Family and Systemic Therapies 353wife no longer runs everything in the house if the therapist is telling her
what to do; or if she resists the directive she will be less domineering.
The assumption is that if the symptom was presented as a way of gaining
an advantage, it will resolve once it puts the patient at a disadvantage
(see Box 41.3).
Humour and metaphor. These may be used to tap into a family’s lighter
side, release pressure, and sidestep logical thinking. To get families to
break out of fixed patterns may require tangential, indirect ‘uncommon
solutions’.
Provision of alternatives. Other activities are suggested to replace the
problem behaviour.
Externalising the problem. This technique attributes agency to the symp-
tom in a light-hearted way to enable the family to unite against it, and
has been well described by Michael White. This places less emphasis on
failure, decreases conflict around the symptom, opens up new possi-
bilities for action, and replaces pessimism with optimism. For example,
rather than blame a boy for soiling, the trouble is ascribed to ‘sneaky
poos’ who have to be taken on in a battle to beat them. Imaginative
charts are drawn to show progress and to make it an epic game where
the child is helped to devise creative strategies to win.Box 41.3An example of classical strategic family therapy using
Haley’s approach
The same family described in Box 41.2 is interviewed. However, this time no
structural reorganisation of seating arrangements is made. The therapist notes
that Robert’s abdominal pain serves to keep his mother at home looking after
him rather than return to nursing as she says she wants, but doesn’t seem really to
want. The therapist tells the family that the situation is serious and instructs Mrs
Jones to increase her surveillance of Robert, checking his pain level every hour for
the next fortnight, and under no circumstances is she to leave him unattended
in the house. Robert is to report the slightest twinge of pain, being told that
otherwise, if it is left too long, it is likely to get far worse. He must ask his mother
to attend to him very closely, irrespective of her sacrifice.
After two weeks of this, the family gradually become aware of how dominating
Robert’s pain is. Mrs Jones gets fed up with waiting on him hand and foot. Robert
himself feels constrained as he now has to report sick all the time and isn’t allowed
out to see his friends in the evenings. A shift of attitude occurs and Mrs Jones
responds less keenly to Robert’s episodes of pain. He in turn reports less and starts
going out more, eventually getting back to school.Brief solution-focused therapy
This is a variety of strategic therapy developed by Steve de Shazer among
others. This extends the approach that focuses on success, and typically
involves no more than five to ten sessions. Questioning emphasises the
exceptions: When was the symptomnotpresent? What were you doing at
the time? How could you do more of this? Differences are noticed in the