Rohrbaugh,M.J.,&Shoham,V.(2015).Briefstrategiccoupletherapy:Towardafamilyconsultationapproach. InA.S.Gurman,D.K.Snyder&J.Lebow(Eds.),Clinicalhandbookofcoupletherapy(5thedition),pp.335-357.NewYork:Guil-fordPublications.

CHAPTER10

BriefStrategicCoupleTherapy

MICHAELJ.ROHRBAUGH

VARDASHOHAM

AuthorNote

MichaelJ.RohrbaughisClinicalprofessorofPsychiatryandBehavioralSciences,GeorgeWashingtonUniversity,andProfessorEmeritusofPsychology,UniversityofArizona.VardaShoham,whodiedinMarch2014,wasSeniorAdvisorforAdultTranslationalResearchandTreatmentDevelopment,NationalInstituteofMentalHealth,BethesdaMD.

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In this chapterwedescribeapplicationsandextensions tocouplesof the “briefprob-lem--focused therapy”developedover30yearsagobyRichardFisch, JohnWeakland,PaulWatzlawick, and their colleagues at theMental Research Institute (MRI) in PaloAlto (Weakland, Fisch, Watzlawick, & Bodin, 1974; Weakland & Fisch, 1992;Watzlawick,Weakland,&Fisch,1974;Fisch,Weakland,&Segal,1982).Thisparsimo-nious therapy approach is based on identifying and interrupting ironic processes thatoccurwhenrepeatedattempts tosolveaproblemkeep theproblemgoingormake itworse. Although Fisch, Weakland, and associates did not themselves use the term“ironicprocess,”itcaptureswelltheircentralassertionthatproblemspersistasafunc-tionofpeople’swell--intentionedattemptstosolvethem,andthatfocusedinterruptionofthesesolutionefforts issufficienttoresolvemostproblems(Shoham&Rohrbaugh,1997;Rohrbaugh,Kogan&Shoham,2012;Rohrbaugh&Shoham,2001,2011).1

Thehallmarkofthisapproach,sometimesreferredtoasthePaloAltomodelortheMRImodel,isconceptualandtechnicalparsimony.Theaimoftherapyissimplytore-solvethepresentingcomplaintasquicklyandefficientlyaspossible,soclientscangeton with life: Goals such as promoting personal growth, working through underlyingemotionalissues,orteachingcouplesbetterproblem--solvingandcommunicationskillsarenotemphasized.Theoryisminimalandnon--normative,guidingtherapiststofocusnarrowlyonthepresentingcomplaintandrelevantsolutions,withnoattempttospeci-fywhatconstitutesanormalordysfunctionalmarriage.Becausethe“reality”ofprob-lemsandchangeisconstructedmorethandiscovered,thetherapistattendsnotonlytowhatclientsdobutalsotohowtheyviewtheproblem,themselves,andeachother.Es-peciallyrelevant isclients’ “customership” forchangeandthepossibility that therapyitselfmayplayarole inmaintaining(ratherthanresolving)problems.Finally, incon-trasttomostothertreatments,therapistsworkinginthistraditionoftenseethepart-nersindividuallyinthecontextofcoupletherapy,evenwhenthefocusofinterventionisacomplaintaboutthemarriageitself.

Thismodelissometimescalled“strategic”becausethetherapistintervenestoin-terrupt ironic processes deliberately, on the basis of a case--specific plan that some-times includescounterintuitivesuggestions(e.g., to “goslow”orengage inbehavioracouplewants to eliminate). Calling this approach “strategic therapy” alone, however,risksconfusingitwitharelatedbutsubstantiallydifferentapproachtotreatingcouplesand families developed by JayHaley (who coined the term “strategic therapy”; 1980,1987)andhisassociateCloéMadanes(1981,1991).2Moreimportantly,the“strategic”labelgivesundueemphasistointerventionstyleanddetractsattentionfromthemorefundamental principle of ironic problemmaintenance on which this brief therapy isbased. Although Haley and Madanes sometimes used interventions similar to thosepracticedby theMRIgroup (which shouldnotbe surprisinggiven thatHaleywasanearlymemberoftheMRIBriefTherapyCenter),theirstrategictherapymakesassump-tions about relational structure and the adaptive (protective) function of symptomsthatthePaloAltogroupdeemphasized(Weakland,1992).Usefuldescriptionsofstrate-gic marital therapy drawing on the Haley–-Madanes model can be found in Keim(1999), Cheung (2005), and Mitrani and Perez (2003), as well as in Todd’s (1986)chapterfromthefirsteditionofthisHandbook.

Ourchapterdealsprimarilywithapplicationsofthisbriefproblem--focusedther-apy to couple complaints, but this is a somewhat arbitrary delimitation. As a generalmodel of problem resolution, this therapy approaches couple problems in essentiallythe same way it does other complaints. Furthermore, because practitioners of this

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therapy are inevitably concerned with social interaction, they often focus on coupleinteractionwhenworkingwith“individual”problemssuchasdepression(Watzlawick&Coyne,1976;Coyne,1986a),anxiety(Rohrbaugh&Shean,1988),addictions(Fisch,1986; Rohrbaugh, Shoham, Spungen, & Steinglass, 1995; Rohrbaugh, Shoham, et al.,2001; Shoham,Rohrbaugh,Trost,&Muramoto, 2006), andvarioushealth complaints(Rohrbaugh et al., 2012; Rohrbaugh & Shoham, 2011). For tactical reasons we mayavoid calling this “couple therapy,” especiallywhen clients present health complaints(Rohrbaugh&Shoham,2011).Thisandthepredilectionofstrategictherapiststotreatcoupleproblemsnonconjointly (byseeing individuals),make itdifficult todistinguishbetweenwhatisandisnot“couple”therapy.

BACKGROUND

Coupletherapybasedoninterruptingironicprocessesisapragmaticembodimentofan“interactional view” (Watzlawick & Weakland, 1978) that explains behav-ior—-especiallyproblembehavior—in termsofwhathappensbetweenpeople ratherthanwithinthem.TheinteractionalviewgrewfromattemptsbymembersofBateson’sresearchgroup(whichincludedWeakland,Haley,andMRIfounderDonD.Jackson)toapplyideasfromcyberneticsandsystemstheorytothestudyofcommunication.AftertheBateson project ended,Watzlawick, Beavin, and Jackson (1967) broughtmany ofthese ideas together inPragmatics of Human Communication. Around the same time,Fisch,Weakland,Watzlawick, and others formed the Brief Therapy Center atMRI tostudywaysofdoingtherapybriefly.Theirendeavorswerealsoinfluencedbythe“un-common”therapeutictechniquesofArizonapsychiatristMiltonErickson,whomHaleyandWeaklandvisitedmany timesduring theBatesonproject (Haley,1967). In retro-spect, it isstrikinghowdiscordantthisearlyworkonbrieftherapywaswiththepsy-chodynamic zeitgeist of the late 1960s and early 1970s, when therapies were rarelydesigned with brevity in mind. As Gurman (2001) pointed out, most brief therapiesrepresent abbreviated versions of longer therapies—and most family therapies arebriefbydefault.Initscommitmenttoparsimony,thePaloAltogroupwasprobablythefirsttodevelopafamily--orientedtherapythatwasbriefbydesign.

Beginningin1966,theMRI’sBriefTherapyCenterfollowedaconsistentformatintreating over 500 cases. Under Fisch’s leadership, the staffmet weekly as a team totreatunselectedcases,representingabroadrangeofclinicalproblems,foramaximumof 10 sessions. Onemember of the team served as a primary therapist,while othersconsultedfrombehindaone-waymirror.Aftertreatment(atroughly3and12monthsfollowing termination),another teammemberconducteda telephone follow-up inter-viewwith the client(s) to evaluate change in the original presenting problem and todeterminewhetherclientshaddevelopedadditionalproblemsorsoughtfurthertreat-mentelsewhere.Thecenter’spatternofpracticeremainedremarkablyconsistent,withthethreecoremembers(Fisch,Weakland,andWatzlawick)allparticipatingregularly,untilWeakland’sdeathin1995.3 (Watzlawickdiedin2007andFischin2011.)

FromtheworkofthePaloAltoBriefTherapyCenteremergedamodeloftherapythat focuses on observable interaction in the present, makes no assumptions aboutnormalityorpathology, and remains as close aspossible topractice.The first formalstatementof thismodelappeared ina1974FamilyProcess paperbyWeaklandetal.,“BriefTherapy:FocusedProblemResolution.”Ataboutthesametime,Watzlawicketal.(1974)alsopublishedChange:PrinciplesofProblemFormationandProblemResolution,a more theoretical work that distinguished between first- and second-order change,

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andprovidedmanyillustrationsofironicprocesses.Eightyearslater,Fischetal.(1982)offeredThe Tactics of Change: Doing Therapy Briefly, essentially a how-to--treatmentmanualthatremainsthemostcomprehensiveandexplicitstatementtodateoftheBriefTherapy Center’s clinical method. In 1992, Weakland and Fisch presented a concisedescriptionofthemodel inabookchapter,andFischandSchlanger(1999)laterpro-videdanotherconciseoutlineof themodel,alongwith illustrativeclinicalmaterial, inBrief Therapy with Intimidating Cases: Changing the Unchangeable. Although thesesourcesdonotdealwithmaritaltherapyperse,couplecomplaintsfigureprominentlyin theclinicalprinciplesandexamples.Otherapplications tocouples,especiallywhenoneofthepartnersisdepressed,canbefoundintheworkofformerMRIaffiliateJamesCoyne(1986a,1986b,1988).Coyne’sworkhighlightsthesignificanceoftheinterviewinstrategicmaritaltherapy,particularlyhowthetherapistworksto(re)framethecou-ple’sdefinitionoftheprobleminawaythatsetsthestageforlaterinterventions.4

Inadditiontotheironicprocessmodel’shistoricalconnectiontothestrategicfam-ily therapyofHaley (1980,1987)andMadanes (1981),we shouldmention its some-timesconfusingconnectiontothesolution--focusedtherapyprioneeredbythelateStevedeShazerandInsooBerg(Berg&Miller,1992;deShazer,1991;deShazeretal.,1986).InspiredbythePaloAltogroup,deShazeretal. initiallytookWeaklandetal.’s(1974)“focused problem resolution” as a starting point for a complementary form of brieftherapy emphasizing “focused solution development.” Subsequently, however, solu-tion--focused therapy underwent progressive revision (de Shazer, 1991; Miller & deShazer, 2000) andnowhas a substantially different emphasis than the parentmodel(for a detailed comparison, see Shoham, Rohrbaugh, & Patterson, 1995). One of themainpointsofdisconnectionisthatdeShazeretal.(1986)triedtoavoidcharacterizingtheir therapy as “strategic,” preferring instead to describe it as collaborative,co--constructivist, and (by implication)not somanipulative.This (re)characterizationaligns solution--focused therapywith thenarrative,postmodern tradition that rejectsthe model of therapist-as-expert-strategist in favor of thera-pist-as-collaborative--partner(Nichols&Schwartz,2000).Wesuspectthatthisdistinc-tionmaybemoresemanticthansubstantive.Inanycase,becausetheideaofdeliberateinfluencerunscountertomanytherapists’preferredviews,callingone’stherapy“stra-tegic”isprobablynotaverystrategicthingtodo.

AlthoughresearchattheMRIhasbeenmainlyqualitative,itisnoteworthythattheoriginal description of brief, problem--focused therapy byWeakland et al. (1974) in-cluded tentative 1-year outcome percentages for the first 97 cases seen at the BriefTherapyCenter.In1992,incollaborationwiththeBriefTherapyCenter’sstaffmemberKarinSchlanger,weupdatedthearchivaltabulationofoutcomesforcasesseenthrough1991andattemptedtoidentifycorrelatesofsuccess(Rohrbaugh,Shoham,&Schlanger,1992).For285caseswithinterpretablefollow-updata,problemresolutionratesof44,24,and32%forsuccess,partialsuccess,andfailure,respectively,wereverysimilartothefiguresreportedbyWeaklandetal.(1974)morethan15yearsearlier.Thus,atleasttwo--thirdsofthecasesreportedlyimproved,andtheaveragelengthoftherapywassixsessions.Toinvestigatecorrelatesofoutcomemoreclosely,weidentifiedsubgroupsof“clear success” cases (n = 39) and “clear failure” cases (n = 33) forwhich1-year fol-low-updatawerecompleteandunambiguous.Then,aftercodingclinical,demographic,and treatment variables from each case folder,we compared the success and failuregroups and found surprisingly few predictors of outcome. Interestingly, however, itappears that about40%of the early cases seen at theBriefTherapyCenter involvedsomeformofmaritalorcouplecomplaint,andwetouchonsomefindingsfromthear-

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chivestudyinsectionstofollow.

Today,apartfromourownworkandthatofseveraldirectdescendantsoftheMRIbrieftherapyteam(e.g.,Ray&Sutton,2011),pureformapplicationsofbriefstrategiccouple therapy based on interrupting ironic processes appear relatively rare. On theotherhand,principlesandpractices fromthisapproachhaveacentral role inseveralintegrativemodels (e.g., Eron & Lund, 1998; Fraser & Solovey, 2007; Scheinkman &Fishbane,2004)andhavecertainlyinfluencedsystemstherapiesmoregenerally.

ANON-NORMATIVEVIEWOFCOUPLEFUNCTIONING

Couple therapy based on interrupting ironic processesmakes no assumptions abouthealthy or pathological functioning. In this sense, the theory is non--normative andcomplaint-based: In fact, ifnooneregistersacomplaint, there isnoproblem(Fisch&Schlanger,1999).At the relationship level, thismeans thatpatternssuchasquietde-tachmentorvolatileengagementmightbedysfunctionalforsomecouplesbutadaptiveforothers.Whatmattersistheextenttowhichinteractionpatternsbasedonattemptedsolutions keep a complaint going ormake it worse—and the topography of relevantproblem–-solutionloopscanvarywidelyfromcoupletocouple.

At theheartofbriefproblem--focused therapyare two interlockingassumptionsaboutproblemsandchange:

Regardlessoftheiroriginsandetiology—if,indeed,thesecaneverbereliablydeter-mined—theproblemspeoplebringtopsychotherapistspersistonlyiftheyaremain-tainedbyongoingcurrentbehavioroftheclientandotherswithwhomheinteracts.Correspondingly,ifsuchproblem--maintainingbehaviorisappropriatelychangedoreliminated,theproblemwillberesolvedorvanish,regardlessofitsnature,ororigin,orduration.(Weaklandetal.,1974,p.144)

These assumptions imply that howa problempersists ismuchmore relevant totherapy than how the problem originated, and that problem persistence dependsmainly on social interaction, with the behavior of one person both stimulated andshapedbytheresponseofothers(Weakland&Fisch,1992).Moreover—andthisisthecentral observation of the Palo Alto group—the continuation of a problem revolvespreciselyaroundwhatpeoplecurrentlyandpersistentlydo(ordonotdo) tocontrol,prevent, or eliminate their complaint; that is, how people go about trying to solve aproblemusuallyplaysacrucialroleinperpetuatingit.

Aproblem,then,consistsofaviciouscycleinvolvingapositivefeedbackloopbe-tweensomebehaviorsomeoneconsidersundesirable(thecomplaint)andsomeotherbehavior(s) intended to modify or eliminate it (the attempted solution). Given thatproblemspersistbecauseofpeople’scurrentattemptstosolvethem,therapyneedcon-sistonlyof identifyinganddeliberately interdicting thesewell--intentionedyet ironic“solutions,”therebybreakingtheviciouscycles(positivefeedbackloops)thatmaintainthe impasse. If these solutionscanbe interrupted, even ina smallway, thenvirtuouscyclesmaydevelop,inwhichlessofthesolutionleadstolessoftheproblem,leadingtolessofthesolution,andsoon(Fischetal.,1982).

SuchanironicfeedbackloopcanbeseeninthefollowingpassagefromPragmaticsofHumanCommunication (Watzlawick et al., 1967),which highlights the familiar de-mand–-withdrawcyclecommontomanymaritalcomplaints:

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Supposeacouplehaveamaritalproblemtowhichhecontributespassivewithdrawalwhileher50%isnaggingandcriticism.Inexplainingtheirfrustrations,thehusbandwillstatethatwithdrawalishisonlydefenseagainsthernagging,whileshewilllabelthis explanation gross andwillful distortionofwhat “really” happens in theirmar-riage: namely, that she is critical of him because of his passivity. Stripped of allephemeralandfortuitouselements,theirfightsconsistinamonotonousexchangeofthemessages,“Iwillwithdrawbecauseyounag”and“Inagbecauseyouwithdraw.”(p.56)

Watzlawicketal.(1974)elaborateasimilarpatterninChange:

In marriage therapy, one can frequently see both spouses engaging in behaviorswhichtheyindividuallyconsiderthemostappropriatereactiontosomethingwrongthattheotherisdoing.That is, intheeyesofeachofthemtheparticularcorrectivebehavioroftheotherisseenasthatbehaviorwhichneedscorrection.Forinstance,awifemayhavetheimpressionthatherhusbandisnotopenenoughforhertoknowwhereshestandswithhim,whatisgoingoninhishead,whatheisdoingwhenheisaway fromhome, etc.Quitenaturally, shewill therefore attempt to get theneededinformationbyaskinghimquestions,watchinghisbehavior,andcheckingonhiminavarietyofotherways. Ifheconsidersherbehavioras too intrusive,he is likelytowithhold fromher informationwhich inandby itselfwouldbequiteharmlessandirrelevant to disclose—“just to teach her that she need not know everything.” Farfrommakingherbackdown, thisattemptedsolutionnotonlydoesnotbringaboutthedesiredchangeinherbehaviorbutprovidesfurtherfuelforherworriesandherdistrust—“if he does not even talk to me about these little things, theremust besomethingthematter.”Thelessinformationhegivesher,themorepersistentlyshewillseekit,andthemoresheseeksit,thelesshewillgiveher.Bythetimetheyseeapsychiatrist, it will be tempting to diagnose her behavior as pathological jeal-ousy—-providedthatnoattentionispaidtotheirpatternofinteractionandtheirat-temptedsolutions,whicharetheproblem.(pp.35–36)

The“solutions”ofdemandandwithdrawalintheseexamplesmakeperfectlygoodsense to the participants, yet their interactional consequences serve only to confirmeach partner’s unsatisfactory reality. How such a cycle began is likely to remain ob-scure, andwhat causeswhat is amatterofmoreor less arbitrarypunctuation: Fromthisperspective,theproblem--maintainingsystemofinteractionisitsownexplanation.

THEPRACTICEOFBRIEFSTRATEGICCOUPLETHERAPY

TheStructureofTherapy

Thebasictemplateforbrieftherapybasedoninterruptingironicprocessesinvolvesthefollowingsteps:(1)Definethecomplaintinspecificbehavioralterms;(2)setminimumgoalsforchange;(3)investigatesolutionstothecomplaint;(4)formulateironicprob-lem–-solution loops (howmore-of-the-same solution leads tomore of the complaint,etc.);(5)specifywhatless-of-the-samewilllooklikeinparticularsituations(thestrate-gicobjectives);(6)understandclients’preferredviewsofthemselves,theproblem,andeachother;(7)usetheseviewsto framesuggestions for less-of-the-samesolutionbe-havior; and (8) nurture and solidify incipient change (Rohrbaugh & Shoham, 2001).Sessionsarenotnecessarilyscheduledonaweeklybasis,butallocatedinamannerin-tended tomaximize the likelihood that changewill bedurable.Thus,when the treat-

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mentsettingformallyimposesasessionlimit(e.g.,boththeMRI’sBriefTherapyCenterandourownclinicslimitedtreatmentto10sessions),themeetingsmaybespreadovermonthsor even a year.A typical pattern is for the first few sessions tobe at regular(weekly)intervalsandforlatermeetingstobelessfrequentoncechangebeginstotakehold. Therapy endswhen the treatment goals have been attained and change seemsreasonably stable. Termination usually occurs without celebration or fanfare, andsometimesclientsretain“sessionsinthebank,”iftheyareapprehensiveaboutdiscon-tinuingcontact.

Althoughtwo(co)therapistsarerarely in theroomtogether,practitionersof thisapproachusuallyprefertoworkasateam.AttheBriefTherapyCenterandinmostofourownwork,aprimarytherapistseestheclients,withotherteammembersobserving(andparticipating) frombehindaone-waymirror.Teammembers typicallyphone insuggestionstothetherapistduringthesession,andthetherapistsometimesleavestheroomtoconsultbrieflywith the team.A typical time forsuchameeting is late in thesession,whenthe teamcanhelp the therapistplantheparticularsofahomeworkas-signmentorframingintervention.

The team format also opens the possibility of clients’ having contact withmorethanonetherapist.Asiftodownplaythesanctityof“therapeuticrelationshipfactors,”theoriginalPaloAlto group (Fisch,Weakland,Watzlawicket al.) hadno reservationsabout one therapist substituting for another who could not be present—and in fact,about25%ofcases inthefirst3yearsof theBriefTherapyCenterdidseemorethanonetherapist,but thisproportion fell to11%in theearly1970s,andtounder5%bythe late 1980s (Rohrbaugh et al., 1992). In our own manual--guided treatments forcoupleswhofacedrinkingorsmokingproblemsinoneorbothmembers,weroutinelyholdbrief individualmeetingswith thepartners in thesecondsessionand,wheneverpossible,usedifferentmembersoftheteamtodothis(Rohrbaughetal.,1995,2001).

As a treatment for couples, this approach differs from most others in that thetherapist iswilling, and sometimes prefers, to see one or both partners individually.Thechoiceofindividualversusconjointsessionsisbasedonthreemainconsiderations:customership,maneuverability,andadequateassessment.First,abriefstrategicthera-pistwouldratheraddressamaritalcomplaintbyseeingamotivatedpartneralonethanby struggling to engage a partnerwho is not a “customer” for change. In theory, thispractice should not decrease the possibility of successful outcome, since the interac-tionalsystemsviewassumesthatproblemresolutioncanfollowfromachangebyanyparticipant in the relevant interactional system (Hoebel, 1976; Weakland & Fisch,1992).Asecondreasontoseepartnersseparately,evenwhenbotharecustomers,istopreservemaneuverability. If the partners have sharply different views of their situa-tion,forexample,separatesessionsgivethetherapistmoreflexibilityinacceptingeachviewpointandframingsuggestionsonewayforherandanotherwayforhim.Thesplitformatalsohelpsthetherapistavoidbeingdrawnintothepositionofrefereeorpossi-bleally.Thegoal,however,remainstopromotechange inwhathappensbetweenthepartners.

Athirdreasonforinterviewingspousesseparatelyistofacilitateassessment.Forexample, strategic therapists oftenmake a point of seeing thepartners alone at leastoncetoinquireabouttheircommitmenttotherelationshipandassessthepossibilityofspousalabuseorintimidation(Coyne,1988;Rohrbaughetal.,1995).Thisassessmentisespeciallyimportantincaseswherethereisdomesticviolencebuttheabusedpartner

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istoointimidatedtointroducethisviolenceasacomplaintintheconjointinterview.

InourstudyoftheBriefTherapyCenter’sarchives(Rohrbaughetal.,1992),caseswithmaritalorcouplecomplaintsweremorelikelytobesuccessfulwhenatleasttwopeople(thetwopartners)participatedintreatment.ThisfindingwouldnotseemtofitwellwiththeMRIviewthatmaritalcomplaintscanbetreatedeffectivelybyinterveningthroughonepartner.Ontheotherhand,wedidnotevaluatethepotentiallyconfound-ingroleofcustomershipinthesecases,orthepossibilitythattheabsentpartnerswereasuncommittedtotherelationshipastheyapparentlyweretotherapy.Inanycase,theCenter’sowndatadolittletoundermineGurman,Kniskern,andPinsof’s(1986)empir-ical generalization that “…when both spouses are involved in therapy conjointly formarital problems, there is a greater chance of positive outcome thanwhen only onespouseistreated”(p.572).

RoleoftheTherapist

Theessentialroleofthetherapist,asexplainedearlier,istopersuadeatleastonepar-ticipant in the couple (ormost relevant interactional system) to do less-of-the-samesolutionthatkeepsthecomplaintgoing.Thisessentialroledoesnotrequireeducatingclients,helpingthemresolveemotionalissues,orevenworkingwithbothmembersofacouple.Itdoes,however,requirethatthetherapistworkwiththecustomerandpreservemaneuverability. The customership principle means simply that the therapist workswith the person or persons most concerned about the problem (the “sweater” orsweaters).Preservingmaneuverabilitymeansthatthetherapistaimstomaximizepos-sibilitiesfortherapeuticinfluence,whichinthismodelishisorhermainresponsibility.InTheTacticsofChange,Fischetal. (1982)outlinetactics forgaining(andregaining)control,evenininitialphonecontacts,since“treatmentislikelytogoawryifthethera-pistisnotincontrolofit”(p.xii).Preservingmaneuverabilityalsomeansthatthether-apistavoidstakingafirmpositionormakingaprematurecommitmenttowhatclientsshould do, so that later, if they do not do what is requested, alternate strategies forachievingless-of-thesamewillstillbeaccessible.

Despite thispreoccupationwith controlling the courseof therapy, good strategictherapists rarelyexert controldirectly in the senseofofferingauthoritativeprescrip-tionsor assuming the roleof anexpert.Muchmore characteristic of this approach iswhatFischetal.(1982)call“takingaone-downposition.”Earlyintherapy,forexample,a Columbo-like stance of empathic curiosity might be used to track behavioral se-quencesaroundthecomplaint(e.g.,“I’malittleslowontheuptakehere,socouldyouhelpmeunderstandagainwhatitisyoudowhenJohnraiseshisvoicethatway?”);lat-er,wheninterveningtopromote“lessofthesame,”atherapistmightsoft-sellaspecificsuggestionbysayingsomethinglike,“Idon’tknowifdoingthiswhenhewalksthroughthedoorwillmakemuchdifference,but ifyoucouldtryitonceortwicethisweek,atleastwe’llhaveanideawhatwe’reupagainst.”Onepurposeofthesetacticsistopro-mote client cooperation and avoid the common counter-therapeutic effects of overlydirectorprescriptiveinterventions.5

Empathic restraint, exemplified by the go slow messages discussed later in theTechniquessection,isarelatedstancestrategictherapistsusetoneutralizeapprehen-sion and/or resistance to change. For example, once change begins, continued gentlerestraint helps the therapist respect the clients’ pace and avoid pushing for morechange than they can handle. A typical response to clear progress would be for thetherapist to compliment clients on what they have done, yet caution them against

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prematurecelebrationandsuggestagainthataprudentcoursemightbeto“goslow.”Similarly,whenclientsfailtofollowasuggestion,acommonresponseisforthethera-pist to take theblameonhim-orherself (e.g., “I think Isuggested thatprematurely”)andseekalternativeroutestothesamestrategicobjective,oftenwithintheframeworkoffurtherrestraint.

AlthoughthewritingsofthePaloAltogroupattachlittleimportancetothethera-peutic relationship, this does notmean that strategic therapists come across as cold,manipulative,oruncaring.On thecontrary,most therapistswehaveknownandseenworking thiswaywould likelyreceivehighratingsonclientrapportand“therapeuticalliance.”Areasonmaybethatpracticingthisapproachrequiresverycloseattentiontoclients’unique language,metaphors,worldviews—andthatcommunicatingeffectivelywithintheframeworkofsomeoneelse’sconstructsystem(ifonlytoframeaninterven-tion)usuallyentailsagooddealofempathy.

Assessment

Themaingoalsofassessmentareto(1)definearesolvablecomplaint;(2)identifysolu-tion patterns (problem–-solution loops) thatmaintain the complaint; and (3) under-stand clients’ unique language and preferred views of the problem, themselves, andeachother.Thefirsttwogoalsprovideatemplateforwheretointervene,whereasthethirdgoalisrelevanttohowtointervene.

The therapist’s first task is to get a very specific, behavioral picture of the com-plaintandassesswhosees itasaproblem,andwhyit isaproblemnow.Becausetheproblemisnotassumedtobethetipofapsychologicalorrelationaliceberg,theaimofassessment is simply to gain a clear understanding of who is doing what. A usefulguidelineforthisphaseisforthetherapisttohaveenoughdetailstoanswertheques-tion,“Ifwehadavideoofthis,whatwouldIsee?”Laterthetherapistalsotriestogetaclearbehavioralpictureofwhattheclientswillacceptasaminimumchangegoal.Forexample, “Whatwouldhe(orshe,or the twoofyou)bedoingdifferently thatwill letyouknowthisproblemistakingaturnforthebetter?”

Thenextsteprequiresanequallyspecific inquiryintothebehaviorsmostcloselyrelatedtotheproblem,namely,whattheclients(andanyotherpeopleconcernedaboutit)aredoingtohandle,prevent,orresolvethecomplaint,andwhathappensaftertheseattemptedsolutions.Fromthisstepemergesaformulationofaproblem–-solutionloop,andparticularlyofthespecificsolutionbehaviorsthatwillbethefocusofintervention.Thetherapist(orteam)canthendevelopapictureofwhat“lessofthesame”willlooklike—that is, what behavior, by whom, in what situation, will suffice to reverse theproblem--maintainingsolution.Ideallythisstrategicobjectiveconstitutesa180degreereversalofwhat theclientshavebeendoing.Although interventions typically involveprescribingsomealternativebehavior,thekeyelementisstoppingtheperformanceofthe attempted solution (Weakland & Fisch, 1992). Understanding prob-lem--maintaining solutionpatterns alsohelps the therapist be clear aboutwhatposi-tionsandsuggestionstoavoid—whatWeaklandandcolleaguescalledthe“minefield.”Thus,ifahusbandhasbeenpersistentlyexhortingawifetoeatorspendless,thether-apist would not want to make any direct suggestions that the wife change in theseways,soasnotperpetuate“moreofthesame”problem--maintainingsolution.Amorehelpful less-of-the-same stance might entail wondering with the wife about reasonswhy she shouldnot change, at least in thepresent circumstances, andabouthowshewillknowwhether,orwhen,thesechangesareactuallyworthmaking.

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Themostrelevantproblem--maintainingsolutionsarecurrentones(whatoneorbothpartnerscontinuetodoabout thecomplaintnow),but thetherapist investigatessolutionstriedanddiscarded in thepastaswell,becausethesegivehintsaboutwhathas worked before—and may work again. In one of our alcohol treatment cases(Rohrbaughetal.,1995),awife,whointhepasthadtakenahardlinewithherhusbandaboutnotdrinkingat thedinner table, later reversed this stancebecause shedidnotwant tobe controlling.Ashisdrinkingproblemworsened,he furtherwithdrew fromthefamily,andshedealtwithitlessandlessdirectlybybusyingherselfinotheractivi-ties or retreating to her study to meditate. Careful inquiry revealed that the formerhard-line approach, though distasteful, had actually worked: When the wife had setlimits, thehusbandhadcontrolledhisdrinking.Byrelabelingher former,moreasser-tivestanceascaringandreassuringtothehusband,thetherapistwaslaterabletohelpthewifereverseherstanceinawaythatbroketheproblemcycle.

Along these lines,wehave found it useful to distinguish ironic solution patternsthatinvolveaction(commission)fromthosethatinvolveinaction(omission).Thesolu-tionofpressuringone’spartnertochange,asinthedemand–-withdrawcycledescribedearlier,exemplifiesacommissionpattern,whereastheindirectstanceofthealcoholic’swife in the case justmentioned illustrates problemmaintenance based on omission.Although commissionpatterns aremore salient, ironic solutions of omission are sur-prisinglycommon,especiallyamongcouplescopingwithhealthproblems,addictions,orboth.Onesuchpatterninvolvesprotectivebuffering,inwhichonepartner’sattemptstoavoidupsettingaphysicallyillspousesometimesinadvertentlyleadtomoredistress(Coyne&Smith,1991;Rohrbaugh&Shoham,2011).

Thedistinctionbetweenthesetwotypesofironicprocessesagainunderscorestheprinciple thatnogiven solutionpattern canbeuniformly functionalordysfunctional:Whatworksforonecouplemaybepreciselywhatkeepsthingsgoingbadlyforanoth-er—anda therapist’sstrategy forpromoting less-of-the-sameshouldrespect thishet-erogeneity.

The final assessment goal—-grasping clients’ unique views, or what Fisch et al.(1982)callthe“patientposition”—iscrucialtothelatertaskofframingsuggestionsinwaysclientswillaccept.Assessingtheseviewsdependsmainlyonpayingcarefulatten-tiontowhatpeoplesay.Forexample,howdotheyseethemselvesandwanttobeseenbyothers?Whatdotheyholdnearanddear?Whenaretheyattheirbest,andwhatdoothers notice at those times? (Eron& Lund, 1998). At some point, the therapistwillusuallyalsoaskfortheirbestguessastowhyaparticularproblemishappening—andwhytheyhandleitthewaytheydo.Wealsofindithelpfultounderstandhowpartnersviewthemselvesasacouple,andtypicallyaskquestions,suchas“Ifpeoplewhoknowyouwellweredescribingyoutwoasacouple,whatwouldtheysay?”or“Whatwordsor phrases capture the strength of your relationship—its values, flavor and uniquestyle?”

Finally,someofthemostimportantclientviewsconcerncustomershipfortherapyandreadinessforchange.Althoughmuchcanbedeterminedfromhowclientsinitiallypresentthemselves,directquestionssuchas“Whoseideawasittocome?”(His?Hers?Both equally?), “Why now?,” and “Who is most optimistic that therapy will help?”shouldmakethiscrucialaspectofclientpositionclearer.Itisalsousefultounderstandhow(ifatall)theclientssoughthelpinthepast,whattheyfoundhelpfulorunhelpful,howthehelper(s)viewedtheirproblems,andhowthetherapyended.

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GoalSetting

Goalsetting inthisapproachservesseveralkeyfunctions.First,havingaclearbehav-ioral picture ofwhat clientswill accept as a sign of improvement helps to bring thecomplaint itself into focus.Withouta clear complaint it isdifficult tohavea coherentformulationofproblemmaintenance(or,forthatmatter,acoherenttherapy).Second,settingaminimumgoalforoutcomesupportsthetherapist’stacticalaimofintroducingasmallbutstrategicchangeintheproblem–-solutionpatterns,whichcantheninitiatearipple or domino effect leading to further positive developments. In this sense, themodel emphasizes what some clinicians would call intermediate or mediating goalsratherthanultimateoutcomes.Forsomecouples,aspin-offbenefitofthisstrategymaybetheimplicitmessagethatevendifficultproblemscanshowsomeimprovementinarelativelyshortperiodoftime.

Before setting specific goals, it isusuallynecessary to inquire indetail about theclients’ complaint(s) and, if there are multiple complaints, establish which are mostpressing.Asthecomplaintfocusbecomesclear,thetherapistatsomepointasksques-tionssuchasthefollowing:

“Howwillyouknowthesituationisimproving?”

“Whatkindsofchangewillyousettlefor?Whatwillneedtohappen(ornothappen)toletyouknowthat,evenifyou’renotoutofthewoodsentirely,you’reatleastontherightpath?”

“Whatwilleachofyousettlefor?”

Asclientsgrapplewith thesequestions, the therapistpresses for specific signsof im-provement (e.g., having a family meal together without someone getting upset andleavingthetable;aspouseshowingaffectionwithoutitseeminglikeanobligation).Itiseasy insuchadiscussiontoconfusemeanswithends,andthe therapistaimstokeepclients focused on the latter (what they hope to achieve) rather than how to pursuethem.Importantassessmentinformationdoescomefromqueriesaboutwhatpartnersthinktheyshoulddotomakethingsbetter,butthisismuchmorerelevanttoformulat-ingproblem–-solutionloopsthantogoalsetting.

Techniques

The Palo Alto group distinguishes specific interventions, designed to interdict ironic,case--specificproblem–-solution loops, fromgeneral interventions that tend tobeap-plicableacrossmostcases(Fischetal.,1982).Mostof thissection isdevotedto illus-trating specific interventions for common couple complaints.We focus especially oninterventionsdesigned to interruptdemand–-withdraw interaction,acommoncouplepatternassociatedwithnotonlymaritaldistressbutalsomanyhealthcomplaintsandaddictions.First,however,wecommentbrieflyonmoregeneralaspectsofthistherapy.

Becauseinterruptinganironicproblem–-solutionloopusuallyrequirespersuadingclientseithertodolessortheoppositeofwhattheyhavebeencommittedtodoing,itiscrucial to frame suggestions in terms compatible with clients’ own language orworldview—-especiallywithhowtheyprefer tosee themselves. Indeed,graspingandusingclients’views—whatFischetal.(1982)call“patientposition”—isalmostasfun-damental to this form of brief therapy as the behavioral prescriptions that interdictproblem--maintaining solutions. Some partners, for example, will be attracted to the

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idea ofmaking a loving sacrifice, but othersmaywant to teach theirmates a lesson.Strategictherapistsarecarefultospeaktheclients’language,usetheirmetaphors,andavoidargumentation.Thesetherapistsnotonlyelicitbutalsoshapeandstructurecli-ents’beliefstosetthestageforlaterinterventions.Forexample,atherapistmightac-ceptawife’sviewthatherhusbandisuncommunicativeandunemotional,thenextendthisviewtosuggestthathisdefensivenessindicatesvulnerability.Theextensionpavestheway for suggesting a differentway of dealingwith a husbandwho is vulnerable,ratherthansimplywithholding(Coyne,1988).Alessdirectwaytobreakanironicpat-tern is to redefinewhatonepartner isdoing inaway that stops shortofprescribingchange,yetmakesitdifficultforhimorhertocontinue(e.g.,“I’venoticedthatyourre-mindinghimandtellinghimwhatyouthinkseemstogivehimanexcusetokeepdoingwhat he’s doingwithout feeling guilty.He can justify it to himself simply by blamingyou”).

Inadditiontointerventionsthattargetspecificproblem–-solutionloops,themodeluses several “general interventions” that areapplicable toabroad rangeofproblemsandtopromotingchangeinallstagesoftherapy.Generalinterventionsincludetellingclients to go slow, cautioning them about dangers of improvement,making a U-turn,andgivinginstructionsabouthowtomaketheproblemworse(Fischetal.,1982).Mostofthesetacticsarevariationsoftherapeuticrestraint,asdescribedintheprevioussec-tion.Themostcommonis the injunctionto“goslow,”givenwithacrediblerationale,suchas“changeoccurringslowlyandstepbystepmakesforamoresolidchangethanchangewhich occurs too suddenly” (Fisch et al., 1982, p.159). This tactic is used toprepareclientsforchange,toconveyacceptanceofreluctancetochange,andtosolidifychangeonceitbeginstooccur.Fischetal.suggesttworeasonswhy“goslow”messageswork: Theymake clientsmore likely to cooperate with therapeutic suggestions, andtheyrelaxthesenseofurgencythatoftenfuelsclients’problem--maintainingsolutionefforts.

Coyne (1988) described several other general interventions that he uses in thefirst or second session with couples. One intervention involves asking the couple tocollaborateinperformingtheproblempattern(e.g.,anargument)deliberately,fortheostensiblepurposeofhelpingthetherapistbetterunderstandhowtheygetinvolvedinsuchano-winencounter,andspecifically,howeachpartnerisabletogettheothertobelessreasonablethanheorshewouldbenormally.Thistaskismorethandiagnostic,however, because it undercuts negative spontaneity, creates an incentive for eachpartnertoresistprovocation,andsometimesintroducesashift intheusualproblem–-solutionpattern.

IntermsofBateson’s(1958)distinctionbetweencomplementaryandsymmetricalinteractionpatterns6 (cf.Watzlawick et al., 1967), someof themost common foci forspecificinterdictionofironicproblem–-solutionloopsinvolvecomplementarypatternssuchas the familiardemand–-withdrawsequencedescribedearlier.Forexample,onepartnermaypressforchangeinsomeway,whiletheotherwithdrawsorrefusestore-spond;onepartnermayattempttoinitiatediscussionofsomeproblem,whiletheotheravoidsdiscussion;onepartnermaycriticizewhat theotherdoes,while theotherde-fendshisorheractions;oronemayaccuse theotherof thinkingordoingsomethingthattheotherdenies(Christensen&Heavey,1993).Eachofthesevariations—demand–-refuse,discuss–avoid,criticize–-defend,accuse–deny—fitstheproblem–-solutionloopformula, because more demand leads to more withdrawal, which leads to more de-mand, and so on. Although the brief strategic model avoids (normative) a priori as-

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sumptionsaboutadaptiveormaladaptivefamilyrelations,theclinicalrelevanceofde-mand–-withdrawinteractionappearswellestablishedbyresearch indicatingthat thispatternissubstantiallymoreprevalentindivorcingcouplesandcliniccouplesthaninnondistressed couples (Christensen & Schenk, 1991), and that couples embroiled inmore intensedemand–-withdraw interactionpatternsare lessready forchange(Sho-ham, Rohrbaugh, Stickle, & Jacob, 1998). Interestingly,many authors have describedthe demand–-withdraw pattern and speculated about its underlying dynamics (e.g.,Napier,1978;Wile,1981),butfewhavebeenasconcernedastheMRIgroupwithprac-ticalwaystochangeit.

Totheextentthatthepartneronthedemandsideofthesequenceisthemaincus-tomer for change, intervention focuses on encouraging that person to do less of thesame.Inthedemand–-refusecycle,onespousemaypressforchangebyexhorting,rea-soning, arguing, lecturing, and so on—a solution pattern that Fisch et al. (1982,pp.139–152) call “seeking accord through opposition.” If the demand-side partner isthemaincomplainant,7achieving lessof thesameusuallydependsonhelpinghimorhersuspendovertattemptstoinfluencethehusband—forexample,bydeclaringhelp-lessnessorinsomeotherspecificwaytakingaone-downposition,orbyperforminganobservational–-diagnostic task to find out “what he’ll do on his own” or “whatwe’rereallyupagainst.”Howthetherapist framesspecificsuggestionsdependsonwhatra-tionalethecustomerwillbuy.Anextremelyreligiouswife,forexample,mightbeame-nabletothesuggestionthatshesilentlyprayforherhusbandinsteadofexhortinghim.Successful solution interdiction in several cases seen at the Brief Therapy Center(Watzlawick&Coyne,1976;Fischetal.,1982)followedfromdevelopingtheframethatthe behavior onepartner sawas stubbornnesswas actuallymotivatedby the other’spride.Becauseproudpeopleneedtodiscoveranddothingsontheirown,withoutfeel-ing pressed or that they are giving in, it makes sense to encourage such a person’spartnerbydiscouraging(restraining)himorher.Ademand-sidepartnerwhofollowssuggestions for doing this will effectively reverse his or her former solution to thestubbornbehavior.

Forsomecouples,thedemand–-withdrawcycleinvolvesonepartner’sattempttoinitiatediscussion(togettheothertoopenup,bemoreexpressive,etc.)whiletheotheravoidsit.Oneofus(Shoham)hadtheexperienceofbeingtheprimarytherapistforonesuchcoupleduringhertrainingatMRI.Thewife,herselfatherapistandthemaincom-plainant,wouldrepeatedlyencourageherinexpressivehusbandtogethisfeelingsout,especiallywhenhecamehomefromwork“lookingmiserable.”Whenthehusbandre-spondedtothisencouragementwithdistraughtsilence,thewifewouldurgehimtotalkabouthisfeelingstowardherandthemarriage(thinkingthatthistopicwouldbringoutpositive associations on his part and combat his apparent misery). In a typical se-quence, thehusbandwould thenbegin togetangryand tell thewife tobackoff. She,however, encouraged by his expressiveness, would continue to push for meaningfuldiscussion, in response towhich—onmore thanoneoccasion—thehusbandstormedoutofthehouseanddisappearedovernight.TheinterventionthateventuallybrokethecycleinthiscasecamefromFisch,whoenteredthetherapyroomwithasuggestion:Inthenextweek,atleastonce,thehusbandwastocomehome,sitatthekitchentable,andpretend to lookmiserable. Thewife’s task,when she saw this look,was to go to thekitchen,preparechickensoup,andserveittohimsilently,withaworriedlookonherface.Thecouplecametothenextsessionlookinganythingbutmiserable.Theyreport-ed that their attempt to carry out the assignment had failed because she—and thenhe—couldnotkeepastraight face,yettheyweredelightedthatthehumorsocharac-

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teristicof theearlydaysof theirrelationshiphad“resurfaced.”Whereasthe interven-tionservedtointerdictthewife’sattemptedsolutionofpursuingdiscussion,italsoin-terruptedtheheavinessanddeadlyseriousnessinthecouple’srelationship.8

When the demand–-withdraw pattern involves criticism and defense, both part-ners aremore likely tobe customers for change; in these cases, change canbe intro-ducedthrougheitherorbothpartners.Onestrategy,notedearlier, is todevelopara-tionaleforthecriticizingpartnertoobservethebehaviorheorsheiscriticizingwithoutcommentingonit.Anotheristogetthedefendingpartnertodosomethingotherthantodefend—forexample,bysimplyagreeingwiththecriticismorhelpingthecriticizer“lightenup”bynottakingthecriticismseriously(“Iguessyou’reprobablyright.Ther-apy is helpingme see I’m notmuch fun and probably too old to change,” or “You’reright.Idon’tknowifIinheritedthisproblemfrommyparentsorourkids”).InChange,Watzlawicketal.(1974)alsodescribeamoreindirectinterdictionofawife’sattemptsto avoid marital fights by defending herself. As homework, the therapist asked thecombativehusbandtopicka fightdeliberatelywithsomeoneoutsidethemarriage. Inthenextsession,thehusbandrecountedindetailhowhisattemptstodothishadfailed,becausehehadnotbeenabletogettheotherpersontolosehistemper.Intheauthors’view,hearingthis“madethewifemoreawareofhercontributiontotheproblemthananyinsight--orientedexplanationorinterventioncouldhavedone”(p.120).

Anotherapproach to interdictingaccusation–-denial cycles isan intervention theMRIgroupcalls“jamming”(Fischetal.,1982).Whenonepartneraccusestheotherofsomething thatbothagree iswrong (e.g., dishonesty, infidelity, insensitivity), and theotherpartner’sdenialseemsonlytoconfirmtheaccuser’ssuspicions, leadingtomoreaccusations andmore denials, the jamming intervention aims to promote less of thesamebybothparties.Afterdisavowinganyabilitytodeterminewhoisrightorwronginthesituation,thetherapistproposestohelpthecoupleimprovetheircommunication(which obviously has broken down), particularly the accuser’s perceptiveness abouttheproblem.Achievingthis,thetherapistcontinues(inaconjointsession),willrequirethat the defender deliberately randomize the behavior ofwhich he or she is accused(e.g.,sometimesacting“asif”sheisattractedtootherpeopleandsometimesnot),whiletheaccuser testshisorherperceptivenessaboutwhat thedefender is “really”doing.Both partners should keep a record ofwhat they did or observed, they are told in aconjointsession,buttheymustnotdiscusstheexperimentorcomparenotesuntilthenextsession.Theeffectofsuchaprescriptionistofreethedefenderfrom(consistently)defendingandtheaccuserfromaccusing;thus,thecircuitis“jammed,”becauseverbalexchanges(accusationsanddenial)nowhavelessinformationvalue.

Sometimes a problem cycle is characterized by indirect demands related to theparadoxical form of communication Fisch et al. (1982) called “seeking compliancethroughvoluntarism.”Forinstance,awifemaycomplainthatherhusbandnotonlyig-noresherneedsbutthathealsoshouldknowwhattodowithoutherhavingtotellhim,ashewouldotherwisebedoingitonlybecausesheaskedhimandnotbecausehereallywantedto.Orahusbandmaybereluctanttoaskhiswifetodosomethingbecausehethinksshemaynotreallywanttodoit.Thebrieftherapystrategyforthesesituationsisto get thepersonwho is asking for something todo sodirectly, even if arbitrarily. Ifclientswanttoappearbenevolent,thetherapistcanusethispositionbydefiningtheirindirectionasunwittinglydestructive;forexample,“ahusband’sreticencetoaskfavorsof hiswife can be redefined as an ‘unwitting deprivation of the one thing she needsmost from you, a sense of your willingness to take leadership’” (Fisch et al., 1982,

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p.155). Intervening through thenonrequestingpartnermightalsobepossible, if thatpersoncanbepersuadedtotaketheedgeofftheparadoxical“Bespontaneous”demandbysayingsomething like, “I’mwilling todo itand Iwill,but let’s face it, Idon’tenjoycleaningup.”

In other complaint--maintaining complementary exchanges, one partnermay bedomineeringorexplosiveandtheotherplacatingorsubmissive.Here,lessofthesameusuallyrequiresgettingthesubmissive,placatingpartnertotakesomeassertiveaction.

Symmetricalpatternsofproblem--maintainingbehaviorare less commonbutof-tenoffermorepossibilitiesforinterventionbecausecustomership,too,isbalanced.Forcombativecouplesembroiledinsymmetricallyescalatingarguments,thestrategycouldbetogetatleastonepartnertotakeaone-downposition,ortoprescribetheargumentunder conditions likely to undermine it (Coyne, 1988). Another symmetrical solutionpatternstemsfrommiscarriageof the(usuallysensible)belief thatproblemsarebestsolvedby talking them through. Yet some couples—-including somewhosemembersare very psychologically minded—-manage to perpetuate relationship difficultiessimplyby trying to talk about them. In a case treatedatMRI, for example, a couple’sproblem--solving “talks” about issues in their relationship usually escalated intofull-blownarguments.Therapyledthemtoadifferent,moreworkablesolution:Wheneitherpartnerfelttheneedtotalkabouttheirrelationship,theywouldfirstgobowling(Fisch,April,1992,personalcommunication).

Interestingly,despitetheiremphasisoninteraction,theMRIgroupacknowledgesa“self--referential” aspect of complaints, such as anxiety states, insomnia, obsessionalthinking, sexual dysfunction, and other problems with “being spontaneous.” Thesecomplaints“canariseandbemaintainedwithouthelpfromanyoneelse.Thisdoesnotmean that othersdonot aid inmaintaining suchproblems; often theydo.We simplymeanthatthesekindsofproblemsdonotneedsuch“help”inordertooccurandper-sist”(Fischetal.,1982,pp.136–137).

Treatmentof suchproblems inacouplecontextmay involvesimultaneous inter-dictionofbothinteractionalandself--referentialproblem–-solutionloops.Forexample,withawomanwhoexperienceddifficultyreachingorgasm,theBriefTherapyCenter’steamtargetedtwoproblem–-solutionloops:oneself--referential(thehardershetried,themoreshefailed)andtheotherinteractional(themorethehusbandinquiredabouthowarousedshewasandwhethershehadhadanorgasm,thehardershetriedtoper-form).One strandof the interventionwasaprescription that, for thewife tobecomemoreawareofherfeelingsduringintercourse,sheshould“noticeherbodilysensations,regardlessofhowmuchorhow littlepleasureshemayexperience” (Fischetal.,1982,p.158, emphasis inoriginal).The second (interactional) strandwasaversionof jam-ming:Inthewife’spresence,thetherapistaskedthehusbandnottointerferewiththisprocessbycheckingherarousal—butifhedid,thewifewassimplytosay,“Ididn’tfeela thing.” Other strategies aimed at combined interdiction of interactional andself--referential solution patterns have been applied in the treatment of “individual”complaints,suchasdepression(Coyne,1986a,1988)andanxiety(Rohrbaugh&Shean,1988).

Interventionsformaritalcomplaintsusuallyfocusononeorbothmembersofthecouple,yettherearecircumstancesinwhichotherpeople—-relatives,friends,orevenanother helper—-figure prominently in this approach to couple therapy, especiallywhenthethirdpartyisakeycustomerforchange.Forexample,amother,understand-

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ably concerned about her daughter’s marital difficulties, may counsel or console thedaughterinawaythatunwittinglyamplifiestheproblemormakestheyounghusbandandwife less likely to dealwith their differences directly. In this case, brief therapymightfocusfirstonhelpingthemother—animportantcomplainant—-reverseherownsolutionefforts,andtakeuplater(ifatall)theinteractionbetweentheyoungspouses,whichislikelytochangewhenthemotherbecomeslessinvolved.Brieftherapistshavealsofoundwaystoinvolvethirdpartieswhomaynotbecustomersforchange,particu-larlyforproblemsrelatedtomaritalinfidelity(Teismann,1979;Green&Bobele,1988).

Finally,forasmallsubsetofmaritalcomplaints,thegoalofbrieftherapyistohelpcouplesreevaluatetheirproblemas“noproblem,”orasaproblemtheycanlivewith;strategiesforachievingthisgoaltypicallyinvolvesomesortofreframing.Indeed,mar-riageisfertilegroundforwhatWatzlawicketal.(1974)callthe“utopiasyndrome”:

Quiteobviously, few—ifany—-marriages liveupto the idealscontained insomeofthe classicmarriagemanuals or popularmythology. Thosewho accept these ideasaboutwhatamaritalrelationshipshould“really”bearelikelytoseetheirmarriageasproblematicandtostartworking toward itssolutionuntildivorcedo thempart.Theirconcreteproblemisnottheirmarriage,buttheirattemptsatfindingthesolu-tiontoaproblemwhichinthefirstplaceisnotaproblem,andwhich,evenifitwereone,couldnotbesolvedonthelevelonwhichtheyattempttochangeit.(p.57)

Publishedcasereportsnotwithstanding,theoutcomeofbrieftherapyrarelyturnsonasingleintervention.Muchdependsonhowthetherapistnurturesincipientchangeandmanagestermination.Whenasmallchangeoccurs,thetherapistacknowledgesandemphasizestheclients’partinmakingithappenbutavoidsencouragingfurtherchangedirectly.Themostcommonstanceinrespondingtochangeconsistsofgentlerestraint(e.g., “Goslow”)andcontinuationofthe interdictionstrategythatproducedit.Specialtacticsmaybeusedwithclientswhoareoverlyoptimisticoroverlyanxious(e.g.,pre-dicting or prescribing a relapse), orwhominimize change or relapse (e.g., exploring“dangers of improvement”). Termination occurs without celebration or fanfare. Ifchange is solid, the therapist acknowledges progress, inquires aboutwhat the clientsare doing differently, suggests that they anticipate other problems, and implies theywill be able to copewithwhatever problems do arise. Otherwise various restrainingmethodsmaybeused.Ifclientsasktoworkonotherproblems,thetherapistsuggeststaking time out to adapt to change and offers to reassess the other problems later(Fischetal.,1982;Rosenthal&Bergman,1986).

Beforeconcludingthesectionontechnique,weshouldnotethatcriticssometimesregard this approach as “manipulative,” because the therapist does not usuallymakeexplicittoclientstherationaleforparticularinterventions(Wendorf&Wendorf,1985)andmay say things he or she does not truly believe to achieve an effective framing(Solovey & Duncan, 1992). Proponents of strategic therapy counter that responsibletherapyisinherentlymanipulative(Fisch,1990),thattherapeuticcandorcanbedisre-spectful(Haley,1987),andthatgoodtherapyshowsprofoundrespectforclients’sub-jectivetruths(Cade&O’Hanlon,1993).

CURATIVEFACTORS/MECHANISMSOFCHANGE

Thecentral curative factor in thisapproach is interruptionof ironicprocesses.Aswehaveemphasized,thisinterruptiondependson(1)accurateidentificationofthepartic-

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ularsolutioneffortsthatmaintainorexacerbatetheproblem,(2)specifyingwhatlessofthosesamesolutionbehaviorsmightlooklike,and(3)designinganinterventionthatwillpersuadeatleastoneofthepeopleinvolvedtodolessortheoppositeofwhatheorshe has been doing. To demonstrate such a process empirically, it is not enough todocumentchangesinthetargetcomplaint.Oneneedstoshowthatchangesinattempt-ed--solutionbehaviorprecedeandactuallyrelatetochangesinthecomplaint.Evidenceof such sequential dependencies in couples is at this point limited to case reports,thoughweareoptimistic thatquantitativemethodscan illuminate theseprocessesaswell.

Aclosely relatedcurative factor isavoidanceof ironic therapyprocesses—ascanoccur,forexample,when“workingthrough”acouplecomplaintinsupportiveindividu-al therapymakes it possible for partners to avoid resolving the problem directly, orwhen pushing a spouse to change recapitulates a problem--maintaining solution ap-pliedbytheclientsthemselves.Thelatterpatternisillustratedbyourstudycomparingtwotreatmentsforcouplesinwhichthehusbandabusedalcohol(Shohametal.,1998).Thetwotreatments—cognitive--behavioraltherapy(CBT)andfamilysystemstherapy(FST)—differedsubstantiallyinthelevelofdemandtheyplacedonthedrinkerforab-stinence and change. Although drinkingwas a primary target for change in both ap-proaches,whereasCBTtookafirmstanceaboutexpectedabstinencefromalcohol,us-ingadjunctiveBreathalyzerteststoensurecompliance,FSTemployedlessdirectstrat-egies toworkwith clients’ resistance. Before treatment began,we obtained observa-tionalmeasuresofhowmucheachcoupleengaged indemand–-withdrawinteraction,focusingonthepatternofwife’sdemandsandhusband’swithdrawalduringadiscus-sion of the husband’s drinking. The retention and abstinence results were striking:When couples high in this particular demand–-withdraw pattern received CBT, theyattended fewer sessions and tended to have poorer drinking outcomes, whereas forFST, levelsof thispatternmade littledifference.Thus, forhigh--demandcouples,CBTmay ironically have provided “more of the same” ineffective solution: The alcoholichusbandsappearedtoresistademandingtherapistinthesamewaytheyresistedtheirdemandingwives.9

Asimilarconcernwithavoidingironictherapyprocesseshasinfluencedthefram-ing of ourmanualized couple therapies for substance abuse and health problems as“family consultation” (Rohrbaugh et al., 1995, 2001, 2011; Shoham et al., 2006). Byconnoting collaboration and choice, the term “consultation” arouses less resistancethan“treatment”andunderscoresourassumptionthatpeoplecometotherapybecausetheyarestuck—notsick,dysfunctional,orinneedofanemotionaloverhaul.

Althoughironicprocessesremainprimary,morerecentapplicationsofthefamilyconsultation (FAMCON) approach to health and behavior problems include a secondsocial-cybernetic pattern of problem maintenance we call symptom-system fit(Rohrbaugh&Shoham,2011),referringtodeviation-minimizingnegativefeedbackcy-cles inwhich some problem or risk behavior appears to preserve relational stability(e.g.,whensharedsmokingordrinkingmaintainscouplecohesion). Inanotherdepar-ture from the pureMRImodel, the FAMCON approach also aims tomobilize and/orcreate communal coping (we-ness) by the people involved as a resource for change(Rohrbaughetal.,2012).

Forbetterorworse,briefstrategiccoupletherapyattacheslittleimportancetothecurative factors, such as alliance, understanding, skills acquisition, and emotional ca-

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tharsis, thatarecentraltoothertherapies.Thefocusisentirelyoninterruptingironicprocessesinthepresent,withnoassumptionthatinsightorunderstandingisnecessaryforsuchinterruptiontohappen.Historymayberelevanttoclients’views,whichinturnarerelevanttohowatherapistencouragesless-of-the-samesolutionbehavior,but in-terpretations (or frames) offered in this context are pragmatic tools for effectingchange,notattemptstoilluminatepsychologicalreality.

A common criticism is that this approach to therapy oversimplifies—-either bymakingunrealisticassumptionsabouthowpeoplechangeorbyignoringaspectsoftheclinicalsituationthatmaybecrucialtoappropriateintervention.Somecriticsfindim-plausible the rolling--snowball idea that a fewwell--targeted interventionsproducingsmallchangesinclients’cognitionsorbehaviorcankickoffaprocessthatwill leadtosignificant shifts in the problem pattern; others grant that brief interventions some-times produce dramatic changes, but doubt that those changes last. Not surprisingly,therapistsofcompetingtheoreticalpersuasionsobjecttothefactthatthesebriefthera-piespointedly ignorepersonalityandrelationshipdynamicsthat, fromotherperspec-tives,may be fundamental to the problems couples bring to therapists. For example,Gurman(quotedbyWylie,1990)suggestedthat“doingnomorethaninterruptingthesequenceofbehaviorsinmaritalconflictmaysolvetheproblem,butnotifonespousebeginsfightsinordertomaintaindistancebecauseofalifelongfearofintimacy”(p.31).Defenders of this approach to therapy reply that such “iceberg” assumptions aboutwhatliesbeneathacouple’scomplaintserveonlytocomplicatethetherapist’staskandmakemeaningfulchangemoredifficulttoachieve.Unfortunately,itisunlikelythatre-searchevidencewillsoonresolvetheseargumentsonewayortheother.

APPLICABILITY

Inprinciple,thisbriefstrategictherapymodelisapplicabletoanycouplethatpresentsaclearcomplaintandat leastonecustomer forchange. Inpractice,however, thisap-proach may be particularly relevant for couples and clients who seem resistant tochange.Forexample,theteam-basedfamilyconsultationforcouplescopingwithhealthproblemsweoutlinebelowisindicatedintheframeworkofsteppedcare,whenother,moreeconomicalorstraightforwardapproacheshavenotbeensuccessful(Rohrbaughetal.,2012;Rohrbaugh&Shoham,2011;Shohametal.,2006).Publishedcasereportsinthebroaderliteraturesimilarlysuggestthatstrategictherapyismostusefulfordif-ficultcases(Fisch&Schlanger,1999).Evenadvocatesofothertreatmentmethodshaverecommended using this model’s principles and techniques at points of im-passe—-either sequentially,when othermethods fail (e.g., O’Hanlon&Weiner-Davis,1989; Stanton, 1981), or as a therapeutic detour to take before resuming an originaltreatmentplan (Spinks&Birchler,1982). Inaddition, controlledstudiesofboth indi-vidualproblems(Shoham,Bootzin,Rohrbaugh,&Urry,1996;Shoham--Salomon,Avner,&Neeman,1989;Shoham--Salomon&Jancourt,1985)andcoupleproblems(Goldman& Greenberg, 1992) suggest that strategic interventions are more effective thanstraightforwardemotion-orskill--focusedinterventionswhenclientsaremoreratherthanlessresistanttochange.

OfparticularnoteisGoldmanandGreenberg’s(1992)studyofcoupletherapythatcompareda systemic treatment toGreenberg’sownemotion--focused couple therapyandawaiting-listcontrolcondition.Thesystemic treatmentemployeda teamformat,with a one-waymirror, and “focused almost exclusively on changing current interac-tions,[positively]reframingpatternsofbehavior,andprescribingsymptoms”(p.967).

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Bothoftheactivetreatmentsweresuperiortothecontrolconditionattermination,butat 4-month follow-up, the couples who had received the systemic therapy reportedbettermaritalquality andmore change in their target complaint than thosewhohadreceived emotion--focused therapy. This finding, coupled with their clinical observa-tions, led the authors to conclude that the strategic approachmay bewell suited forchange--resistant couples with rigidly entrenched interaction patterns. Goldman andGreenberg’s conclusion fits well with the results of our alcohol treatment study, de-scribedearlier,inwhichcouplesembroiledindemand–-withdrawinteractionappearedto do better with a therapy focused on interrupting ironic processes than with CBT(Shohametal.,1998).10

Briefstrategictherapyisprobablyleastapplicabletocoupleswhoseconcernisre-lationship enhancement, prevention of marital distress, or personal growth, becausetherapy requires a complaint and would rarely continue more than a few sessionswithout one. Sometimes a discussion of growth--oriented goals such as improvedcommunication leads to specification of a workable complaint, but short of this, thetherapistwouldnotwanttosuggestorimplythatclientscouldbenefitfromtherapy.Infact, the ironic process idea sensitizes us to therapeutic excess and the possibility oftherapyitselfbecomingaproblem--maintainingsolution. Inthis framework, interven-tionshouldbeproportionatetothecomplaint—andasageneralrule,lessisbest.

At the same time, because this approach is so complaint--focused, critics havepointedoutthattherapistsmayignoreproblems,suchasspousalabuseandsubstanceabuse, if clients do not present them as overt complaints in the first session (Wylie,1990).Althoughcoupletherapistsworkinginthistraditionexplorecomplaintpatternsingreatdetail,andsome(likeus)routinelymeetwithpartnersseparatelytoallowanintimidated spouse to raisea complaint, the focusof intervention remainsalmost ex-clusivelyonwhat clients say theywant to change.Thenon--normative, constructivistpremiseofbrieftherapy,whichrejectstheideaofobjectivestandardsforwhatisnor-mal or abnormal, or good or bad behavior,may too easily excuse the therapist fromattempting to discover conditions such as alcoholism or spousal abuse. According toFisch(ascitedbyWylie,1990),BriefTherapyCenter’stherapistswouldinquireaboutsuspectedwifebeatingonly if itwere in somewayalluded to in the interview.Thus,althoughbrieftherapistsnodoubtrespectstatutoryobligationstoreportcertainkindsofsuspectedabuseandwarnpotentialvictimsofviolence,theyclearlydistinguishbe-tween therapy and social control, and reserve the former for customerswith explicitcomplaints.

Otherethicaldilemmasincoupletherapyconcerndealingwiththe(oftenconflict-ing)agendasoftwoadultsratherthanone.Inthisparticularapproachtocouplethera-py,afurthercomplicationariseswhenatherapistintervenesthroughonlyonememberofa couple,with the implicitorexplicitgoalof changing thebehaviorofnotonly themotivated client but also that of the nonparticipating spouse (Watzlawick & Coyne,1976;Hoebel,1976):Whatresponsibility, ifany,doesthetherapisthavetoobtain in-formedconsentfromotherpeoplelikelytobeaffectedbyanintervention?Suchques-tionshavenoeasyanswers.

Application:AFamilyConsultationApproach

Muchofourownbriefstrategictherapyworkappliesateam-basedfamilyconsultation(FAMCON)formattohelpcouplesandfamiliescopewithdifficulthealthproblemsandaddictions,andwedothisintheframeworkofsteppedcare,afterotherinterventions

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do not succeed (Rohrbaugh et al., 2012; Rohrbaugh & Shoham, 2011). The FAMCONformat, which typically spans up to 10 sessions over 3-6 months, consists of asemi-structured assessment phase followed by a focused feedback (opinion) sessionandfollow-upsessionstoinitiate,amplifyandsolidifyinterpersonalchange. Interven-tions focus on case-specific, often ironic interaction sequences thatmaintain (as theyaremaintainedby)thetargetsymptomorcomplaintandsimultaneouslyaimtobuildor reinforce communal (we-focused) copingby thepeople involved.Procedurally, theFAMCON team first uses preliminary phone contacts to decidewhom to see inwhatformat (preparation phase) and conducts a systemic assessment of prob-lem-maintaining interaction circuits (e.g., ironic problem-solution loops, relation-ship-stabilizingconsequencesofsymptoms)viainterview,directobservation,anddailydiaryreports(assessmentphase).Theteamthenoffersfeedbackinadramatic,carefullyprepared “opinion”sessiondesigned to initiatepattern interruptioneitherdirectlyorindirectlyandtomobilizecommunalresourcesforchange(opinionphase);andadjustsinterventionsstrategies toaddressreluctanceandamplify incipientchange(follow-upphase).SomeFAMCONprinciples of strategic intervention are as follows: (1) call en-counters “consultation,” not “therapy;” (2) formulate strategic objectives specifyingwhat behavior bywhom inwhich situation(s)would suffice to interrupt a particularproblem-maintaining interpersonal pattern; (3) learn and use patients’ language andpreferred views rather than teaching them your own; (4) avoid imparting insight orawareness, allowing cognitive change to follow successful pattern interruption as cli-entsconstructnewmeaningsfortheirchangedbehavior;(5)usetherapeuticrestrainttomanagereluctance;and(6)whenstuck,addpeople–bothconceptuallyand in theconsultingroom.

OurmostsystematicinvestigationsofFAMCONtodatehavefocusedoncouplesinwhichonepartnercontinuedtosmokecigarettesdespitehavingheartorlungdisease(Shohametal.,2006).However,wehavealsousedthisapproachtohelpcouplesandfamiliescopewithproblemsrangingfromheartdisease,cancer,chronicpain,andpedi-atricobesity toalcoholism,anxietyanddepression.Arecentcasereport, forexample,features an older couplewith severe communicationdifficulties copingwith thehus-band’skidneycanceranddiabetes(Rohrbaughetal.,2012).

The following vignettes fromourworkwith change--resistant smokers illustratecouple-levelironicpatterns:

Ahusband(H)smokesinthepresenceofhisnon--smokingwife(W),whocom-mentshowbad it smellsand frequentlywavesherhand to fanaway thesmoke.H,whohad twoheart attacks, showsno inclination tobe influencedby this and says,“ThemoreshepushesmethemoreI’llsmoke!”AlthoughWtriesnottonag,shefindsitdifficultnottourgeHto“givequittingatry.”(Shedidthiswhenhehadbronchitis,and he promptly resumed smoking.) Previously H recovered from alcoholism, butonlyafterWstoppedsaying,“Ifyoulovedmeenough,you’dquit”;whenshesaidin-stead,“Idon’tcarewhatyoudo,”heenrolledinatreatmentprogram.

H,whovaluesgreatlyhis30-year“conflict-free”relationshipwithW,avoidsex-pressing directly his wish for W to quit smoking. Although smoke aggravates H’sasthma,hefearsthatshowingdisapprovalwouldupsetWandcreatestressintheirrelationship.WconfidesthatshesometimesfindsH’sindirect(nonverbal)messagesdisturbing, though she too avoids expressing this directly—andwhen he does thisshefeelsmorelikesmoking.(Rohrbaughetal.,2001,p.20)

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Acentralaimof theFAMCONintervention is to identifyand interrupt ironicpro-cessessuchasthese.As it turnsout,most ironicpatternstendto involveeitherdoingtoomuch, as in the first example, ordoing too little, as in the second.Theymayalsobearonsmokingeitherdirectly(e.g.,naggingtoquit)orindirectly(e.g.,pushingexer-ciseor aparticularquit strategy).Accordingly, theFAMCON therapist–-consultant at-tendscloselytoironicinterpersonalcyclesfueledbywell--intentionedattemptstocon-trolorprotectasmoker,aswellastotherolesmokingappearstoplayinthecouple’srelationship(e.g.,promotingcohesionwhenbothpartnerssmoke,preservingdistancewhenonlyonedoes).Thus,tointerruptanironicpatterninwhichonepartnerpersis-tently attempts (without success) to control theotherpartner’s smokingdirectly, theconsultantwouldlookforwaystohelpthespousebackoff—forexample,bydeclaringhelplessness, demonstrating acceptance, or simply observing the smoker’s habits. Onthe other hand, when an ironic interpersonal pattern involves avoiding the issue ofsmoking,weencourageamoredirectcourseofaction(e.g.,takingastand).Comparedto the alcohol--involved couples we saw earlier, our sample of health--compromisedsmokers tended to show ironic patterns centeredmore on avoidance and protectionthanondirectinfluence.Consequently,ourinterventionsaimedmoreoftentoincreasepartnerinfluenceattemptsthantodecreasethem.

Beyondsuchcase--specificformulations,theFAMCONapproachtosmokingcessa-tion takes great pains to avoid the kinds of ironic therapy processes that can occurwhenacounselor’sdemandforchangeintensifiesclientresistance,orwhenatherapistalignswithfailedsolutionsattemptedbyothersinthesmoker’sfamily.Notsurprising-ly, in the terms of psychological reactance theory (Brehm, 1966; Shoham, Trost, &Rohrbaugh, 2004), many of the smokers we see appear highly motivated to restore“threatenedbehavioralfreedoms”—especiallytheirfreedomtosmoke.Forthisreason,an importantoverarchingguideline is tomaximize the smoker’schoice aboutvariousfacetsof theFAMCONprocess.WealsobelievethatpresentingFAMCONas“consulta-tion,”atermthatconnotescollaborationandchoice,arouseslessreactancethancallingit“treatment”(Wynne,McDaniel,&Weber,1987).

Ideally,FAMCONforchange--resistantsmokersproceedsthroughthreesequentialphases—thepreparationphase, thequitphase,and theconsolidationphase—that to-getherencompassupto10sessionsover3–6months.Thepreparationphaseincludestwoassessmentsessions,scheduledaboutaweekapart,inwhichtheconsultantworkstoidentifyironiccoupleinteractionpatternsthatmayplayaroleinthepersistenceofsmoking.Inthethird(intervention)session,theconsultantpresentsacarefullytailored“team opinion,” in which he or she provides specific feedback based on informationgatheredduringthefirstandsecondsessions.Theopinionincludesobservationsabouthowsmokingfitsthecouple’srelationshipandwhyquittingmaybedifficult,aswellascouple--specificreasonstobeoptimisticaboutsuccessandissuesforthecoupletocon-siderindevelopingaquitplan.Theconsultantcouchestheopinionintermsconsistentwith theclients’preferredviewsof themselvesand their situation,andconcludes thesessionwithaninvitationforthecoupletoconsidersettingaquitdate. Inadditiontohelpingthepartnerscopecooperativelywiththethreatsmokingposestotheirhealthandrelationship,akeyconsideration in thequitphase is toencouragequitstrategiesthatinterruptoravoidironicprocessesandneutralizeanyrelationshipdifficultiesthatcouldarise inasmoke-freesystem.Whensmokersshowsignsof “cold feet,” thecon-sultantmay join themwitha “goslow” intervention;andwhen theydoquit, thecon-sultant conveys “cautious optimism” and refrains from premature celebration ofchange.Finally,duringtheconsolidationphase,theconsultantadjuststherapeuticsug-

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gestionsaccordingtotheclients’responsestopreviousinterventions.

In addition to basic information from clinical interviews, the prepara-tion/assessmentphasedrawsuponquantitativedailydiarydatathatthetwopartnersprovideindependently.Specifically,theclientscallourvoicemail(answeringmachine)everymorning forat least14 consecutivedays toanswera seriesofquestionsabouttheprecedingday.Thequestionsconcernspecificproblemandsolutionpatternsrele-vanttothecase,aswellasmoodandrelationshipquality(e.g.,Howmanycigarettesdidyousmokeyesterday?Howmuchdidyoutrytodiscourageyourpartnerfromsmoking?Howcloseandconnecteddidyoufeel?).Becausethequestionsareansweredquantita-tively,most on a0- to10-point scale, it is possible to identify couple--specific trendsovertime,suchastheextenttowhichwhatonepersondoes(e.g., frequencyofsmok-ing)correlatesfromdaytodaywithwhattheotherpartnerdoes(e.g., intensityof in-fluence attempts). In addition to using this data in research,we find that presentingselecteddailydiaryresultsinthefeedback/opinionsessionenhancesthecredibilityoftheconsultant’sobservationsandtherapeuticrecommendations.Mostcouplesalsodoashortenedversionofthedailycall-insagainlater,foratleastaweekbeforeandaftertheirplannedquitdate,andthisprovidesabasisforregularcontactduringthecriticaltransitiontonotsmoking.

The smoking cessation outcomes for couples who went through the FAMCONtreatment–-developmentproject comparevery favorably tobenchmarks in the litera-ture(Shohametal.,2006).Forexample,the50%rateofstableabstinenceachievedbyourhealth--compromisedsmokersata6-monthfollow-upisapproximatelytwicethatfound in a meta--analysis of other intensive interventions with mostly shorter fol-low-ups (Fiore et al., 2000).Moreover, in an areawhere relapse rates often exceeds50%(Stevens&Hollis,1989), itwasencouragingtoseethatonlythreesmokerswhoquit for at least 2 days relapsed during the next year. It is also encouraging that theFAMCONinterventionappearedwell--suitedtofemalesmokersandtosmokerswhosepartneralsosmoked—twosubgroupsatincreasedriskforrelapse(Homish&Leonard,2005;Wetteretal.,1998).Still,intheabsenceofarandomizedclinicaltrial,wecannotconcludewithcertaintythatFAMCONissuperiortoothercessationtreatments.

CASEILLUSTRATION

Thefollowingcase,seeninauniversitypsychologyclinicandsupervisedbyRohrbaugh,illustratesessentialelementsoftheMRIapproachtocoupleproblems:(1)specificationof a complaint and minimum acceptable change goals; (2) formulation of an ironicproblem–-solution loop, includingwhat less of the same solutionwould look like be-haviorally;(3)focusedinterruptionoftheironicloopinaspecificsituation;and(4)useoftheclient’sownviewsandexperiencestoframe,orsell,thesuggestionforlessofthesame.Becausethetherapistsawonlythe femalememberof thecouple, thiscasealsoillustratesthebriefstrategictherapist’swillingnesstointerveneinarelationalsystemunilaterally,withoutconjointsessions.[Themaninthecouplefelthehadgoodreasonsfornot coming to the clinic, andwe respected this;hedid,however, give consent fortherapytoaddresshispartner’sdifficulties, includingherconcernsabouttherelation-ship, and hewas ultimately pleased by the results.] The casemay also be of interestbecause of what the therapist did not do in terms of exploring or dealing withbread-and--butterissuesofothertherapies.11

Maria,a26-year-oldgraduatestudent inbiology,cameto theclinic for “personal

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counseling.”Wheninitiallyaskedabouttheproblem,Mariasaid,“Ijustdon’tfeelgoodaboutmyself,especiallythewayIamwithmen.”Shewentontotalkatlengthabouthercontributionstothedemiseoftwoearlierrelationships,includingoneinwhichshehadbeenengaged, andworried that shemight soonspoil a third,withHarold,whomshelivedwithandcared forverymuch.Maria sawherself followingapatternwith thesemen,oneshedidnotlikemuch,becauseitwasreminiscentofhowhermotherhadbeenwithherfather:Shesimplycouldnotsucceedinpleasingorsustainingintimacywithamanshe loved,nomatterwhatorhowhardshe tried.At thesametimesheresentedfeelinglikesheshouldpleaseamanandverymuchwantedtoavoidthekindoftradi-tional,subservientrelationshiphermotherhadwithherMexicanAmericanfather.De-spite feminist sympathies, Maria felt that “old tapes from childhood” about woman–manrelationshipshadcontributedtoherdifficultieswithmen.Laterinthesession,shecontrastedherfailuresinlovewithsuccessesinotherpartsofherlife:Notonlywasshebeginningtopublishinherchosenacademicspecialty,shefelt“lessanxious”and“moregroundedpsychologically”thanshehadseveralyearsearlier,whensheenteredgradu-ate school. Maria attributed this mainly to her practice of “mindfulness meditation,”whichshehadtakenupduringherfirstyearingraduateschool,shortlyafterbreakingoff a brief engagement to Carlos (whom she feltwas becoming emotionally abusive),andabout6monthsbeforeshebecameseriouslyinvolvedwithHarold.Atthetimeofthefirstinterview,MariaandHaroldhadbeenromanticallyinvolvedfornearlyayearand had lived together (in his house) for 5 months. They did not discuss long-termplans,andMaria’searlierhopesthatmarriagewouldbeintheoffingwerebeginningtodim.

AfterlisteningattentivelytoMaria’shistoricalaccountofproblemswithmen,thetherapist askedhow thesedifficultieswere showing themselvescurrently inher rela-tionshipwithHarold.Tothistheclientsaid,“Well,Ijustseemtobringouttheworstinhim,”thenwentontoexplainhowHarold,a36-yearoldfacultymemberinanotherde-partment,was a very kind, loving, and sensitivemanwho, unlike the younger,moremachistaCarlos,couldappreciateandrespectacompetentwoman.Nevertheless,Har-oldwassometimessensitivetothepointof insecurity:Hehadsome“jealousyissues,”whichthecoupleattributedto“traumaticresidue”fromhisex-wife’saffairssomeyearsearlier.Tryas shemight,Mariahadnotbeenable toprovide the reassuranceHaroldseemed toneed. In fact, theirattempts todiscuss the jealousy issuesometimes led to“reallybadarguments,liketheonelastweekbeforeIcalledtheClinic”—hence,thefearabout“bringingouttheworst.”

Seekingamorebehavioralcomplaintdescription,thetherapistatthispointaskedMaria to describewhat typically happenedwhen she andHarold tried to discuss thejealousy issue,perhapsusing thepreviousweek’s incidentasanexample: “Howdoestheissuecomeup?Whosaysordoeswhat?Whathappensthen?Ifwerecordedyourinteraction on video,whatwould I see?” Fromquestions along this line emerged theoutline of a problem–-solution loop:When Harold expresses concern about whetherMariafindshimsexuallyattractive,Mariatypicallyexplains(patientlyatfirst)thatyes,shedoesfindhimattractive,andinfacthasneverlovedamanthewaysheloveshim.Apparentlyunconvinced,Haroldthenasksfurtherquestions,eitheraboutthedetailsofher past sexual experiences (especiallywith Carlos) or aboutmen she finds sexuallyattractivenow.Forherpart,Mariarespondstothisbydenyingotherinterests,offeringfurtherreassurancesthatHaroldreallyhasnothingtoworryabout,andexpressinghergrowingfrustrationwithHarold’sinabilitytotrusther.Once,inresponsetopersistentquestioning,MariahadactuallytriedtodescribeherlovemakingwithCarlos,callingit

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“vigorous,atleastonhispart,”but“unsatisfyingforme,becauseIfeltused.”ToMaria’sdismay,Haroldquestionedherabout“vigorousorgasms”inalaterdispute,andtheac-cuse–denysequencebetweenthemhadseveral timesescalatedto thepointofyellingandname--calling.Ononesuchoccasionshestormedoutofthehouse,andonanother,Harold threwabook,accidentallybreakinga lamp.These “blow-ups”were invariablyfollowedbyperiodsof remorse, inwhichbothpartners (but especiallyMaria)wouldtry to take responsibility for what happened and resolve not to let it happen again.While allowing thatHarold’s fits of jealousywereoften “unreasonable,”Maria clearlyregarded them as anomalous to his otherwise pleasing personality and felt that theblow-upsmainlyreflectedherinabilitytomeethisneeds.Despitethesecomplications,MariaconfidedthatsheandHaroldreallydidhavegoodsex,especiallywhentheyhadnot triedbeforehand to talkabout it,whichwasall themorereason tosave therela-tionship.

Towardtheendofthefirstsession,thetherapistaskedwhatMariahopedtogainfromcomingtotheClinic,andwhatshewouldtakeasatangiblesignthatthesituationwithHaroldwasimproving.Shesaidshemostwantedtounderstandwhyshewasun-successfulwithmen,becausethismighthelphersavetherelationshipwithHarold.Thetherapistdidnotchallengethis,butpressedinsteadforaminimumchangegoal:“What,when it happens,will let you know that you andHarold are getting a handle on thejealousyproblem?Orthateventhoughhemightnothaveproposedmarriage,yourre-lationship isat leastheading in the rightdirection?”Maria said she justdidnotwanthim tobe jealous, andeventually sheagreed thatnothavingarguments about sexualmatters,evenifHaroldbroughtitup,wouldbeasignificantindicationthatthingswereimproving. After consulting with the team behind the one-waymirror, the therapistclosedthesessionbysuggestingthatMariatellHaroldat leastaboutherfirstgoal(tounderstand her contribution to problems in important relationships), and to askwhetherhemightbewillingtohelpwiththislater,particularlysinceheknowshersowell—-assuming that we (the team) could think of something he could do. [The ra-tionaleherewastoopenthedoorforHarold’spossibleparticipationinthetherapy,yetto do so in away that respectedMaria’s—and perhaps also Harold’s view—that theproblemwashersratherthanhisoreventheirs.[Inretrospect,itwouldprobablyhavebeenbetter to askMaria’s permission to callHarolddirectly, so thatwe couldbetterassess his customership and control the message. Later, after the next session, thetherapistinfactdidthis.]

Maria opened the second sessionby announcing that her homework assignmenthadnotgonewell.AlthoughHaroldhadknownaboutthecounselingappointmentandfelt OK about Maria getting help, he had not expected (she said) that so much timewouldbespenttalkingabouthim.Furthermore,asforhelpingwiththetherapy,therewasnowaythathe,atenuredprofessorattheuniversity,couldbecomfortablewiththevideotaping and observation room setup, or with talking about personal matters tograduatestudentsandfacultyfromanotherdepartment.WhenaskedwhyshethoughtHaroldreactedthisway,andhowshehandledit,Mariasaidshethoughthemighthavebeenembarrassed.Shehadtriedtoreassurehimthatshewasreallycomingtoworkonherownproblems,nottocomplainabouthim,butthisdidnotwork,soratherthanriskanother argument, she decided to apologize quietly and drop the subject. After aphone-infromtheteam,thetherapistconveyedtoMariatheteam’sapologyforputtingherinthisawkwardpositionandaskedpermissionforustocallHaroldandapologizeto him as well. Maria was initially reluctant, but agreed to the call, adding that shewouldprobablywarnHaroldwhatwascoming.

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The rest of the second sessionwasdevoted to further investigation of the prob-lem–-solutionpatternidentifiedinthefirstsessiontodevelopaclearerpictureofwhatless of the same (the strategic objective) might look like on Maria’s side. Althoughcharacteristic “solutions” suchas explaining, reassuring, anddenyingwerealready infocus, it was not clear in what situation(s) the escalating interaction sequencemosttypically occurred. Questions about this yielded few specific answers: In fact, MariafounditdisconcertingthatshecouldnotpredictwhenHaroldwouldaskhera“sexualattraction”question,because if she could, shemightbetterprepare for it: “It can justcomeoutof theblue, likewhenhe’sreflectingonthings—evengoodthings.”AnotherusefulpieceofinformationcamefromquestioningMariaaboutsolutionsthatdidworkforher,atleastwithotherproblems.Herewewereparticularlyinterestedinhowsheusedmindfulnessmeditation,andwhat thismeant toher.Mariadidmeditationexer-ciseseverymorningandpreferredtodothemwhenHaroldwasnotinthehouse,soasnottodisturbordistracthim.Shealsosaidthatmeditations—andmoregenerally,theEastern idea of “yielding”—hadhelped her copewith interpersonal stresses, particu-larlyafterproblemswithHarold.Whenfeelingstressedinthisway,Mariawouldtryto“yield”by takinga “miniretreat,”whichamountedtoabriefperiodofprivatemedita-tion, again away from Harold. These miniretreats were inevitably “healing, at leasttemporarily,” but theywere not always possible to arrange. A final line of questionsconcernedtheviewsandpossiblesolutioneffortsofpeoplebeyondthecouple,suchasrelatives, friends, and colleagues. Here we learned that Maria spoke several timesweekly on thephonewithhermother,whose opinionwas that the relationshipwithHaroldwasunlikely to succeed, in part becausehewas fromadifferent cultural andreligiousbackground.Mariadidnotarguewithhermotheraboutthis,butatthesametimeshestiffenedherresolvetosucceedinlove,aswellaswork.Afterall,hermotherhadatfirstbeenskepticalabouthercareerplans,too.

The therapist calledHarold several days after the second session as agreed, andfoundhimsymmetricallyapologeticaboutthemisunderstandingssurroundingMaria’stherapy.HaroldsaidhehopedthecounselingcouldhelpMaria,whohe feltwasoften“toohardonherself,”andmaybeifthathappened,therewouldbesomeindirectbene-fitsfortherelationship.Hehopedthetherapistwouldunderstand,however,whyhedidnot want to come in himself. Sensing that this was not amatter for negotiation, thetherapistsaidshedidunderstandandthatwe,too,wishedthebestforhisandMaria’srelationship.Althoughcarefulnottocommentoraskquestionsaboutanyparticularsofthe relationship, the therapist did ask Harold if shemight call him again “sometimedowntheroad”toconsult,ifsheandMariathoughtthatmightbehelpful.Afterabriefhesitation,heagreedtothisrequest.

Atastaffmeetingafewdayslater,theteamreviewedtheaccumulatedinformationabout the case, sharpened its formulation of problemmaintenance, and planned theparticularsofaninterventionforthethirdsession.Focusingonthejealousysequence,itwasclearthatthemainthrustofMaria’ssolutioneffortinvolvedtalkingwithHaroldabouthis fearsandconcerns,notably,explainingandreasoningwithhim,offeringre-assurances, anddenying that shewas sexually attracted to othermen. Itwas equallyclearthatlessofthissolution—thestrategicobjectivethat,ifaccomplished,wouldsuf-ficetobreakthecycle—-shouldinvolvenottryingtotalkHaroldoutofhisconcernsor,perhapsbetter,nottalkinginthefaceofaccusationsatall.[TheteambrieflyconsideredwaysMariamightreverseherusualstance(e.g.,byagreeingwithHaroldandamplify-inghisconcerns),butthisseemedprovocativeandmuchtoorisky.]Becauseitisusual-ly easier in such a context for clients to do something than not to do something, the

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teamconsideredwhatthetherapistcouldaskMariatodothatwouldeffectivelyblockherusualsolutionefforts.Aftersomediscussion, itwasdecidedthatthesimpleactofmeditation, if done at the right time in Harold’s presence, could serve this purposenicely.Anadvantagewasthatthebehaviorofsittingquietly,breathingevenly,andfo-cusinginwardly,withhereyesclosed,wasfamiliartoMariaandaprovenwayofcopingwithstress.Ontheotherhand,becauseMariapreferredtomeditatealone,soshewouldnotdistractordisturbhim,itmightbedifficulttopersuadehertodothiswithHaroldnotonlypresentbutalsoactivelyattemptingtoengageherinconversation.Afinalcon-siderationwasthatthetargetsequenceoftencame“outoftheblue,”withnopredicta-ble onset. This meant that Maria’s strategic meditation would need to occur contin-gently,andthatwhentoattemptthisshouldbespelledoutclearlyintheintervention.

AstheteamponderedhowtoframethemeditationinterventioninawaythatMa-riawould accept, several aspects of her preferred views, or “position,” seemed espe-ciallyrelevant:First,savingtherelationshipandbeinghelpfultoHaroldwerehighonMaria’s list of concerns. Second, she understood that mindfulness meditation andknowingwhentoyieldcanhelppeoplecopewithstressfulsituations,soperhapsthisideacouldbeextendedtoincludepossiblefuturebenefitsforHaroldandtherelation-ship, aswell as for her. Second, becauseMaria believed that self--understandingwasthepreferredpath topersonalgrowthandchange, itmightbeadvisable to framethemeditationtaskassomething likely toprovokeunforeseen insights,primarily forher,butperhaps(eventually)forHaroldtoo.AnotheraspectofclientpositionthattheteamconsideredwasMaria’sresolvenottobeconstrainedbyhermother’sexpectations,butbecausethisdidnotseemapplicabletoframingthemeditationintervention,itwasheldinreserveforpossibleuselaterinthetherapy.

Session3beganwithareportonHarold’sreactions to the therapist’sphonecall,whichMariacharacterizedasmorethoughtfulandconsideratethanshehadexpected.Although the couplehadhadagoodweek,withno jealousyor sexual--attractiondis-putes,Mariawasnotoptimisticthatthisstateofaffairswouldcontinue.Thetherapistagreedwithherassessment,adding that the teamhadgivensome thought toMaria’ssituationandhadcomeupwithsomeideasthatmighthelpinherself--analysis.WhenMariasaidshewouldliketohearaboutthoseideas,thetherapistproceededtoframetheintervention:First,shesaid,itmightbehelpfulifMariahadawaytocopewiththejealousy situationon the spot, so itwouldbe less likely togetoutofhand.Second, itmightbepossibletodothis inawaythathelpsusunderstandmoreaboutwhyMariabehavesasshedoes,atleastwithHarold,whichinturncouldgivecluesabouthowtochange.Finally,thoughtheteamwasnotsure,whattheyhadinmindmightalsohelpHaroldwiththestresshemustbeexperiencing,andperhapsevenhelphimtakestockofwhathecoulddotomaketherelationshipbetter.[Throughallofthis,boththether-apistandteambehindtheone-waymirrorcarefullywatchedMaria’snonverbalexpres-sion,particularlyherheadnods,toseewhethersheseemedtobeacceptingtheframe.Only the part about Harold taking stock of his own contributions seemed to evokeskepticism,andthetherapistquicklydownplayedthisas“aprettyunlikelypossibility.”]Takingapositionofmild restraint, the therapist then said that although sheknewofseveralsmallbutspecificstepsMariacouldtaketoaccomplishthesethings,thosestepscouldbedifficult,andshe(thetherapist)wasreluctanttoaddtoMaria’sburden.AfterMaria respondedby affirmingher commitment to “doingwhatever is necessary,” thetherapist,withanairofcaution,proceededtolayoutthestrategicmeditationideaanditsrationale.

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Thekeytodoingthemeditationsuccessfully,thetherapistexplained,wouldbeforMariatopaycloseattentiontoherownreactions.Whenshewassureshefeltlikede-fendingherselfor reasoningwithHaroldaboutsexualmatters, sheshoulddo the fol-lowing:(1)Looktowardtheceilingandpolitelysay,“Excuseme,Harold”;(2)ceremo-niouslyassumeacomfortablemeditationpositiononthefloor;(3)closehereyes;and(4)beginmeditating. IfHaroldattemptedto interruptthisordrawher intoconversa-tion, she should simply say,withoutopeninghereyes, “The counselor suggested IdothiswhenIfeelstressed.I’llbeavailableagaininabout15minutes.”IfHaroldbecameupsetortriedtoroustherfrommeditation,shewouldsimplyremainsilentandyield,Gandhistyle,nomatterwhattheprovocation.Afterwards,shemightdowhatever feltnatural, eitherwithHarold orwithout him. The therapistwent on to underscore thepotentialenlightenmentvalueofthisexercise,pointingoutthattheteamwasreasona-blyconfidentthatshouldMariahaveopportunitytodothisafewtimes,someinsightswouldemergetoshedlightoneitherherhabitualdifficultieswithmenorwhatthefu-turemightholdforherselfandHarold.Theteamdidnotknowwhatformtheseinsightsmighttake,whattheymightmean,orhowsoontheywouldemergeafterameditationsession,butthetherapistexpressedconfidencethatsheandMariawouldknowhowtohandlethemwhenthetimecame.ThesessionclosedwithMariareassuringthethera-pist that themeditationexperimentwouldnotbetooburdensomeforher.Mariaalsonoted that, in her experience, important awarenesses usually occurred well after amindfulness meditation, for example, while taking a hike. The therapist was unsurewhatMariameantbythis,butshedidnotexploreitfurther.

WhenMariareturnedforSession4,twoweekslater,shereportedtherehadbeennooccasions to try themeditation experiment.Although shehad considereddoing itseveral times when shewas beginning to feel irritatedwith Harold, these situationswere not really related to the jealousy issue, so she held back. Actually, Maria said,knowingwhat shewould do if/when a difficult situation cameup hadmade her feelmoreconfident,andshewonderedwhethershemighthavebehavedalittledifferentlyaroundHarold because of this. The therapist complimented her on feeling confident,but suggested that she “go slow”withbehavingdifferently aroundHarolddue toun-certaintiesabouthowhe(andthey)mighthandleit.ThetherapistalsoexpressedmildchagrinthatHaroldhadnotprovidedMariawiththelearningopportunityshehadan-ticipated. After a period of general discussion about parity in man–woman relation-ships, the therapist returned to the “missed opportunity” problem and suggested thepossibilityofdelaying thenext sessionuntilHaroldhad “misbehaved” to thepointofallowingMariatotrythemeditationexperiment.Mariaatfirstseemedpuzzledbythis,becauseshe thought talking thingsoutwouldcontinue tohelpher,but sheagreed tocallinamonthforanotherappointment,orpossiblysooner,ifshehadthefortunate(?)opportunitytomeditateinfrontofHarold.

RoughlyamonthafterSession4,thetherapistreceivedaphonemessagefromMa-riaannouncing: “Bignews!Haroldproposed!!!”And inasessiona fewdays later, sheexplainedwhathadhappened.Oneeveningnotlongafterthelastsession,HaroldhadagaintriedtodrawMariaintoadiscussionofCarlos’ssexualprowess,andafteronlyaminute of this, shehad invoked themeditation routine.After shebegan, hehad said,“What thehell?”Witheyes closed,Maria repeated thebrief explanationabout feelingstressed.Asbestshecouldtell,Haroldlefttheroomaminuteorsolater,thenleftthehouse.Hecamebackfairlylate,afterMariahadgonetobed,butthenextmorningbe-fore she finishedher showerhehadpreparedpancakes (somethinghehadnot donesinceearlyinthecourtship).Atbreakfast,afteraperiodofsilence,Haroldprofferedan

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awkward apology forhis insensitivity over thepast fewmonths, then askedwhetherMariamightteachhimhowtomeditate.Thiswassomethingshehadurgedhimtotryanumberoftimesinthepast,buthehadshownlittleinterest,andshehadthoughtbetterofpursuingit further.Inanycase,MariaandHaroldhadgoodsexthatevening;after-wards, she instructed him in mindfulness meditation. Much to her delight, they hadmeditatedtogethereverymorningsincethen,exceptforafewdayswhenHaroldwenttoameetingoutoftown.Therehadbeentwopotentialrecurrencesofthejealousyse-quences, butMaria had nipped each of these in the bud—the first by looking at theceilingandclosinghereyes,andthesecondbyplayfullysaying“Meditationtime.”Asfor“insightandawareness,”MariasaidthatoncesheandHaroldbeganmeditatingtogeth-er,sherealizedhow“enabling”shehadbeenbypreventinghimfromtakingafullshareofresponsibilityforthesuccessoftheirrelationship.Again,however,theteamwasnotentirelysurewhattomakeofthisrealization,sothetherapistrespectfullyvalidateditwithoutmuchelaboration.

Finally,whenaskedwhyshedecidedtocomebacktotheclinic,Mariasaidshehadthoughtaboutcalling toscheduleanappointmentearlier,aroundthe timeof the firstpotentialjealousyrecurrence,butshedecidednottoriskspoilinghersuccess(andup-settingHarold)bydoingthat.Infact,shewouldprobablynothavecalledwhenshedidexceptthat,thistime,Haroldhadsuggestedit.Therapyterminatedatthispoint,amidmessages thatbothcongratulatedMaria (and, throughher,Harold)onwhat theyhadaccomplishedandcautionedheragainstthinkingtheroadaheadwouldbetroublefree.Thetherapistwouldbeavailableoverthenextfewmonthsincaseshe(orthey)wantedtovisittheclinicagain,andMariacouldcountonaroutinefollow-upcallfromtheclinicin6–12months.Afewdays later, thetherapistreceivedapersonalnote fromHarold,expressinghissincere thanks for “helpingMariacometo termswith thestress inherlife.”Haroldfeltthatthishadhelpedhim,too.Inthefollow-upcontact9monthslater,Mariareportedno furtherrecurrencesof the jealousycomplaint. Inaddition,shewasmarriedandpregnant.

ACKNOWLEDGMENTS

ThisworkwaspartiallysupportedbyGrantNos.R21-DA13121,R01DA17539,andU10DA15815fromtheNationalInstituteonDrugAbuse.

SUGGESTIONSFORFURTHERSTUDY

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