>> There are several forms of strategic family therapy addressed in the textbook. The first model with this approach was developed at the Mental Research Institute, or MRI, in Palo Alto, California. There the ideas of Gregory Bateson and later Milton Erickson were tested out with families, many of whom had a member diagnosed with schizophrenia. Jay Haley was part of this initial group, but he eventually left for the East Coast where he worked with Salvador Minuchin at the Philadelphia Child Guidance Center before starting his own institute in Washington, DC. Both the MRI and the Washington models influenced the development of a third approach in Milan, Italy at a center under the direction of Maria Salivini Palesoli. In this video we focus on the strategic intervention model developed by Jay Haley and Coley Madonis [assumed spelling] in Washington, DC. It involves the use of a co-therapist team behind a one-way mirror who occasionally phone in directives to the family through the consulting therapist. You will notice that Dr. Bitter stops periodically to answer the phone and then passes the directive on to the family for demonstration purposes. These interventions happen more than they normally might, and each of them involves a paradox school directive usually prescribing the symptom. Think about how comfortable or uncomfortable you might be in this process. You might also want to think about the context in which the paradox is given and what ethical issues might also be involved.

>> Bitter: Good morning. I'd like to get to know each of you and know a little bit about why you came in for therapy. I should probably start by telling you a little bit about how I work. There's a team of therapists that you met who are behind a mirror, and they occasionally might have some ideas that will help us. If they do they'll call in, and we'll stop and listen to what they have to say. So I'm interested, as I said, in getting to know you. Which of you called for the appointment?

>> Betty Ann: I did. I'm concerned about Megan.

>> Steve: Yeah, she seemed to be getting depressed. We had to bring her home from college. Her roommate called and said that she was thinking about suicide

>> Bitter: Well, that's the kind of information that usually strikes panic inside a family.

>> Betty Ann: I was panicked for sure. Steve didn't want to even go get her.

>> Steve: I thought she was just homesick.

>> Betty Ann: Thinking of suicide is not just being homesick.

>> Bitter: Okay, so some part of you, Steve, was, you know, not alarmed about Megah's depression?

>> Steve: No, you know, I guess I was just, you know, just thinking that perhaps she was, you know, just having the kind of difficulties people have when they first begin.

>> Bitter: Okay, at this point, we have you all here and maybe we can sort some of this out. I still needed to meet everyone. So Steve, you're the father. Why don't you tell me about your family?

>> Betty Ann: There's just the 3 of us.

>> Steve: I can do this. Yes, Megan is our child although she was sick a lot when we were young, when she was young, and sometimes she would cry when nothing was wrong.

>> Betty Ann: Well, Megan did cry a lot, but just because you couldn't figure out what was wrong didn't mean that there wasn't something wrong. You don't care as much about Megan as I do.

>> Megan: That's not true. Dad loves me, too.

>> Betty Ann: Megan, you came from my body.

>> Bitter: Sounds like that's something that has real meaning for you.

>> Steve: Well, what she's referring to is that, you know, I do have a low sperm count. So we had to get assistance in order for her to become pregnant, but still that doesn't mean I don't love her.

>> Betty Ann: Well, you wouldn't have even went and gotten her.

>> Steve: But I did go to get her. You were not feeling well and so, you know, I did go to get her, and I've certainly always been there for her when she really needed me.

>> Bitter: Megan, sounds like there's some real concern going on for you. Maybe you could tell me what's going on about you.

>> Megan: Well, I was really depressed at college.

>> Bitter: Uh-uh, and do I understand that you felt like suicide?

>> Megan: Yeah.

>> Bitter: Okay. So tell me how did all of this transpire that there was a call home. How did that go?

>> Megan: Well, I talked to Keely. She was my roommate, and, I don't know, she shouldn't have called dad.

>> Bitter: Uh-uh, but that's who she did call, and he came to get you or what? So what happened?

>> Megan: Yeah, he came to get me and I've just been at home since.

>> Bitter: Okay. So tell me a little bit about college. Why were you feeling so badly there?

>> Megan: I just didn't really even have any interest in going to college, and I didn't really like my classes. I didn't like the other students there, and none of my friends were there, and, I don't know, I just started getting bad grades, and I've never had bad grades before, I mean, not the kind where you flunk out anyway, and eventually I started skipping classes altogether, and I just stayed in my room and slept until 2 or 3 in the afternoon, and then I wouldn't go to sleep until 3 in the morning.

>> Bitter: Okay, so, I don't know, did you get along with your roommate, Keely? How'd that go for you?

>> Megan: Yeah, she was really nice, I guess, but I don't think she was really excited about being around me. She was always on me about cleaning up the room, and I just didn't have enough energy to do that. So eventually she started doing it all on her own, and I don't think she was very happy about it, and I don't know, she didn't like my drinking either.

>> Bitter: Were you drinking a lot?

>> Megan: Not a lot. Just maybe 3 or 4 bottles most of the time.

>> Betty Ann: You didn't tell me you were drinking.

>> Megan: Well, I didn't want you to know because I knew that you would just get upset and cry.

>> Bitter: Well, how often were you drinking?

>> Megan: Every night. Well, most nights anyway and I would, I don't know, just I'd be in my room by myself, and I would just sip on beer. So since I was alone it wasn't like I was hurting anybody.

>> Bitter: Yeah. Okay, so you were depressed and you were drinking. You didn't seem to find anything much helpful going on in your classes, and it doesn't sound like you had many friends there either.

>> Megan: Right.

>> Bitter: So, Steve, you went to get Megan. Is that right?

>> Steve: Yes, I sure did,

>> Bitter: And could you tell me about that, how it went?

>> Steve: Well, she was sleeping. We drove up. She was sleeping, and we woke her up and put her stuff into the car-put her items in the car, and came on home.

>> Bitter: Okay. Did you... did she withdraw from college?

>> Steve: By... we did that later, by phone and fax.

>> Bitter: Okay, so, I don't know. Were you worried about her? Did you have her see anybody when she got home?

>> Steve: Yes, we took her to her pediatrician. He referred us to a psychiatrist. So we went over to see him, and he prescribed medication, gave us some pills.

>> Bitter: Okay, and does she take the pills?

>> Steve: I don't know. Do you take them?

>> Betty Ann: You mean you took her to a psychiatrist and not even making sure she is taking her medicine? You know she needs supervision.

>> Megan: Well, I take them sometimes. I don't know. Well... not really.

>> Steve: Well, that's one of the reasons why we came to see you to figure out how to help when something like this happens.

>> Bitter: Well, Megan, tell me a little bit about what it's been like for you since you got home.

>> Betty Ann: She's just been up in her room.

>> Megan: I stay in my room a lot, and I can't seem to stop crying except when I'm sleeping, and I really wish that I would go to sleep and just not wake up.

>> Bitter: Okay. Do you get up at all?

>> Megan: For a few hours.

>> Bitter: And what do you do?

>> Megan: Sometimes I watch Oprah or play video games, but not a lot.

>> Bitter: [Phone ringing] Excuse me. Okay.

[ Pause ]

Okay, yeah, thanks. Megan, the team has asked me to tell you that what you're doing is very important. While they've been listening, I want to get this just the way they said it, it's been clear to them that you needed to come home, and they marvel at how effective you were at getting your parents to call college off and to actually get you home.

>> Betty Ann: What do you mean?

>> Bitter: Well, just that it's very important for Megan to be home right now with the two of you, and that she's done actually a masterful job of getting the two of you to cooperate in bringing her home.

>> Betty Ann: Then I don't understand. Why does Megan need to be at home?

>> Bitter: Oh, well, there's no telling what would happen if she were away. The two of you must seem to her like you are very angry with each other, and left to your own, no telling what could happen. You might get divorced, or one of you might actually even hurt or kill the other.

>> Steve: That would never happen, Megan. That would never happen.

>> Megan: So you haven't thought about divorce.

>> Steve: Well thinking and doing are two different things.

>> Bitter: Yeah, sometimes thinking, however, about something, Megan, is also the first step to doing it, like how close were you to committing suicide? Did you have a plan? Were you thinking about a plan?

>> Megan: Yeah.

>> Betty Ann: Megan, no.

>> Bitter: My point is that if it's possible for you to think about something and to have a plan for it, it's also possible for your parents to do that, too. That's why it's very important for you to be home and to stay home and I think you're correctly assessing the situation. Without you there, no telling what would happen to the two of them. They might be at each other or separate or do both. [Phone ringing] Excuse me.

[ Pause ]

Okay.

[ Pause ]

Yes, thanks. The team wants me to tell you, Megan, that it's not enough for you just to be at home for a while. While you're there, your parents are going to cooperate for a while with you, but they can't last if all you are is depressed. The team wants you to commit to never growing up, to always staying their young child, their baby. Not coming out of your room can only work so long that after a while, they want... they feel like you will just have disappeared. So what the team wants you to do is to not only be depressed but also be demanding.

>> Megan: How do I do that?

>> Bitter: Well, you have to get them to do lots of things for you. You deserve some service. After all, you are depressed, and you're the youngest... the only child I should say, and you know your parents need to take care of you. If you can successfully do this, you may be able to get them to cooperate with each other in some way, but it all starts with you.

>> Megan: So you want me to stay depressed?

>> Bitter: Yeah, and demanding. Tell them what you need, insist that you get it, and don't just stick with your father who seems to be pretty easy for you. You need to tell your mom what you need and insist that she does it for you, too.

>> Megan: You said that they get angry, but I get angry, too.

>> Bitter: Oh, yeah, you probably do get angry, but you're not consistent with it. They are very consistent with their anger, and it actually could get a lot worse if you got angry. Just imagine that if you get angry at them, they're going to have to get angry at you, and then everything blows up. Right now you're doing exactly what you're supposed to do. It's very wise of you. If at this point in time, as long as you stay depressed, they're only mildly angry, and they actually get along with each other sometimes in taking care of you. So you're the person who's holding the family together at the moment, and as long as you can stay depressed, you're doing that.

>> Megan: So I have to stay depressed for them?

>> Bitter: Yes, and demanding. This is what your work is. It's a very important job. I would say it's essential. I want to meet with your parents over the next few weeks to see if we might talk with them about what their life might be like without you at some point, but that's a ways down the road, and it's going to be difficult to do, and it may not work.

>> Betty Ann: We have to learn to get along without Megan?

>> Bitter: Yes, and that can only happen if Megan's willing to commit to being young, to staying your young child and not growing up.

>> Betty Ann: But I want her to grow up.

>> Bitter: Do you? Do you want her to grow up and leave home?

>> Betty Ann: Yeah, well not too far from home.

>> Bitter: Well, she already has that now. She pretty much stays in her room so she's close to you, but she's staying away from you, too. She's doing exactly what she's supposed to do. To keep the two of you together, she has to be both close and distant at the same time.

>> Steve: Well there's a lot that Betty Ann and I argue about. We have a tough time getting along. Maybe we'll struggle with that.

>> Bitter: [Phone ringing] Excuse me again.

[ Pause ]

Okay.

[ Pause ]

Uh-uh.

[ Pause ]

Okay, thank you. Steve, the team agrees with you. They think it would be too hard for the two of you to jump right into getting along with each other. So the team wants me to see each of you, you and Betty Ann separately in separate sessions for a while until we can sort out what your life for each of you is going to be like once Megan is on her way. I'm to instruct the two of you not to talk to each other about this or to discuss the ways that you might want to be after Megan has gone, and again that we're going to go very, very slowly with this.

>> Steve: So you want to see us separately?

>> Bitter: Yes.

>> Steve: What about Megan? When will she be...

>> Bitter: I'll be happy to see Megan at any time that she would like to come in, but really she's doing everything that she needs to do right now. She's keeping the family together, and all she needs to do to keep doing that is to allow herself to continue with her depression but to add to that the capacity to be demanding.