplifying Change / Intervention: Positive
connotation and rituals
8. Phase 6: Termination
9. Post session discussion
There is a reflecting team behind a one way mirror.

28. Positive connotation
• Similar to positive reframing; however, it
includes a systemic component.
• reframe problem as one that preserves family
homeostasis
• the therapist can help the family begin to
realize the homeostatic need for the
behaviours.
• The symptomatic family member is seen in a
more favorable light, and the symptom may
actually be welcomed

29. Treatment Techniques
• Hypothesizing — prepares team members to
treat family
• Circular questioning — focuses attention on
family connections by addressing differences
in perception
• Neutrality- is an attempt for the therapist to
see each person’s point of view. This later
changed to curiosity (Cecchin 1987)

30. Hypothesizing
• Systemic hypothesizing is the Milan therapist’s
way of confirming or disconfirming necessary
information regarding how the family functions
and how the therapist conceptualizes their
functioning.
• Hypothesizing begins with the initial telephone
call from the family.
• Prior to the first session, the Milan team exhausts
all possible hypotheses about the family’s symptoms and functioning based on the telephone
conversation.

31. Hypothesizing
• reflecting team members inform the therapist halfway
through the session of the new developed hypothesis.
• A new therapeutic direction may develop based on the
consensus of the reflecting team
• As the session comes to a close, the team arrives at a final
neutral hypothesis : the most systemic and powerful
hypothesis for the family.
• The final hypothesis not ascribe blame to any single family
member; often results in a prescription or ritual developed
by the
• reflecting team.
• Later, after the family leaves, the reflecting team and
therapist discuss how the family reacted to the intervention
and plan for the next session.
• In some cases, a therapeutic letter is written

32. Circular Questioning
• Circular questioning is an interviewing method
used to gain descriptive assessments and deliver
interventions through questioning of the family
members
• Circular questioning is to expand the family’s
beliefs beyond the meanings that they currently
hold.
• This is often done by asking questions to
individuals that probe how others view the
situation.

33. Circular Questioning
• Meaning formulation is an important component
of this approach to develop context. “Without
context, there is no meaning” (Campbell, 2003, p.
19).
• to examine their belief systems and the Meanings
that they attached to their behaviours.
• based on inquiries about the differences within
the relationships of family members and their
perceptions

34. Circular Questioning
• The therapist continually searches for patterns,
feedback loops, differences in beliefs among
family members (called openings), and the
covert rules that support family interactions.
• openings allow a place during the session to
begin questioning, , and exploring differences

36. Karl Tomm 3 papers
1. (1987) Interventive Interviewing: Part
1. Strategizing as a Fourth Guideline
for the Therapist
2. (1987) Interventive Interviewing: Part
11. Reflexive Questioning as a Means
to Enable Self-Healing
3. (1988) Interventive Interviewing: Part
111. Intending to Ask Lineal, Circular,
Strategic,or Reflexive Questions?

37. Neutrality/Curiosity
• neutrality was that if every family member were
asked at the end of a session, ‘Whose side was the
therapist on during the session?’ they would all say,
‘My side’”
• neutrality has been misunderstood and challenged as
implying cold or aloof (Cecchin, 1987)
• A curious therapist allows all family members a voice
• Therefore, adhering to neutrality, the curious
therapist is more likely to be open to numerous
hypotheses about the system and invite the family
members to explore those hypotheses, increasing
the number of options for change

38. Treatment Techniques
•
Rituals:
–
–
–
Engage family in actions that run counter to, or exaggerate,
rigid family rules & myths
Occur daily at mealtime, bedtime & during chores
Include 5 components essential to family health:
•
–
–
Membership; Belief expression; Identity; Healing; Celebration
Purpose - change cognitions or meaning of behavior
Therapist should be specific in what is to be done, who is
to do it & how it is to be done

39. PARADOX
•
" …the specific tactics and manoeuvres which are in apparent
opposition to the goals of therapy, but are actually designed
to achieve them
• “. . . paradox not only can invade interaction and affect our
behaviour and our sanity, but also it challenges our belief in
the consistency, and therefore the ultimate soundness of our
universe”

40. PARADOX: When to prescribe?
1. Presupposes an intense complementary relationship, with a
high degree of survival value for the family
2. Within this context an injunction is given which is
structured so that it
• (i) reinforces the behaviour that the patient expects to
be changed
• (ii) implies that this reinforcement is a vehicle of
change, and
• (iii) creates a paradox by telling the patient to change
by remaining unchanged.
3.
The therapeutic situation prevents the patient from
withdrawing or revealing the paradox by commenting on it,
by virtue of (i) and (ii).

41. Process & Outcome
• Symptom resolution in 10 or fewer sessions
• Family dynamics change
– Systemic connection becomes clear
– Member stops being scapegoat
– Games change
• Old epistemology is discarded & more
productive behaviors emerge
• Process of growth continues

42. Unique Aspects of Systemic Theory
• Flexibility makes it applicable to treating a
variety of families
• Therapists work in teams
– Some in room, some behind one-way mirror
– Papp’s “Greek chorus”
• Concentration on one problem over short
period of time

43. period
Ten months, divided into ten sessions spaced at monthly
intervals
Initial contact
Usually telephonic Therapist ties to maintain neutrality in
order not to be seen by other family members as being in a
coalition with the whoever made the initial call Questions
phrased in social terms
Calls between sessions
Neutral stance of therapist maintained In case of emergency
calls (e.g. suicide attempts) therapist assumes role of social
control agent rather than that of therapis
Resources
Therapist brings in other members of the therapeutic team
Supervision Observatio
Therapy session – five components Team discusses the family Family interview with other team
members observing Team discussion of the family and the
session Conclusions of the team presented to the family
with other team members observing Post-session where
team sums up
Termination
Mutual agreement by therapist and family Respect for
family’s decision to terminate Warning of possibly of relapse
or doubt

44. SUMMARY
• Circular questions asked from positions of curiosity and
irreverence (neutrality) to bring forth the family’s
construction of the problem.
• Challenging the family belief system that underpins
problem maintaining interaction patterns.
• Circular questioning within sessions and end of session
interventions are used to promote change.

45. 7. EVALUATION OF MFT

46. Comparison with Other Theories:
Systemic
• European bias toward nonintervention makes it not
widely used anywhere besides Europe
• Controversial view of schizophrenia
– Palazzoli believed it resulted from child’s attempt to take
sides in stalemated relationship between parents
• Tailor interventions to specifics of family
– Therapists responsible for creating innovative treatment
plans
– Limited generalisation of specific interventions

47. Evaluation
• Post-Milan therapists also moved away from
desiring particular outcomes from therapy and
instead saw their role as merely to “poke the
system” (jar the system, perturb the system),
which left families responsible for the outcome.
• Milan family therapy has been shown to be
effective with families dealing with various
childhood disorders, including oppositional
defiant disorder, attention deficit disorder,
autism, childhood depression, and anxiety.
• Additionally, couples with marital/relational
issues find benefits, as do families with a member
involved in drugs or alcohol.

48. Evaluation
• Families seeking answers to the past or desiring
an analysis of why their problems have developed
will not benefit as much because the Milan family
therapist does not pathologize.
• Milan family therapy might not be as culturally
sensitive as necessary: today you need to
incorporate sensitivity to cultural, racial, and
sexual orientation differences into a hypothesis
formulation

49. Readings
• Selvini et al (1998) Hypothesizing, Circularity, Neutrality,
Three guidelines for the conductor of the session. (Required
reading)
• Ceccin (1993) Hypothesizing, Circularity and Neutrality
Revisited an invitation to curiosity (required reading).
• Dallos, R. & Draper, R. (2010) chap 1 & 2
• Metcalf, L. (2011) Chap 9
• Burnham & Harris (1992) Systemic family therapy the Milan
approach
• Tomm (1995) Circular interviewing: A multifaceted clinical
tool.
• Tomm,K.(1987) Interventive_interviewing part 1. Strategizing
as a fourth guideline for the therapist
• Advanced reading
• Brown (2010) The Milan Principles extinction, evolution or
emergence