How to Assess Whether a Case Needs Individual or Family-Level Intervention

The decision regarding the unit of treatment is the first and most consequential strategic choice you make. If you choose the wrong unit, you are fighting the social structure of the client’s life every time they leave your office. We recognize that symptoms are not merely internal malfunctions of a single person. They are often the logical outcome of a specific organizational arrangement. When you decide to see an individual alone, you are making a statement that the problem can be solved within that person. When you decide to see a family or a couple, you are stating that the problem is a function of their interaction. We define the unit of treatment based on where the power to maintain the problem resides. If the power to sustain a child’s temper tantrum lies in the father’s refusal to support the mother’s discipline, then seeing the child alone is a strategic error.

You begin your assessment during the very first telephone contact. You do not wait for the intake form to be completed. You listen for the way the caller describes the difficulty. If a mother calls and says that her son is depressed, you ask her what she does when he refuses to get out of bed. You ask her how her husband reacts to her efforts. If she tells you that her husband thinks she is too soft and she thinks her husband is too hard, you have already identified that the unit of treatment must be the parents. You are not treating a depressed boy. You are treating a parental hierarchy that has split down the middle.

I once worked with a young man who was twenty-six years old. He had failed to finish university and spent most of his time in his parents’ basement. He was referred to me for social withdrawal and a lack of ambition. The referral came through his father, who was a successful and demanding executive. If I had seen the young man alone, I would have spent months trying to build his confidence while his father continued to pay his bills and criticize his character every evening at dinner. Instead, I required the father and mother to attend the first session. Within twenty minutes, I saw the father interrupt the son to answer for him. I also saw the mother gently touch the son’s arm as if to comfort him every time the father became stern. The son did not need to find his ambition. He needed the parents to agree on a single plan for his independence so he could no longer play one against the other to remain in the basement.

We must always look for the person who is most concerned about the problem. In strategic therapy, the person who is most distressed by the symptom is often the most important member of the treatment unit. This person has the most motivation to follow a directive. If a wife is distressed by her husband’s drinking but the husband claims he has no problem, you do not try to convince the husband he is an alcoholic. You treat the wife as the primary agent of change. You work with her to change her response to his drinking. You might direct her to stop cleaning up his messes or to stop making excuses to his employer. When the wife changes her behavior, the husband’s drinking will either become much more difficult for him to maintain or it will change its function in the marriage.

You must observe the physical arrangement of the people in the room. This gives you immediate data on the family hierarchy. If you have a mother, a father, and a teenage daughter in the office, and the daughter sits between the two parents, she is occupying a position of power or she is acting as a buffer. If the parents constantly look at the daughter when they speak to one another, the daughter is the center of the organization. We use these observations to determine who should be in the next session. If the parents are using the child to avoid their own conflict, you may decide to see the parents alone to force them to deal with their relationship without the child acting as a shield.

Jay Haley emphasized that the therapist must be in charge of the session. You do not ask the family who should come back next week. You tell them. If you allow the family to decide the unit of treatment, they will inevitably choose the arrangement that protects their current, dysfunctional organization. They will try to keep the person who holds the most power out of the room. You must be prepared to refuse to see a client if the necessary family members will not attend. I once told a father that I could not help his daughter unless he was present. He argued that he was too busy with work. I told him that his daughter’s recovery was apparently less important than his business meetings and that I would be happy to see them both when his priorities changed. He was in the office the following Tuesday.

We use the initial session to test the flexibility of the family structure. You give a small directive to see who follows it and who undermines it. You might ask a mother to move her chair so she is sitting next to her husband instead of next to her son. If the son immediately complains that he feels crowded or if the husband fails to make room for his wife, you have seen the resistance of the system in real time. This resistance tells you that the unit of treatment must include all three. You cannot resolve the son’s behavior until you resolve the parents’ inability to sit together.

You should also be wary of the individual who wants to use the session to complain about someone who is not present. If a woman spends fifty minutes describing her mother’s intrusive behavior, you are listening to a one sided report. You have no way of knowing how the woman herself invites that intrusion. We know that every interaction is a loop. In this situation, you have two strategic choices. You can invite the mother into the session to observe the interaction directly, or you can treat the daughter by giving her directives to change her half of the loop. However, you must never accept the daughter’s description of the mother as the absolute truth. You treat it as a description of a relationship, not a description of a person.

Milton Erickson often used the person who was most resistant as the key to the change. If a family brings in a rebellious teenager and the father is highly skeptical of therapy, you do not try to build rapport with the father by being nice. You align with his skepticism. You tell him that he is right to be cautious and that you are not yet sure if this family is ready for the hard work of change. By doing this, you take control of the resistance. You become the one who is skeptical, which forces the father to defend the family’s ability to improve. You have shifted the unit of treatment from a rebellious teen to a skeptical father who now has to prove he can lead his family to success.

We must remember that the unit of treatment can change as the case progresses. You might start with a whole family to stabilize a crisis and then move to seeing a couple to address the underlying marital tension. You might then see the father and son together to build a stronger hierarchical line. You do not stay with one unit out of habit. You stay with it only as long as it is the most effective way to reach the goal. If the progress stalls, you change the unit. You bring in a grandparent who has been living in the home or you exclude a child who has become too involved in the parents’ business.

Your primary tool is the directive. Every directive you give is a test of the unit. If you tell a husband to buy his wife a gift and he fails to do it, you look at how the wife responded to the instruction. Did she tell him it was a waste of money before he even left the office? If so, the unit of treatment is the couple’s inability to allow a positive exchange. The husband’s failure to follow the directive is not a lack of cooperation but a successful execution of the family’s rule that no one should feel better. You must see the husband and wife together to break this rule.

We watch for the moment a client tries to form a secret alliance with us against another family member. If a father calls you between sessions to tell you something he does not want his wife to know, you must be careful. If you accept the secret, you have joined a coalition that destroys your power as a strategic agent. You must tell the father that you will not hold secrets and that he should bring the information to the next session. By refusing the secret, you maintain the integrity of the treatment unit and keep the hierarchy clear. The power of the therapist is directly tied to their ability to remain outside the family’s dysfunctional coalitions while remaining in control of the treatment structure. The person who attempts to exclude others from the room is often the person who is most afraid of the change that will occur when everyone is present.

We define this fear not as a personal failing but as a structural necessity for the family to remain exactly as it is. When a client tells you that their spouse is too busy to attend or that their child is too fragile for the conversation, you are receiving a map of the family power structure. The person who stays away is often the one who holds the most influence over whether the problem persists or disappears. We assume that if a person is part of the problem, they must be part of the solution. You do not ask for permission to include family members. You state it as a requirement of the clinical process. If you treat an individual for a problem that is maintained by a marriage, you are attempting to move a heavy piece of furniture while someone else is standing on top of it.

I once worked with a young woman who sought help for her inability to complete her university degree. She was twenty-four years old and lived at home with her parents. She claimed her father was a tyrant who controlled every aspect of her life, while her mother was a victim who needed protection. The daughter spent her days “supporting” her mother, which left her no time for her studies. When I insisted that the parents attend the session, the daughter protested that her father would never agree and that the mother would be too intimidated to speak. I told her that if they did not attend, I could not help her finish her degree because her parents were the ones currently managing her schedule. The entire family arrived for the next appointment.

We observe the seating arrangement in such a meeting to identify the incongruous hierarchy. In this case, the daughter sat between the parents. She spoke for the mother. She corrected the father. Although she presented herself as a victim of his tyranny, she was actually the one in charge of the emotional climate of the house. Every time the parents began to argue, the daughter would start to cry or mention her failing grades. The parents would immediately stop their conflict to focus on her. Her symptom, the academic failure, functioned as a peace-keeping mechanism for the marriage. As long as she was failing, the parents stayed together to worry about her.

You must recognize that symptoms serve a function. If you focus only on the individual and their internal state, you miss the sequence of behaviors that makes the symptom necessary. We look for the sequence: the father criticizes the mother, the mother looks distressed, the daughter fails a test, and the parents unite to discuss the daughter. To change the daughter, you must change the parents’ way of interacting. You do not do this by explaining their behavior to them. You do it by giving them a directive that forces a new sequence.

I instructed the father and mother to go out to dinner alone twice a week. I told them that under no circumstances were they to discuss their daughter during these meals. If either of them mentioned her, they were to pay a twenty dollar fine to the other spouse on the spot. I then told the daughter that her job was to stay in her room and study during those exact hours, specifically forbidding her from helping her mother prepare for the date. This directive removed the daughter from the role of protector and forced the parents to face one another without the buffer of the child’s failure. When the parents started to relate as a couple rather than as parents of a problem child, the daughter suddenly found the concentration necessary to finish her thesis.

We use the unit of intervention to clarify who is responsible for what. If you are working with an individual who is struggling with a professional conflict, you may still need to assess the family system. I recall a man who could not hold a job for more than six months. He was forty-five years old. He would start a new position with great energy but would inevitably offend a supervisor and get fired. We could view this as a personality flaw or a lack of social skills, but I looked at his relationship with his wife. She was a highly successful executive who earned a substantial income. Whenever he was unemployed, she became the dominant provider and the moral authority in the house. When he was working and successful, she felt insecure and began to complain about his long hours.

You must look for the equilibrium. In this case, the husband’s failure was the price he paid for the wife’s security. To intervene, I did not work on the man’s resume. I worked on the wife’s anxiety. I instructed her to ask him for financial advice every evening, even while he was unemployed. I told him to give her one piece of bad advice each night. This disrupted the hierarchy where she was the only competent adult. By making her seek his help and making him intentionally “unhelpful,” we broke the rigid pattern of her being the successful one and him being the failure. He was back in a stable job within three months because his success no longer threatened the stability of the marriage.

When you decide whether to work with an individual or a family, you must evaluate the age and developmental stage of the primary client. For children and adolescents, the family is almost always the necessary unit. We do not believe a child can change if the parents continue to treat them as the problem. If a ten year old is setting fires, you do not talk to the child about his feelings toward matches. You look at how the parents handle discipline. Often, you will find that one parent is the disciplinarian while the other is the secret rescuer. This split in authority creates a vacuum that the child fills with problematic behavior.

You handle this by putting the “soft” parent in charge of the discipline. If the mother is the one who usually makes excuses for the child, you instruct her to be the one who determines the punishment for the fire-setting. You tell the father, who is usually the harsh one, that he must remain silent and only support the mother’s decision. This closes the gap between the parents. When the child can no longer play one parent against the other, the need for the extreme behavior vanishes. We are not interested in why the mother is soft or why the father is harsh. We are only interested in the fact that they are inconsistent.

We must also be prepared to work with the individual as a way to reach the system. If the family truly will not come in, you work with the person who is present as a lever. You instruct the individual to change their part of the sequence. If a woman complains that her husband is distant and cold, you do not encourage her to talk to him about her feelings. This usually makes a distant man move even further away. Instead, you might instruct her to become even more distant than he is.

I told a woman in this situation to spend three evenings a week out of the house without telling her husband where she was going. When she returned, she was to be pleasant but vague. By changing her part of the sequence from “pursuer” to “withdrawn,” she forced the husband to change his role. He began to pursue her to find out what was happening. You change the system by changing the steps of the dance. If one person changes their steps, the other person cannot continue the old pattern.

The hierarchy of the family reveals itself most clearly when you demand a change in the sequence of their daily rituals.

We use these demands as experiments to locate the exact point of systemic rigidity. When you encounter a family that agrees with every suggestion but changes nothing, you are facing a system that uses compliance as a defensive shield. To break this, you must stop offering helpful advice and instead issue a directive that is slightly absurd or inconvenient. If a mother complains that her teenage daughter is chronically late for school, and the usual reminders have failed, you do not discuss the daughter’s motivation. You instead direct the mother to wake the daughter up at four in the morning to practice putting on her shoes and coat for thirty minutes. If the mother refuses to do this because she says she needs her sleep, you have learned that the mother’s desire for comfort is greater than her desire for her daughter to be on time. The mother is the unit of intervention because she is the one maintaining the status quo through her own inaction.

I once worked with a young man who claimed he was unable to leave his house due to intense social anxiety. His parents were supportive and paid for his housing, his groceries, and his internet connection. I told the young man that for every day he did not walk to the corner store and speak to the clerk, he had to spend two hours in the evening cleaning his parents’ garage with a small toothbrush. After three days, his mother called me to say that the garage was already clean enough and that I was being too harsh. I realized then that the young man was not the primary problem. The mother required his disability to maintain her role as a protective caregiver. We changed the unit of treatment to the parents alone. I instructed them that they could only discuss their son’s anxiety while standing on one leg in the backyard. This ridiculous requirement made their habitual worry so physically taxing that they stopped talking about him and started talking to each other.

You will find that the most effective way to determine the unit of treatment is to observe who in the room is allowed to interrupt whom. If a husband interrupts his wife every time she begins to express a grievance, and she allows it, you are looking at a hierarchy that forbids the wife from having a voice. You do not ask the husband why he interrupts. Instead, you direct the wife to stand up and walk around her chair three times every time he speaks out of turn. This physical action disrupts the verbal sequence. If the husband becomes angry or tries to pull her back into her seat, you have confirmed that the marital power imbalance is the engine of the problem. We use these physical disruptions because they are harder to intellectualize than conversation.

We often see practitioners make the mistake of assuming that the person who is most vocal about wanting change is the best candidate for individual therapy. In the strategic tradition, we know the opposite is often true. The person who is loudest about wanting change is frequently the person who is most invested in the current struggle. I worked with a manager in a large firm who complained that his assistant was incompetent. He brought in a thick folder of documented errors. I instructed the manager to spend the next week intentionally making two errors himself and letting the assistant find them. The manager could not do it. He confessed that if he were not perfect, he would lose his sense of superiority over his staff. The manager’s need for perfection was the actual barrier to the assistant’s performance. By changing the manager’s behavior, we changed the entire department without ever speaking to the assistant.

When you decide to work with an individual, you must ensure they have the structural power to carry out your directives. If you give a directive to a person who is financially or emotionally dependent on a hostile partner, that directive will likely result in a punishment for the client. We assess this by asking the client what will happen at home if they follow our instructions. If a woman says her husband will stop speaking to her for a week if she goes out with her friends, you do not tell her to go out anyway. You instead instruct her to ask her husband for a list of ten things she can do to be a better wife that week. This paradoxical move puts her in control of the submissive role. It often confuses the husband so much that he encourages her to go out just to regain a sense of normalcy.

We also use the concept of the secret to test the unit of intervention. If a client tells you something in private and asks you not to tell their spouse, you are being invited into a coalition against the spouse. You must refuse this invitation. You should tell the client that you cannot keep secrets because it limits your ability to be effective. You might say that if they have something to say, they must say it in the session where everyone is present. If the client refuses, you know that the secret is the primary mechanism they use to maintain a distance in the marriage. The unit of treatment must then be the marriage itself, with a focus on how they manage information and privacy.

I remember a case involving a ten year old boy who was setting small fires in the backyard. The parents were divorced and lived in separate houses. Each parent blamed the other’s parenting style. I brought both parents into the room and told them they were both right. I said the boy was setting fires because he was trying to provide enough light for them to see each other clearly. I then directed them to meet at a neutral location like a coffee shop for thirty minutes every Tuesday to discuss nothing but the boy’s fire setting. They were forbidden from talking about anything else. By forcing them into a rigid, task oriented cooperation, the boy’s need to provide a crisis vanished. The fire setting stopped within two weeks because the parents had been forced into a functional hierarchy that excluded the child from their conflict.

You must be willing to be the person who is blamed for the inconvenience of the therapy. We do not seek to be liked by the family system. We seek to be the catalyst that makes the symptom more uncomfortable than the change. If a family complains that your sessions are too expensive or too far away, you can use that as part of the treatment. You might tell them that since the drive is so long, they must use that time to argue as loudly as possible so they are exhausted by the time they arrive. This turns the environment of the car into a laboratory for their conflict. If they arrive at your office and report that they had a pleasant drive because they were tired of arguing, you have successfully used the environment to shift their interaction.

We define the success of an intervention not by how the client feels, but by how the social structure around the symptom has rearranged itself. If you are working with a woman who is depressed, and she suddenly starts a new hobby while her husband starts complaining of loneliness, you have successfully moved the system. You must then direct the husband on how to support her new interest without becoming a burden. You might tell him to buy her the supplies she needs but he is not allowed to look at her work until it is finished. This maintains a healthy distance and reinforces her individual agency within the marriage.

The most difficult part of assessing the unit of treatment is managing your own desire to help the person who seems most in pain. We must remain detached enough to see that the person in pain is often the one holding the most power through their suffering. I once saw a man who had not worked in five years because of a vague back injury. His wife worked two jobs to support him. I told the man that since he could not work, his job was to ensure his wife was as comfortable as possible. I directed him to massage her feet for one hour every night and to have a four course meal ready when she got home. If he failed to do this, he had to donate fifty dollars of his wife’s money to a charity she chose. The man suddenly found that his back was strong enough for a part time desk job. The secondary gain of his injury was no longer worth the labor I had assigned him.

You must remember that the symptom is a logical solution to an existing structural problem. When you identify the unit of treatment, you are identifying the group of people for whom the symptom is the most useful. We change the unit when the current arrangement no longer serves a purpose or when the cost of maintaining it becomes too high for the participants. The decision to work with an individual or a family is never a matter of preference but a matter of where the leverage for change is located. We look for the smallest possible change that will create the largest possible disruption in the problem sequence. Every directive you give is a probe into the system to see where it will give way and where it will push back. Your authority as a practitioner comes from your ability to remain outside the family’s habitual patterns while directing them to behave in ways that make the symptom unnecessary. The person who brings the client to the office and pays the bill is often the person who most needs to be in the room.

The presence of a symptom is always a signal that the current hierarchy is failing to manage a transition in the life cycle of the individual or the family. Within the first ten minutes of a session, we can see if the parents are united or if one is using a child to punish the other. You should watch for the subtle glances between family members when you ask a difficult question. If a child looks at the mother before answering a question you asked the father, you know the mother is the gatekeeper of information. You must then direct your next comment to the mother to acknowledge her power before you can ever hope to influence the father. This strategic alignment allows you to move the system from the inside out. We do not challenge the power structure directly; we use it to redirect the family’s energy toward a more functional arrangement. The resistance you meet is not a sign that you are doing something wrong, but a sign that you have touched the actual mechanism that holds the problem in place. Every failed directive is a piece of data that tells you exactly who is currently in charge of the symptom. When a child stops being the mediator for the parents, the child often becomes rebellious for a short period to test if the parents can actually handle their own lives. You must warn the parents that this rebellion is a sign of health and that they must remain united to meet it. The moment the parents successfully manage a child’s outburst without retreating into their old patterns of conflict is the moment the therapy has reached its goal. A symptom that no longer has a function in the family hierarchy will inevitably wither and disappear.