Therapeutic Interventions in Life Threatening Situations
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Journal of Marital and Family Therapy
1987, Vol. 13, No. 3,225-239
THERAPEUTIC INTERVENTIONS IN LIFETHREATENING SITUATIONS*
Monte Bobele
Texas Tech University
Therapists who encounter life-threatening behavior in their clinical practice are
at risk in providing interventions which do not take into account the systemic
effects of their interventions. Specifically, therapists are likely to engage in “more
of the same” behavior with clients whopresent with suicidal or homicidal threats.
This paper presents two case studies that employed therapeutic methods derived
from the systemic therapy of the Palo Altogroup. I n these case studies, the author
illustrates the importance of the therapist’s ability to speak the client’s language
in formulating a n intervention that has the potential for reducing the likelihood
of actual violence. The first case illustrates the use of the client’s world view about
her situation to assist her in dealing with domestic violence. The second case
presented describes the use of systemic interventions in the case of a young woman
known to have made homicidal threats. The author discusses the appropriateness, as well as the ethical issues, of the techniques described. Also offered, is a
discussion clarifying the theoretical underpinnings of the clinical work presented
and an amplification of some of the ideas originally presented by the Palo Alto
group.
Behaviors or situations which are possibly life-threatening pose unequaled problems for psychotherapists. Clients who have announced suicidal or homicidal intentions
call for unusually careful therapeutic measures, especially because the ’Parasoff (1976)
decision has detailed the therapist’s responsibilities in such cases. Such intentions, also,
are likely to create a feeling of urgency in the therapist, who appropriately senses a
need to do something to reduce the chances of violence.
This paper takes the position that preserving human life is an important concern
in life-threatening situations, but interventions designed to prevent the dangerous
behavior without taking into account the interactional context of the threat run the
risk of actually increasing the likelihood that tragedy will occur. In such situations, it
is imperative that the therapist join the client’s world view, and tailor-make therapeutic
interventions accordingly.
There can be little doubt that therapists respond to their clients in ways that are
consistent with the theoretical notions that underlie their daily practice. It is also clear
that life-threatening behavior is a relatively common encounter in the day-to-day prac~
~
~~
*A portion of this paper was completed while the author was a fellow at the Galveston Family
Institute, Galveston, TX 77550.
The author wishes to thank the following colleagues who have offered helpful comments as
this paper has developed:Harold Goolishian, Marcia Brown Standridge,Brad Keeney, Tom Conran,
Lee Winderman, and Steve de Shazer.
Monte Bobele, PhD, is Director of Clinical Training, Marriage and Family Therapy Program,
Department of Human Development and Family Studies, Texas Tech University, Box 4170, Lubbock, TX 79409.
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tice of many clinicians. A number of publications have reviewed the standard approaches
to such situations (e.g., Bagarozzi & Gittings, 19831, but such works are not clear about
how to develop interventions which take the client’s world view into account. It is the
purpose of this paper to present a systemic approach to therapy in these situations.
Domestic violence and threats of violence against other people are situations which
suggest that an interpersonal approach to the problem would be useful. Several studies
have provided support for examining the relationships between people and the situations
in which they find themselves, as the causative factors in domestic violence (Anderson,
1977; Bard, 1971; Ennis, 1967). The literature that exists, for the most part, describes
techniques for dealing with hazardous situations that are based upon theories that are
basically intrapersonally rather than interpersonally oriented, although there is no
consensus regarding the treatment of choice (Bagarozzi & Gittings, 1983; Saunders,
1977, 1981). One authority on domestic violence has lamented the fact that in the
absence of knowledge about the patterns of marital violence, many therapists have
relied upon stopgap methods of treatment and prevention (Gelles, 1976). There is a
conspicuousabsence of material describingtherapeutic work deriving from the approaches
of the Mental Research Institute in treating potentially violent or life-threatening
behavior. An exception is the work by the Everstines (1983). In their descriptions of the
application of systemic therapy to crisis situations, they demonstrate that the systemic
therapist need not switch paradigms in order to treat people in crisis or life-threatening
situations. Indeed, they discuss cases involving family violence, adult and child victims
of sexual assault, suicide, hostage negotiation, and other situations that contain a high
potential for violence. This paper provides a clinical demonstration of the use of these
principles in two volatile situations that are not uncommon in the average clinician’s
practice. These examples also demonstrate the value of using a team of therapists for
rapid resolution of these crises.
Watzlawick, Weakland and Fisch (1974) depict the situation which follows from
ineffectual attempts at problem solving. People generally apply a particular solution,
or class of solutions, to a problem because they believe the class of solutions will work.
If the solution fails, people generally blame their application of the solution, not the
solution, itself; so they try again, or try harder. Trying again, or trying harder, in fact,
often solves problems. If not, a t least two results are possible: (a)the problem may get
worse, or (b) the problem may appear worse to those involved because it has persisted.
Often, what may be needed is a change of the manner, or process, in which change is
being attempted. A change of change attempts has been referred to as second-order
change (Bateson, 1972; Watzlawick et al., 1974).
Another way that Watzlawick and his colleagues describe second-order change is
in terms of a change of the rules which govern a relationship; simply adding or revising
a current rule is not what is meant by changing the rules that govern a relationship.
For parents to change the household rules so that their teenager is required to come in
a t 11:OO p.m. instead of 1O:OO p.m. is not second-orderchange; a husband telling his wife
that she can spend more money than she has been accustomed to is also not a secondorder change. For second-orderchange to occur in the rules which govern a relationship,
a change in the manner in which the rules are made must occur. In the former case, the
parents may abandon setting a curfew, altogether, and the time, if any, at which the
teenager comes home will be determined by some other contingencies. In the latter case,
were the wife to begin to tell her husband how much he was allowed to spend, the rules
of the relationship would still essentially be the same-that is, one of the pair regulates
the other’s spending behavior. Second-orderchange in this situation might involve some
unanticipated circumstances.
As Keeney and Ross (1985) have clearly illustrated, the notion of a problem carries,
imbedded within it, the notion of a solution. Problems, a s well as their associated
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solutions, are distinctions that we make as observers; they are ways of punctuating our
experience. Particular solutions, or goals, carry with them, conversely,a particular class
of problems. As someone has said, if the only tool one has is a hammer, everything looks
like a nail. Change, then, may be brought about by changing the class of solutions used
or by changing the class of problems perceived. A change in either would bring about
second-orderchange as described by the MRI group. Every probledsolution is imbedded
within a context which has the effect of distinguishing both problems and solutions in
a unique manner. One way to bring about a change in the class of solutions applied or
problems perceived is to change the context that distinguishes the situation. A change
in the context is essentially a change in the meaning that one attributes to a particular
probledsolution interaction.
In potentially life-threatening situations, clients, as well as therapists, often get
caught up in ineffective attempts at first-order change. People naturally apply the
solution that they think will work, given their understanding of the nature, cause(s),
and context of the problem. If one’s understanding of the context of the problem changes,
the class of solution behaviors available will also change. Ifthe understanding, or context
of a problem is successfully altered, second-order change, a change in change-seeking
behavior will occur. Therapists, in particular, need to be ready to abandon “obvious”
problem solutions when they have proved ineffective. It is easy for a therapist to fall
prey to the process of trying harder when first attempts a t helping a client fail. When
these attempts to try harder result in “more of the same” therapeutic techniques, the
therapist becomes stuck as well as the client. Finding out from the client what has not
worked in the past is crucial to the successful outcome of therapy (Haley, 1976). Determining what the client has tried to do about the problem, as well as what others have
suggested, provides valuable guidance to the therapist about what is not likely to work
with a particular client. Moreover, knowing what advice the client has resisted helps
the therapist understand the client’s world view and design an intervention that would
speak to the client’s world view. Suggestions and advice that the client has not followed
in the past may be considered to be suggestions that are not consistent with the way
the client views his situation. Therefore, knowing what is not in the client’sworld view
is as valuable as knowing what is.
The following two case examples are presented to illustrate how interventions aimed
at changing the context of the client’s interpersonal quandary permit a subsequent
change in the class of solution behaviors attempted. An important principle that the
following treatment depends upon is the deliberate use by the therapist of the “language”
of the client in reframing the problem situation. As Watzlawick et al. (1974) describe
this process:
. . . successful reframing needs to take into account the views, expectations, reasons,
premises-in short, the conceptual framework-of those problems to be changed . . .
Reframing presupposes that the therapist learn the patient’s language. (p. 104)
Here, language is not limited to using the client’s words. Reframing is something that
is sometimes misunderstood to be a simple renaming or relabeling of something that
the client has been telling the therapist. Sometimes, reframing is misunderstood to be
synonymous with psychoanalytic interpretations. The following cases demonstrate that
successful reframing is dependent upon a thorough understanding of the client’s world
view, so that a shift in the meaning that the client attributes to a particular circumstance
is achieved. This is different than the wholesale shifting of the client’s reality to that of
the therapist’s so that the client will accept the therapist’s attributions. Understanding
reframing in this way is more economical because the therapist does not have to teach
the client a new way of looking at the world-a time consuming endeavor. Potentially
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dangerous situations, such as those described below, do not lend themselves to lengthy
therapeutic strategies.
Case Example #1
A woman in her mid-30’swas referred by a local women’s crisis shelter for counseling. During the interview, she described her boyfriend as an exceptionally kind and
loving man, most of the time. He had been a good stepfather for her children and they
cared a great deal for him. The client said that her boyfriend did not drink or use any
drugs to excess. She was in love with him and did not want to give up her relationship
with him; she simply wanted to find a way to stop his violent outbursts and make him
feel more secure and trusting of her. She took obvious care to describe him to the therapy
team in a positive, noncritical manner. The client related a long history of violent abuse
in her relationship with her live-in boyfriend. Following the violent episodes, she said
that he reverted to his loving, gentle nature; for a few days afterward, he did everything
to atone for his behavior. She characterized her boyfriend as inordinately insecure in
the relationship; he seemed to need frequent reassurance of her love for him. She
recounted situations in which any conflict between the two of them was seen by her
boyfriend as evidence that she did not love him. In spite of her repeated assurances to
the contrary, he continued to point to incidents that convinced him that she did not care
enough for him. This particular pattern of relationship has been described as a complementary one. A complementary relationship is one that is based upon the interactions
of individuals around the maximization of their differences (Bateson, 1979; Watzlawick,
Beaven & Jackson, 1967). Accordingly, t o demonstrate her love for him, she began
bending over backwards to do things to please him. These efforts reportedly infuriated
him more because he alleged that these were not spontaneous loving acts on her part,
but were only measures t o patronize him.
She had, at first, talked with friends and others, t o seek their advice about what
she might do to clearly express her love for him. Her friends, however, encouraged her
to give up and leave him, and even these attempts to help their relationship were seen
by her boyfriend as disloyalty when he discovered them.
Further interviewing with this client ascertained that she had talked with family,
friends, clergymen, and the local hotline. Her family had offered her a place to stay and
encouraged her t o leave her boyfriend. The hotline had referred her to various therapists
and encouraged her to leave for a woman’e shelter a t the next sign of impending violence.
Moreover, she attended several sessions with a volunteer counselor at a center for
battered women. The counselor encouraged her to stand on her own two feet, to be more
assertive, and to abandon her dependent position by taking college classes, or getting a
job to improve her self-esteem and financial independence. All these help givers had
been justified in their concern about her situation and had proposed excellent solutions
based on their perception and understanding of the problem. The client had, however,
“resisted” all of them and remained in her situation with nothing changed. The client
explained that everyone she had talked to had really cared for her, but that if they had
understood the depth of her love for her boyfriend they would have known that she
could not leave him. This is not an uncommon situation. Women’s shelters report an
extremely high proportion of their client populations who return to the battering situation repeatedly (Walker, 1980).
By the time the woman sought counseling, the situation had escalated to the point
where her boyfriend had pulled out a pistol on two occasions and fired shots in her
direction. The night before the team saw her, the couple had had an argument she did
not feel had been successfully resolved. She described this episode a s if he were a
frustrated child. She did not think that he really intended t o shoot her, but she was
worried that his anger might get the best of him, eventually. He had left the house early
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in the morning to go to work, and she was worried that when he returned home that
evening, things might pick up where they had left off the night before. If this happened,
she was afraid of what he might do because each time one of these fights got going, he
was more violent than the last time.
The therapy team was extremely concerned about the explosivenessof the situation
and that he might even regard her contact with the therapy team as further evidence
of her disloyalty. At this point, the team hypothesized that the boyfriend‘s behavior had
been designed to change the woman into a more loving, reassuring and loyal person;
his behavior seemed to be based upon a belief that she did not love him and was not
loyal. It was seen that his attempts to get her to be more reassuring had not worked,
and he had persisted in ineffective attempts to change her. The more he failed, the
harder he tried. The team deliberately avoided generating hypotheses about him which
would have cast him as a violent person, a man who could not relate to women, etc.
Such understandings of him might have led the team to the same ineffectual recommendations that previous helpers had made. Although there is little doubt that some
men behave in a manner that is violent, such a n intrapsychic explanation would have
obscured the interactional understanding of the situation that the team was striving
for. The client, rightfully, understood that leaving him would be perceived as the ultimate
disloyalty and could incite certain violence. The woman saw him as a loving man who
was insecure in his relationship with women. She believed then, that the way to change
his insecurity was to become more reassuring and submissive so that he would come to
understand how much she loved him. The more she failed at changing him, by doing
these things, the harder she continued to try. The team also deliberately avoided understanding her behavior as the result of passivity, masochistic tendencies, or any other
context that would cast her as a victim. There exists a pervasive, culturally supported
tendency of therapists who work with victims of abuse, t o overtly or covertly blame
them, and this tendency has been identified as a hindrance to successful treatment
(Saunders 1981). The team hypothesized that each had persisted in applying an ineffective class of solutions, and, ironically, their solutions made matters worse between
them. The team attempted to positively connote (Palazzoli, Boscolo, Cecchin, & Prata,
1978) for themselves the intentions of both the woman and her boyfriend so that they
could begin to apprehend the client’s world view. The client’s language during the
interview was one of loving concern for her partner’s welfare and selfless sacrifice for
him.
This effort on the part of the team was seen as a first step in helping the woman
feel understood and heard within her own world view. The team knew that in order to
begin to understand the client’s perspective, a positive view of the intentions of both the
client and her partner would help in constructing an intervention that would communicate to the client that she had been heard and that the team understood the difficulty
of her situation. A negative connotation would have had the unproductive effect of
communicating to her that the team thought that she was a fool for loving such man,
that she was not smart enough to figure out that she could leave him if she decided to,
that her judgment was impaired by having become involved with him in the first place,
that her reality testing was impaired, or perhaps, that she was dependent upon strangers
to tell her how her life should be led. The team actively avoided any language among
themselves or with the client which could have attributed these qualities to the woman.
It was assumed that the client did not hold these ideas about herself, but even if she
did, pointing them out was not likely to be productive.
An important, but often overlooked point, is that all the previous “helpers’ solutions had failed, thus far, to alleviate the dangerous situation, although all of the helpers
had tried excellent common sense approaches to the problem. Every one of the previously
proposed solutions had, in common, the goal of changing the woman, or the man, but
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not their relationship, or its context. Watzlawick cautions therapists against seeking a
second-order solution or intervention when a first-order intervention is all that is
required, while also urging therapists to avoid becoming stuck in more of the same
situation that has not helped the client (Watzlawick et al., 1974, p. 39). Unequivocal
guidelines for knowing when to abandon first order strategies do not exist, but the MRI
group suggests that one not “try, try again” in the face of failure. This particular case
is an example of an instance where the standard, first-order interventions, described in
the domesticviolence literature (Gelles, 1976; Saunders, 19771, had already been attempted
without success. What was clear to the therapy team, was that a change in the way the
woman viewed her situation was needed in order for her to find other ways to solve her
problem with her boyfriend. In other words, a change in her understanding of the
problem context was needed so that she could apply a different class of solutions to the
problem.
The potential explosiveness of the situation initially paralyzed the team into assuming a position that was invested in finding ways to insure that the woman would not
suffer harm. A more thorough evaluation of the situation, which would include a
consultation with the boyfriend or others who had come into contact with the situation,
would have been desirable before further action was taken on this case, but the team
knew that there was no time available. Clearly, further action was going to take place,
with or without further assessment. The team had every reason to believe, from the
information revealed in the interview, that the woman would not be dissuaded from
returning to her home after she left the office. She was well aware of the available
shelters and other facilities that she could make use of rather than returning home.
The team was reluctant t o even make cautionary suggestions which would have reduced
their credibility with the woman as previous helpers’ suggestions had.
The more the team considered its options for intervention, the more i t became
apparent that the team was struggling with first-order solutions. These first-order
solutions belonged to the class of unsuccessful solutions that had already been attempted
by previous helpers, and failed. The team also was aware that this stage of therapy was
important in gaining the position necessary to disrupt the existing pattern of ineffective
solution behaviors. If the team did not develop a relationship with the client in which
she felt heard and understood, there was a high probability that she would not return
to therapy and that the violent pattern would continue to escalate. Seeking outside help
for her Situation, rejecting advice, and then not continuing the process of therapy was
recognized as a n important part of the process that was included in the pattern of
violence. When the team recognized that it had become invested in a particular firstorder solution (saving her from a life-threatening situation), and not in changing the
context of the woman’s behavior, it was possible to rethink the situation and arrive a t a
more systemic intervention.
The following intervention was made toward the end of the first session:
We have been impressed with the enormity of the situation that you have been dealing
with over the last few years. It is obvious to us that you love your boyfriend more than
most women would be capable. In fact most women, would have by now, given up on ever
being able to convince such a man of the depth of their love and the amount of caring
that exists. God knows that you have tried everything you know to do. In fact, you have
continually sacrificed your own happiness over and over again to try to show him how
much you care.
Although there is a part of you that wants to leave, the team senses that you could
not live with yourself if you had not convinced yourself that you had done everything in
your power to demonstrate the depth of your love for him. From what you have told us
about him, he is a man who may feel unloveable, in spite of your attempts to show your
love for him. You also know that you are the only woman who may ever convince him
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that he could be loved, and you fear what would become of him if you were to leave him.
We are sorry to say that we see no easy way out of this situation for you. We are afraid
that in order to convince him of your love, you may have to make the ultimate sacrifice
for him. You may have to stand in front of his loaded gun and let him pull the trigger so
that he will understand that you love him so much you would be willing to give up your
life to prove your love for him.’
This message was given in a very serious, nonsarcastic tone that conveyed to the
client the team’s understanding of the situation that she had described to them. If
anything, the team had made explicit the implicit (Watzlawick et al., 1974, p. 120 ff.)
implications of the client’s predicament and her description of it. At this point, the client
began sobbing for the first time in the interview and agreed that it might come to that,
and, in fact, she had imagined such an ending to her life. She indicated that the team
had understood her situation and that she had not expected the team to provide her
with expedient solutions. The team expressed to her their understanding of the complicated nature of the situation and asked her to return for another appointment in order
to explore her situation more thoroughly. After satisfying themselves that she would be
able to take care of herself until then, another appointment was scheduled for a couple
of days later, after assuring the woman that the team would be available earlier if the
situation warranted. Although there was some concern that the situation to which she
was returning was unstable and potentially dangerous, the team was reasonably confident that any attempts to dissuade her from returning home would meet with the same
determined resistance that other helpers had encountered. She was obviously afraid to
go home, but it was clear, also, that she was aware of the various alternatives such as
the women’s shelter that she could go to instead; she did not want to go to any of them.
In fact, she reassured the team that she would ultimately be in more danger if she did
not go home.
The therapist began the second interview by expressing the team’s concern about
whether the situation at home might have become even worse since the last interview.
The client smiled and said:
I don’t know why, but on the way home I started thinking about what you said last time.
When I got home, I went up to him and asked if his gun was still out in the truck. He
said it was and I asked him if it was loaded. He said no, so I told him to get it, load it,
and come back in and shoot me because I wasn’t going to spend the rest of my life trying
to convince him that I loved him and worrying about whether he believed me. He wouldn’t
get the gun. I think he was surprised that I stood up for myself. Anyway things have
been different for the last few days.
The client’s behavior was surprising, considering the fact that the team had not
explicitly directed the client to do anything in general, and had not asked her to do
what she had done in particular. The team had, in fact, directed the client’s attention to
her situation and verbalized the outcome that she had feared, and not verbalized herself,
until that moment. The client’s report had the sense of something almost nonsensical.
At best, the therapy team had hoped that the result of the previous meeting had
established the beginning of a therapeutic relationship from which they could begin to
engage the client, and eventually her partner, in therapy. The client had drastically
altered her behavior vis-8-vis her boyfriend in a completely unpredictable, discontinuous
manner. The position taken by the therapy team was one which apparently was congruent with the client’s world view, did not arouse resistance, and enabled the client to
act differently because she thought differently about her situation.
The position that she took was one that is often encouraged by those who work with
battered women, that is, one of asserting herself. Occasionally, when a woman in this
situation asserts herself the results are less than satisfactory, sometimes with disastrous
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results. In this instance of assertion, however, she was able to make herself clear to her
partner in a calm manner, rather than in a n emotionally charged one. Retrospective
examination of her behavior reveals that her “surrender,” as she arranged it, actually
served to initiate a permanent change in her relationship with her partner. Up until
this time, the relationship had been developing in a complementary manner (Watzlawick, Beaven & Jackson, 1967)with the man becoming more and more dominating and
abusive while the woman became increasingly docile and helpless with each round of
violence. The woman’s sudden and noncomplementary behavior toward her boyfriend
represented the first step toward a reorganization of the relationship between them.
Following this session, then, the way that the client was attempting to change her
current relationship with her boyfriend was changed sufficiently(second-orderchange),
so that the team could begin to work with the entire system toward further reorganization. There would have been an explicit danger in attempting to find ways to help her
escape the situation. By doing so, the team would have been allied with her efforts
against him to stop his abuse and would have been attempting more of the same and
perhaps escalating the potential for violence. If she were to escalate her attempts to
change her boyfriend’s suspiciousness into trust, then so might his attempts to change
her through violent confrontation. Furthermore, the boyfriend was likely to have felt
misunderstood and overwhelmed by the number of strangers who had never met him,
but were urging his partner to leave him. Therefore, the judgment of the team was that
the most irresponsible thing the team might do would be to do “more of the same” and
become a part of the problem with the potential for additional violence. Furthermore,
any premature attempt to engage her boyfriend in treatment might also have been seen
as threatening to him and may have escalated the struggle.
Still another point to consider about the team’s strategy was that this client’s history,
as she related it, consisted of a pattern of seeking help following a n alarming episode of
violence. During the interview with her, it also became evident that she did not return
to these helpers because she did not think that they sufficiently understood her enough
to help her. Specifically, she rejected out of hand the advice of those who counselled
leaving her partner, and did not seek further help from them. It seemed to the team
that any attempt to be helpful by trying t o get her to leave her boyfriend would be
politely refused, and that she would not return for therapy. Also, it was clear that any
discussion of her partner of a negative sort would not be listened to. The struggle that
she had been involved in with previous helpers was trying to convince them of the depth
of her love for him and the fact that the violent episodes were temporary aberrations in
his otherwise exceptional character. This was her world view, her language about her
partner. The team needed to find a way to talk with her that communicated their
understanding of her dilemma and willingness to work with her on the problem as she
defined it. The client’s previous attempts to solve her problem and the advice that she
received, were both important parts of the context she presented. There is no doubt that
the strategy that the team devised would have been different had she not already
considered other alternatives and rejected them.
Case Example #2
Marie’ was a 16-year-old girl whose baby had been born 3% months prematurely.
The baby died, and the interview with her took place the afternoon following the baby’s
funeral. Marie was referred by juvenile probation for a n evaluation of her suitability
for placement in a halfway house. The probation department was concerned over homicidal threats she had made during recent weeks. Originally, she had been placed in a
state detention facility for truancy and running away from home. After her placement,
it was discovered that she was pregnant. Marie was then sent to a home for unwed
mothers.
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In narrating the events that led up to her baby’s premature delivery and death, she
told how she had looked forward to having her baby. She cared a lot for the baby’s father
and had made arrangements in her local hometown to take care of the child after it was
born. During the early part of the interview, she described her childhood and recent
past with a bravado and “tough-guy” attitude, which is sometimes seen in children who
spend much of their lives on the street. This facade had apparently alienated certain
members of the staff in the home where she was staying.
She described the events which led up to the baby’s birth, in complete detail. For
several days she had been feeling ill from what the staff nurse had called the “flu.” She
was advised to stay in bed and rest. One of the staff members, Mrs. Thompson, asked
her to work in the nursery, but Marie refused because of her illness. The client reported
that she later overheard Mrs. Thompson saying that some of the girls, like the client,
were particularly lazy.
The next morning she awoke with abdominal cramps which got worse as the day
went on. The nurse had given her a heating pad and told her to rest in bed. Her cramps
became more intense as the afternoon wore on. The nurse went off duty at 3 p.m. and
Marie had to take her complaints to Mrs. Thompson. Mrs. Thompson thought that she
simply had a stomach ache, or at worse, “false labor,” and should remain in bed and
rest. By this time, the client was becoming increasingly worried and began to ask to be
taken to the hospital. According to the client, Mrs. Thompson did not take her repeated
complaints seriously, possibly because she thought Marie was lazy and a “goldbricker,”
and did not take her to a hospital. It was not until the night nurse came on at 11 p.m.
and became alarmed a t the client’s condition, that she was taken to a hospital.
The client was told by the doctors that she was indeed in labor, as she had suspected
all along, and that they did not think that they could stop the labor at this advanced
stage. They did not, and the client delivered a baby girl, 3?h months prematurely, the
following morning. The baby lived for about a week, but died from numerous complications. Marie’s animosity toward Mrs. Thompson, who she thought was responsible for
this tragedy, mounted during the days following the birth, and then death, of the baby.
During the interview, Marie described a recent incident in which she had tried to
push Mrs. Thompson down a flight of stairs. She also related that she had been carrying
a gun until the day before, and had turned it over to her probation officer, saying that
she did not need a gun to get even. It was clear to the therapist that Marie’s actions and
intentions were aimed a t avenging the death of her baby by getting even with the
“neglectful” staff person. The therapist, as well as the rest of the team, was concerned
that the girl represented a threat to the woman, and the situation was a highly volatile
one.
Initially, the therapy team directed their interventions toward preventing Marie
from making good on her threats to kill the woman. All these attempts belonged to a
class of solutions that had, as their goal, changing Marie’s mind about the intended
murder. At first, attempts were made to dissuade her by pointing out that she had
already warned Mrs. Thompson, and she would be on guard. This idea had little effect
on Marie, who pointed out that Mrs. Thompson could not be on guard all of the time.
The therapist pointed out that Marie would lose the opportunity to have future children
if she was in prison for murdering Mrs. Thompson. This intervention also did little to
lessen her resolve; Marie said that she would gladly make that sacrifice in order to
punish the person who had been responsible for her baby’s death. At this point, a
consultation break was made to assess the situation.
It was evident to the team that they were not speaking the client’s language, that
they were not understanding her world view. One clear sign of this to the therapists,
was the process of trying to convince Marie of something that she was not becoming
convinced of. The therapist and the rest of the team were aware of feeling that they
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were working hard to convince the client of one argument after another, and all of the
arguments were based on the premise that it would not be in Marie’s best interest to
kill Mrs. Thompson. The therapists’ reasons for not harming Mrs. Thompson were not
reasons that were congruent with Marie’s world view. The “resistance” was a sign that
the team was not speaking the client’s language.
The team decided that the therapist would explore what had stopped the girl so far
from making good on her threats. It was hypothesized that whatever had prevented her
from acting thus far, represented something which might represent her own self-interests and that it should be magnified, in an effort to alleviate the threat. The therapist
returned to the room and began that exploration. Marie said that she had wanted to
wait until the baby’s funeral before she did anything. She then elaborated on how Mrs.
Thompson should be made to suffer for what she had done, and that a lawsuit would be
too good for her. The girl also told the therapist, a t this point, that she knew that Mrs.
Thompson already felt guilty and that this was proof that revenge was justified. Marie
had told Mrs. Thompson that the baby’s death was going to be on her (Mrs. Thompson’s)
conscience for the rest of her life, and Marie had shown her a picture of the baby to help
the guilt along. She had also considered calling a local TV personality, who had a
reputation as a consumer watchdog, and showing him the baby’s pictures so that an
understanding of how the little girl and Marie had suffered, could be made public. Marie
thought that this would also increase the burden on Mrs. Thompson’sconscience.
At this point, another consultation was held, and the therapist discussed the situation with the rest of the team. A new perspective on the client’s understanding of Mrs.
Thompson had arisen in the session, as well as a refined perspective on the girl’s
understanding of what was needed. The team decided to offer the client an alternative
connotation of killing Mrs. Thompson. It was believed that if the act of killing Mrs.
Thompson could be reframed, or put into a context that would have a meaning different
than the one that Marie had been attributing to it, perhaps a shift in her thinking about
the situation would occur. As a result of the team’s understanding of Marie’s need to
have the other woman suffer for her misdeeds, the following intervention was made:
Therapist:
Comment:
Client:
Therapist:
Client:
Therapist:
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The thing that I’m impressed with is that you’ve thought about a lot of
ways to even the score with Mrs. Thompson. (At this point the client’s head
was hanging down.) You’ve thought about pushing her down the stairs,
about shooting her, putting a contract out on her and suing her. . . . And
I’m just amazed that as angry at her as you are, you’re willing to let her
off so easy.
Here, the therapist has briefly outlined the solutions that the client has
attempted or considered. These might be considered as members of the class
of solutions that she has attempted and rejected, or failed with. Next, the
therapist has begun to gently reframe these attempts. Notice that the following elaboration of this reframing is done within the client’s world view.
(Looks up, surprised.) What do you mean let her off easy?
Well, you said that she was real scared. . .and that you could already sense
that it was on her conscience. . . that she already feels pretty guilty about
it . . . (Client resumes staring at her feet.)
And she is!
. . . and a woman like that is likely to have that on her mind for the rest of
her life, and is probably not going to be able to sleep very well at night.
She will probably be a miserable, sad old woman for the rest of her life
because of that. . . . But, . . . if you go ahead and kill her next week, that’s
letting her off easy because she won’t have to suffer very long. You might
do her a big favor by killing her . . . I guess I don’t understand why you
would be willing to let her off so easy, because if you kill her it will be over,
like that (snaps fingers) and she won’t have to suffer.
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This further elaboration begins to suggest a meaning for the death of Mrs.
Thompson that is not the one that Marie is attempting to communicate by
her revenge. When the therapist says that Marie would do Mrs. Thompson
“a big favor’’ by killing her, it is because Marie is not at all interested in
doing Mrs. Thompson any favors. The therapist, here, is capitalizing on
Marie’s anger and uncharitable feelings about Mrs. Thompson.
(Marie looks up.) So what you’re saying is, just let her suffer?
Client:
. . . . Well, I just wonder which would be worse for her. To live for the next
Therapist:
50 years with the death of your baby on her conscience day and night, or
if you were just to put her out of her misery?
Client:
(30-second pause, looks down.) I don’t know, because I’m very angry.
Phone rings: Therapist consults with team over the phone, and hangs up. Here, the team
offersa suggestion based upon their assessment of the degree of fit that the
current meanings have within the client’s world view.
Therapist: . . . . You know, you were talking about showing her a picture of your baby.
(Client looks up again.) I think even that would be letting her off easy. You
should give her a picture of your baby, . . . if you don’t decide to let her off
real easy.
Client:
Give her my baby’s pictures? (Incredulous.)
Therapist: You could make copies for her. So that she’ll be reminded every day while
she’s in that place with all those pregnant women, about what she did. . . .
Killing her would certainly make you feel better, but it would be letting
her off easy. . . . If she were to die next week, you would still have your
baby on your mind for the rest of your life, and you’re going to be suffering
for the rest of your life with the memory of what happened. It’ll probably
keep you up at night sometimes. . . . Of course, if you or your bandito
friends kill her, she wouldn’t be suffering the same way you’re going to
continue to suffer.
Comment: Here, the therapist manages to cast more explicitly killing Mrs. Thompson
as having a different meaning then revenge. If one considers that a part of
Marie’s thinking is that not only she, but other people need to see that her
baby’s death has been revenged, then the meaning being offeredcreates some
doubt as to whether murder will accomplish hergoals. The therapist is also
speaking the client’s language of self-sacrifice here.
Client:
. . . . Sounds like a good idea, giving her a picture of my baby (looks up
smiling).
Comment: Here, the client acknowledges that the offered solution has more potential
than the previous course of action being considered.
Therapist: . . . .Well, you need to give some careful consideration and thought to what
you want to do, because it may be that you want to let her off the easy
way.. .
Comment: Here, again, the therapist is taking advantage of the client’s unwillingness
to be at all kind to Mrs. Thompson.
Client:
(60-second pause, looks up.) Where can I get copies made?
Comment:
The turning point in the above interview was changing the interpersonal meaning
of the client’s solution behavior. This change of meaning from killing the woman as
revenge to letting her live as revenge may have been successful for several reasons. For
one thing, the client could now abandon her vendetta in a face-saving manner, assured
that the woman’s conscience, aided by the baby’s pictures, would punish her more
severely than death. Secondly, the team’s intervention was consistent with the client’s
world view, and therefore, more acceptable to her than the interventions that had been
based on the therapy team’s world view (i.e., killing this woman is wrong and should
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not be done). The intervention also allowed the client to select a new class of solutions
to “get even” with the woman.
Again, in this case, can be seen the effect of conducting an interview in such a way
as to understand the client’s world view so that the therapists could convey to the client
the fact that she was understood. Communicating such an understanding to the client
was a necessary first step in gently reframing the context in which her problem was
embedded. By conducting the interview in this manner, an alternate meaning within
those permitted by her world view, was constructed with her which enabled her probled
solution to be reframed.
In the second case, the “problem” (i.e., getting revenge) remained unchanged for
the client. The newly constructed context allowed her to continue to seek revenge upon
Mrs. Thompson for the wrongs that had allegedly been done, but the class of solutions
changed as a result of the change in the meaning attributed to her original methods of
revenge. The intervention was not aimed a t changing Marie’s mind about seeking
revenge. “Seeking revenge” was seen as a goal that was a solution to the problem of
setting things right with her dead daughter.
Extrapolating from the language that she was using in the interview, it seemed to
the team that she had a very strong sense of an “eye for an eye” justice. The client’s
language during the interview was one of anger for her baby’s death, revenge for the
injustice that was done to her baby, a need for her nemesis to suffer and pay for her
negligence, and self-sacrifice on Marie’s part. The team’s intervention was designed to
provide Marie with a different class of solution behaviors that would enable her to
avenge her baby’s death. This different class of solutions would not include Mrs. Thompson’s death as an outcome.
Follow-up later revealed that the girl ceased her threats, had given Mrs. Thompson
a picture of her baby, and was allowed to move into the halfway house. Her behavior,
however, was disruptive, and eventually she was transferred to another facility. The
disruptive behavior that continued was of a long-standing nature and not the focus of
the interview that has been described here. The therapists’ goal in this case was essentially crisis intervention. There, doubtlessly, remained many problems that could be
dealt with in further therapy with this girl. Marie and her probation officer were
encouraged to contact the team if, in the future, there arose anything with which we
could help them. In any case, the violent threats ceased. The manner in which Marie
was attempting to change Mrs. Thompson had changed. This change of a change might
be considered second-order change because a completely different class of solution
attempts was begun by the client.
DISCUSSION
In both of these cases, there was clearly a life-threatening situation a t hand. Also
common to both cases, was the need for the therapist to recognize that interventions
which were designed to block the life-threatening behavior of the “victim” or of the
“aggressor” would have been tactical errors which might guarantee that the situations
would worsen, or, a t best, not change. There would have been explicit dangers in overtly
helping the battered woman escape her situation, or in overtly attempting to prevent
the angry girl from attempting to carry out her threat. In doing so, the team would have
become invested in first-order change attempts which might have escalated the interpersonal struggles in which the clients were both involved. There was sufficient evidence
in both of these cases that a number of first-order interventions had been attempted
without success. Therefore, the most irresponsible thing the teams might have done, in
either case, would have been to endorse solution attempts that had already been dem-
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onstrated as ineffective, in the former case by previous helpers and in the latter, by the
present helpers.
These cases illustrate the therapists’ use of the clients’ language and world views,
to change the manner in which the clients were attempting to change their current
state of affairs. It is important to note that the therapists did not prescribe a particular
course of action for either of the women, but did suggest an alternate meaning for the
manner in which they were attempting to change their current situation. One might
wonder whether or not, in either of these cases, the client switched their understanding
of their situation to the one offered by the therapist. It is not necessary for the client to
switch to the newer view; what is necessary is that the therapist offer a context which
is sufficiently convincing that the client is no longer able to see the situation without
also seeing the altered context. This experience is similar to the 9-dot problem (Watzlawick et al, 1974, p. 25), in that having once seen the solution to the puzzle, one can
never be confronted with the puzzle without also remembering aspects of its solution.
Even though one has seen the solution the apperception of the 9 dots is still basically
the same, but the puzzle now has a new context for the observer. Many other compelling
visual illusions also illustrate this phenomenon.
Also demonstrated, is the unpredictable, discontinuous nature of second-order change
which follows the successful disruption of a pattern of ineffective attempts a t first-order
change. As Watzlawick, Weakland and Fisch, the authors of Change put i t “. . . secondorder change usually appears weird, unexpected, and uncommonsensical; there is a
puzzling, paradoxical element in the process of ~ h a n g e (1974,
”~
p. 83).
Although the teams could not have predicted the specific behaviors that followed
their interventions, they were confident that, by having put the problem and its previously attempted solutions in a different light, the clients would not continue their
previous attempts a t solving their problems (first-order change), but would see their
problems in a new context, requiring new solutions.
It is important to address important potential criticisms of this work. But first, it
is imperative that the reader understand that the strategies employed in the cases
described above were consistent with the theoretical orientation that the therapy teams
employed on a daily basis. The approaches were not selected because they appeared
“paradoxical.” If anything, the strategies were selected because they were consistent
with the teams’ basic stance of working within a client’s world view. Secondly, the teams
did consider both of these cases to be appropriate for interventions that were aimed a t
second-order change, because sufficient evidence existed to indicate that first-order
attempts had been attempted without success. This was consistent with the teams’
reluctance to continue to try interventions that have not yet promoted change in a
system. As pointed out above, therapists need to be prepared to readily abandon change
attempts that are not ~ o r k i n gThe
. ~ first case illustrates this abandonment after numerous other helpers had been unsuccessful with the client. The second case illustrates the
therapy team’s abandonment of its own unsuccessful strategy during a single session
and adopting one that appeared consistent with the client’sworld view and implemented
using her language and attributions.
Some readers might question whether or not the interventions used in this paper
were appropriate, given the high risk for violence in both of the cases. Weeks and L‘Abate
(1982), for instance, caution their readers against the use of “paradoxical” techniques
in cases of homicidal and suicidal behavior. Fraser (1984) has provided an excellent
theoretical discussion of the use of systemic interventions in precisely the types of cases
for which this type of intervention is usually proscribed. The approach being used by
the therapy teams here, however, does not actually fit the definition of paradoxical
therapy given by Weeks and L’Abate:“. . . the guiding principle of a paradoxical therapist
is: ‘If a therapist would do it, do the opposite’ ” (Weeks & L’Abate, 1982, p. 4).
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This is a regrettable error in understanding of the clinical and theoretical principles
which underlie the work of the Mental Research Institute. In fact, a true paradox lies
in the above definition. If “paradoxical” therapists (as described by Weeks and L’Abate)
were to adhere to the alleged dictum, then they would be required to be “non-paradoxical,” and so on. It is also important for the reader to make a distinction between a
characteristic of second-orderchange, i.e., that it is usually paradoxical, and the therapy
that facilitates second-order change. All therapists have observed a discontinuous or
paradoxical change in their clients at one time or another. But not all therapists,
including those described here, set out to be “paradoxical” in their work. A common
source of confusion in the field of psychotherapy is the confusion between technique and
the underlying principles influencing the particular techniques or strategies chosen by
the therapist, a confusion of logical types. Attempts have been made to clear up this
confusion by pointing out that technique, or behavior in the therapy room, and theoretical statements are different levels of description (Keeney & Ross, 19851, or that they
are the result of failing to distinguish between opinion and transaction (Fraser, 1984).
Weeks and L‘Abateare typical of writers who fail to make explicit the distinction between
descriptions of behavior and technique. The work that they have done is a n attempt to
describe behavior in the therapy room, while a t the same time ignoring the theoretical
basis for the choice of a particular technique. In fact, a t one point they assert that
paradoxical therapy “. , . has no underlying theory t o guide its development and practice” (1982, p. 17). This statement ignores many excellent descriptions of theoretical
positions that lead to descriptions by some observers of therapy as paradoxical (Bateson,
Jackson, Haley & Weakland, 1956; Keeney & Ross, 1985; Palazzoli et al, 1978; Watzlawick et al., 1974).
One might question the course of action to be taken if a crisis had followed the
session with either of these clients. Experienced therapists know that, oftentimes, there
is no way to predict a crisis when working with difficult cases. A prudent therapist,
then, will attempt to work in the most responsible fashion possible, choosing a course
of action that is thought to have the highest probability for avoiding violence and harm
to clients and their families. The only course of action that would have reduced, substantially, the danger of immediate harm in these cases would have been incarceration
in a hospital or a jail. Haley (1976) has addressed the negative consequencesthat follow
from the therapist’s pursuing treatment as an agent of social control through the use of
hospitals and jails. At the end of both of the initial sessions described in this paper, the
considered judgment of the team of clinicians was that the risk of immediate danger
was sufficiently reduced. Further steps beyond scheduling additional appointments and
making arrangements with the probation authorities for follow-up were not thought to
be necessary.
Perhaps the most important caution to be made regarding the work described here
is that it is difficult for therapists to clearly grasp the world view being expressed by a
client because each client is uniquely different from the therapist, and because the
emotionally charged nature of situations encountered in crises is likely to distort the
therapist’s understanding of that world view. It is extremely likely that, had any of the
team members on either of these cases been working alone, a different strategy would
have been selected. The benefits of working in teams on cases with a high potential for
violence are the availability of multiple views of the therapy and the increased security
of having colleagues available for live consultation. In this way, there can be a mutual
checking out of understandings so that the therapist does not become involved in “more
of the same solutions” that have the potential for escalating the violence.
There is also little doubt that interventions such as the ones described here are
entirely dependent upon the unique features of each of the client’s world views, their
language, their situations and the skill and abilities of the therapy teams. Readers are
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reminded that therapy that is based upon developing an understanding of each client's
world view generates interventions that are not replicable with other cases. Although
the basic principles of working this way have been described by the MRI group, the
specific interventions are never applicable to other cases.
REFERENCES
Anderson, G. M. (1977, August). Wives, mothers and victims. America, 137,46-50.
Bagarozzi, D. A. & Gittings, C. W. (1983). Conjugal violence: A critical review of research and
clinical practices. American Journal of Family Therapy, 11,3-5.
Bard, M. B. (1971). The role of law enforcement in the helping system. Community Mental Health
Journal, 7, 151-160.
Bateson, G. (1972). Steps to an ecology of mind. New York: Ballantine Books.
Bateson, G. (1979). Mind and nature: A necessary unity. New York E. P. Dutton.
Bateson, G., Jackson, D. D., Haley, J. & Weakland, J. H. (1956).Toward a theory of schizophrenia.
Behavioral Science, 1 , 251-264.
Ennis, P. H. (1967, June). Crime, victims and the police. Transaction, 3, 36-44.
Everstine, D. S. & Everstine, L. (1983). People in crisis: Strategic therapeutic in.terventions. New
York: BrunnedMazel.
Fraser, J. S. (1984). Paradox and orthodox: Folie B deux? Journal of Marital and Family Therapy,
10,361-372.
Gelles, R. J . (1976). Abused wives: Why do they stay? Journal of Marriage and the Family, 38,
659-668.
Haley, J. (1976). Problem-solving therapy. San Francisco: Jossey-Bass.
Keeney, B. P. & Ross, J. M. (1985). Mind in therapy. New York: Basic Books.
Palazzoli, M. S., Boscolo, L., Cecchin, G. 8z Prata, G. (1978). Paradox and counterparadox. New
York: Aronson.
Saunders, D. G. (1977). Marital violence: Dimensions of the problem and modes of intervention.
Journal of Marital and Family Counseling, 39,43-49.
Saunders, D. G. (1981). Treatment and value issues in helping battered women. In A. S. Gurman
(Ed.), Questions and answers in the practice of family therapy. New York: BrunnedMazel.
Tarasoff v. Regents of the University of California: 17 Cal. 3d 425,131 California Reporter 14,551
P. 2d. 334 (1976).
Walker, L. E. (1980). Battered women. In A. M. Brodsky & R. T.Hare-Mustin (Eds.), Women and
psychotherapy (pp. 339-363). New York: Guilford.
Watzlawick, P., Beaven J. H. & Jackson, D. D. (1967).Pragmatics of human communication. New
York: W. W. Norton.
Watzlawick, P., Weakland, J. & Fisch, R. (1974). Change: Principles of problem formation and
resolution. New York W. W. Norton.
Weeks, G. R. & L'Abate, L. (1982).Paradoxicalpsychotherapy:Theory andpractice with individuals,
couples and families. New York BrunnedMazel.
NOTES
'It is difficult to convey in print the affective tone, pacing, and careful attention to the client's
body language that the therapist attended to while delivering this intervention and the one that
follows.
ZNameshave been changed for anonymity.
3Unfortunately, all too many therapists mistake nonsensical and weird interventions with
good systemic therapy. The point, here, is that the result of second-order change has the described
appearance, not the therapy that produces it. A grave error is committed when a therapist believes
that the intervention is what should be weird, unexpected or uncommonsensical.
T h i s includes therapists' attempts to promote second-order change.
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