Milan Family Therapy

Distinguishing Ideas
Theory Conceptualization
Therapeutic Process
External Links

I. Distinguishing Ideas

A therapy based on information with an emphasis on differences in behavior and relationships. Focus on uncovering family games, faulty attempts at solutions and devising interventions to break-up the game.

Theory- Milan was influenced by MRI and communication theory, second order cybernetics, constructivist, and social constructionist meta-theories.

Assumptions of Milan:

  1. Family systems involve language, relationships, and differences which comprise complex circular interactions that are beyond linear understanding. Observers are subject to errors because of the limitations of our brains.
  2. There are different levels of meaning in behavior. The may is not the territory…and the behavior we observe provides information about the organization of a system. Family systems have homeostatic functions. Family member interactions are described as a showing of behaviors as opposed to a way of being.
  3. No distinction exists between the "symptom" of an identified client and the "symptomatic behaviors" shared by all members of the client's family.
  4. All systems have some way of organizing themselves.
  5. Each family system presents a therapist with conflicting sets of information. Change me/don’t change me.
  6. Much of family interaction takes place at a non-verbal and unconscious level. Families cannot verbalize interactions or provide insight. Interventions should be made to jog the system within its own structure.
  7. Intent of therapy is to disrupt the homeostasis of the system by confronting them with rituals, behaviors, prescriptions, or insights that capture different levels of meanings within the family structure.
  8. A covert family game is a useful metaphor for describing family dynamics and processes that maintain the symptomatic behavior of family members. The behaviors and attitudes of family members are viewed as moves with the purpose of perpetuating the family game. All family interactions are geared toward the continuation of the game and increased involvement amongst its players. "Anything goes" as long it serves to perpetuate the game.
  9. Families will induct therapists into the family game and therapists have to avoid this tendency. Therapy is supposed to be neutral and distant.
  10. Milan therapists do not believe in normality for families. Families should have clear generational boundaries.

Assumptions according to Palazzoli, Cecchin, Boscolo, and Prata (1978):

  1. The family regulates and organizes itself by adhering to rules or guidelines that are formed through the process of trial and error ("a series of transaction and corrective feedbacks").
  2. In pathological systems, people have the habitual inclination to repeat established solutions so that they can maintain balance within the family.
  3. It is an error in thinking to say that one person's actions are the direct cause of another person's behaviors.
  4. Power does not belong to anyone involved in an interaction, but rather in the rules of the game (which cannot be altered by people in the situation). Nobody wins and nobody loses, though each player may believe in secret that they are winning.
  5. Every family transaction is a series of behavioral responses which influence other behavioral responses and so forth.
  6. A relationship must be clearly defined before its redefinition can be made possible.

II. Contributors

Gianfranco Cecchin- Co-founder of the Milan Model of Family Therapy, Co-author of Paradox and Counterparadox and Milan Systemic Therapy
Luigi Boscolo
Mara Selvini Palazzoli
Giuliana Prata
Lynn Hoffman

III. Theory Conceptualization

A. Problem Formation

Problems develop in a family system because family hierarchies are flawed (no clear boundaries) and/or a family member develops symptoms to control others in the family system.

  • So, Milan therapists focus on family's history and hidden power struggles (family games)

B. Problem Maintenance

C. Problem Resolution

Milan therapists focus on manipulating and outwitting the family and their games by introducing strategies designed to expose their family games and reframe family members' motives for their behaviors.
Milan therapists attempt to manipulate the family by exposing the games they play (such as behaviors and actions that create the problems) by introducing sneaky strategies to outdo the family's rituals and games.

IV. Therapeutic Process

A. Therapist Roles

Milan family therapists are relational therapists; they are generally more interested in what goes on between people rather than in people.
The therapist may point out the family interaction patterns that the families may not have noticed or suggest different ways of interacting.
They are also more interested in the maintenance and/or solving of problems rather than trying to identify one single cause.

B. Interventions

1. Reassigning the role of "identified client" from one sibling to another. It is used to disrupt the status quo and give power to previously disadvantaged family members.
2. Placing responsibility for the client's problems on the therapists. It shields the therapists from entering into the family game or having to assign blame to any of the family members.

Homework Tasks:
According to Palazzoli, Cecchin, Boscolo, and Prata (1978):
Prescriptions are usually given at the end of the first session. The goal of the prescription is to:
1. make the environment therapeutic
2. bring about or influence the family to become motivated for change in therapy
3. narrow the amount of observation the family does (by giving them a prescription that is specific), if not the family may observe too much over the next week.
4. give structure for the following session (Palazzoli, Cecchin, Boscolo, & Prata, 1978)
Family Rituals involve an action or series of actions, usually accompanied by verbal formulas or expressions, which are prescribed to all family members. The therapists detail for the family all aspects of ritual they are expected to carry out. This includes the place where the ritual will take place, when and how often the ritual should be repeated, who engage in the verbal expressions, in what order, etc. The repetitive nature of the ritual introduces the family to a new pattern of interacting and provides them with a new set of rules, or norms to replace the old ones.

C. Assessment

- traditional assessments, such as inventories and questionnaires are not always appropriate
- clinical interviews with all persons involved in the attempted problem resolution are sources of assessment by asking questions about the context of the problem

D. Treatment Planning

Structure of Therapy (Five Parts):
1. The Presession - The therapists read and discuss the client’s information or the notes from the previous session. A hypothesis is made about how the problem formed, what is maintaining the problem, and possible beliefs the family may have about the problem. In the original Milan team, the beginning of therapy began with a telephone interview, where the therapist would obtain information about the family and the person who made the referral. Many times, the person who made the referral is asked to attend the first session, especially if the individual is part of the family or a close friend to the family.
2. The Session - Clients are seen for about an hour. Therapists interview in a way that will allow them to test their initial hypothesis about the family. Circular questioning is incorporated into each session because it was believed to be a helpful way of provding family members with new inoformation about their situation that may be contributing to the maintenance of their problem. In addition, the therapists strive to be neutral during the session by avoiding comments that would appear as though they are taking one person's side over another family member's.
3. The Intersession - The therapists and observers meet in a private room to discuss the session and how to finish it.
4. The Intervention - The therapists go back to the therapy room to make positive connotations by emphasizing with the family how the problem has continued to be maintained by the family's actions and underlying beliefs. Next, the therapists deliver a paradoxical intervention. This discussion is kept short and the therapists may choose to send a written message at the end of their session in some situations. Rituals are directives to engage the whole family in some behavior that exaggerate or break rules and family myths.
5. The Post-session - The therapists and observers meet to discuss the observations, comments, the intervention, and to how to write the note.

V. References

Selvini-Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1978). Paradox and counterparadox: A new model in the therapy of the family in schizophrenic transaction. New York: Jason Aronson.

Selvini-Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing-circularity-neautrality: Three guidelines for the conductor of the session. Family Process, 19, 3-12.

VI. External Links

Critique of Milan SystemicTherapy