Family & Couple Therapy PPT 3 – Structural Family Therapy – Flashcards

Born and raised in Argentina Child psychiatry, psychoanalytically trained Started seeing families at a school for delinquent boys in the 50s Self taught, collaborated with a variety of thinkers, including Jay Haley (Strategic Family Therapy) in the early 60s Became head of the Philadelphia Child Guidance Clinic in 1965 Started his own center in NY in 1981

The Disorganized and Disadvantaged Family: Structure and Process (1967) *Families of the Slums (1967)* Psychoanalytic Therapies and the Low Socioeconomic Population (1968) Families and Family Therapy (1974) Psychosomatic Families: Anorexia Nervosa in Context (1978)

Structural Family Therapy (SFT) is a form of psychotherapy that strives to *identify* *subsets* *within a family construct* in order to *isolate dysfunctional subsets and remap them into more harmonious, healthy relationships.* Minuchin theorized that an *individual's symptoms* were a *result* of the *dysfunctional family system,* and he identified *hidden hierarchies and relationships within the family that lead to dysfunction.* In Minuchin's model, it is the role of the therapist to identify patterns and help family members establish healthier relationships and coping skills. SFT utilizes rules in order to maintain order and boundaries. Additionally, *family rules ensure that the subsets within the family are in the proper orientation.* The therapist can move family members physically, or introduce other elements, to enhance the therapeutic process. Clients who participate in SFT report that the fundamental changes that occur within the family are maintained far outside the limits of the therapeutic walls. Minuchin also helped to develop treatment protocols for the *eating disorders.* He argued that anorexia is a *psychosomatic* illness that often has its *origin within the family*, as outlined in his *book Psychosomatic Families: Anorexia Nervosa in Context.* His methods for treating the disease integrate elements of both behavioral therapy and structural family therapy.

Structural Family Therapy (SFT) refers to a body of theory and a therapeutic model developed by Minuchin. Focuses on *family organization, rules and boundaries (called "the structure"), and the ways in which these structures govern interactional patterns.*

.... consists of (1) *subsytems* within the family or between systems, and (2) *boundaries* between or among these subsytems. *Subsystems* are subgroupings within the family system based on age (or generation), gender, and interest (or function) -parenting -spousal -sibling Subsystems are set up by the implicit or explicit RULES concerning WHO participates in WHICH subsystem and in WHAT manner. Boundaries and the subsytems they define MAY CHANGE over time and with variable circumstances. In this model, *boundaries between subsystems are described as CLEAR, RIGID (too closed!), or DIFFUSE (too open!).*

*Boundaries* are invisible (often unconscious) barriers that regulate contact between members -*Diffuse* -- too weak, or "enmeshed" -*Rigid* -- too fortified, or "disengaged" (Diffuse boundaries are not just enmeshed but are generally not clearly defined or maintained, resulting in blurred generational roles and responsibilities. Diffuse boundaries often, but not always, lead to enmeshed relationships.)

A loss of autonomy that occurs as a result of diffuse boundaries, resulting in family members being overly involved in one another's emotional lives.

As defined by Minuchin (1974), *"family structure is the invisible set of functional demands that organizes the ways in which family members interact."* A family is a system that operates through transactional patterns. Repeated transactions establish patterns of how, when, and with whom to relate, and these patterns underpin the system. For example, a mother tells her child to pick up his socks and he obeys. This interaction defines who she is in relation to him and who he is in relation to her. Repeated interactions constitute a transactional pattern. An operational definition of structure sees structure as the proximity and distance between members in a system. The functionality and dysfunctionality of this proximity and distance are determined on the basis of the developmental stage of the family members. This mother telling her son to pick up his socks *may be appropriate when the boy is three but not when he is twenty.*

A functional organization within the family must have *appropriate (but not too rigid and not too diffuse) boundaries between subsystems:* the parental, the siblings, the family unit as a whole, and the individual.

DYSFUNCTION, in this model, stems from *BOUNDARIES that are either too RIGID or too DIFFUSE*, both of which prevent the system and its subsystems from achieving its goals. Example is father who is very close and enmeshed with older son who hunts with him, and disengaged with daughter who is quietly depressed and cutting herself.

Boundaries are reciprocal -That means that a weak boundary (enmeshment) in one relationship usually means that the same person is disengaged from someone else. -Another example is wife who is enmeshed with child and disengaged from husband.

*"Enmeshed":* the family (or a subsystem) is overly close. *"Disengaged":* the family is too distant from one another. Other concepts that follow are *triangulation*, where one person is torn between two other people. For example, in the case where the parents disagree and they ask the child, "Is Mommy right or is Daddy right."

Assessments of structure are gauged against developmental norms. Enmeshment is the inappropriate closeness of family members against a backdrop, of course, of developmental appropriateness.

Families (people) are competent and capable of solving their own problems -- an attitude derived from the existential-humanistic tradition. Therapists work *collaboratively with families -- not as experts who can solve problems*, but as consultants and coaches who can work to *bring the family's dormant capacities to the surface.* Therapists respect the family's unique culture. The question should be, not "What's ideal?" but *"Does it work for them?"*

*Coalitions:* two family members form a COVERT alliance, either temporary or durable, against a third. Coalitions usually form across generational boundaries, i.e., between one parent and a child (against the other parent or against another child). Coalitions create power blocks in families, which serve either to balance another coalition or establish control.

*Detouring:* when two family members attempt to preserve their relationship by defining their conflict as a disagreement about a third person, keeping the focus on that person rather than themselves and their problem.

*Parentified Child:* the assignment of a role which stems from the FUNCTIONAL REMOVAL OF A CHILD FROM THE SIBLING SUBSYSTEM. The parentified child differs from a child with healthy responsibilities in 2 ways: (1) the parentified child's responsibilities are POORLY DEFINED and therefore, unlimited; and (2) the responsibilities are BEYOND the scope of the child's developmental capabilities. Such children often become psychosomatic when they cannot handle or perform a responsibility they are assigned. Parentified child is one who is given privileges and responsibilities that exceed what would be considered developmentally consistent with age.

Must develop complementary patterns of mutual support, or accommodation (compromise), between each other in the spousal subsystem. Must develop a boundary that separates the couple from children, parents and outsiders. Must claim authority in a hierarchical structure.

Inflexible response to developmental and environmental challenges leads to *conflict-avoidance* through disengagement or enmeshment. Disengagement and enmeshment tend to be compensatory (I'm close here to make up for my distance elsewhere.) This leads to what is called the cross-generational *coalition*, which is a triangular structure.

In *first order change*, structures can be affected without altering the organization of the system. In *second order change*, the organization's rules and structure need to be adjusted (often with therapeutic intervention).

In a paper written by Minuchin and Fishman (1979) called *"The Psychosomatic Family in Child Psychiatry"*, it was proposed that the self is multi-faceted and that behavior and emotion expressed by a given individual are the result of not only history, temperament, and biology, but are called forth by *demand characteristics of the present context.* In a clinical setting, the goal is to change the patient's social context, thus diminishing a problem or dysfunction *as different facets of the patient's self are expressed.*

*Therapy is directed at altering family structure (aka "restructuring")* -General goals of family are important, but not as important as creating an effective structure. Need to create: (1) an effective hierarchy (2) an executive subsystem Structural problems are usually viewed simply as a failure to adjust to changes. The therapist doesn't solve the family's problems, that's the family's job. The therapist observes family interactions and then seeks to *restructure* accordingly by manipulating interactions within the session. Boundaries must be strengthened in enmeshed relationships, and weakened (or opened up) in disengaged ones.

*Spontaneous behavior sequences:* form the basis for hypotheses about family structure *Enactments:* interactions suggested by the therapist as a way to diagnose structure, and to provide an opening for restructuring.

#1: Joins the family in a position of leadership. #2: Maps the family's underlying structure (boundaries, hierarchy, subsystems). #3: Intervenes to transform the existing structure.

Not a matter of creating new structures, but activating dormant ones. What distinguishes SFT from other forms of family therapy is the emphasis on modifying family structure *in the immediate context of the therapy setting.* When new patterns are repeated, and result in improvement of family relationships, they will stabilize and replace old patterns without having to keep supporting them. (Similar to the behaviorist notion of reinforcement.)

*Joining* in a position of leadership: -Family is set up to resist you. You are a stranger, and know nothing about their struggles, and their goodness. -*Important to join with angry and powerful family members.* -Important to build an alliance with every family member. -Important to respect hierarchy.

..... techniques used both in assessment and treatment of families. Members are either instructed to engage naturally with each other (spontaneous behavior sequences) or advised what to do in enactments to showcase particular problems and experiment with strategies to change it.

A joining technique in which the therapist gains acceptance by mimicking the gestures, communication, and behavioral patterns of family members.

An engagement technique in which the therapist participates in the family dynamic, while privately noting the dysfunctional or unbalanced processes being enacted. The therapist must assume the *median* position: paying attention to him/herself while engaging with the family.

Inquiring into the family's view of the problem, and tracking the sequences of behaviors that they use to explain it.

..... in ways that capture the interrelationship of members (a structural map is essential!): -Family structure is manifest only with members interact -By asking everyone for a description of the problem, the therapist increases the chances for observing and restructuring family dynamics.

A technique in which the therapist asks questions and/or makes *provocative comments designed to evoke responses* which help to obtain info about how the family operates. Even failure to obtain the family's cooperation provides information about their boundaries.

Use of reframing to illuminate family structure Use of circular perspectives, e.g. helping each other change Boundary setting Unbalancing (briefly taking sides) Challenging unproductive assumptions Use of intensity to bring about change (not giving up) Shaping competency Not doing the family's work for them (refusing to answer questions, or to step in and take charge when it's important for the family members to do so)

Should be used to increase contact between disengaged parties, To reinforce boundaries between individuals and subsystems that have been enmeshed Should be something that is not too ambitious Minuchin did caution family members to expect setbacks, in order to prepare them for a realistic future.

Structural Therapy (Major theorist: Salvador Minuchin) Gladding, Chapter 12 (family) & Gurman, Chapter 11 (couple) "Structural therapy is, first of all, a therapy of families, and only derivatively a therapy of couples."

~Gladding, Chapter 12 (family) & Gurman, Chapter 11 (couple) The formation of the therapeutic system (i.e., joining). Provoking disequilibrium and change.

~Gladding, Chapter 12 (family) & Gurman, Chapter 11 (couple) Primary premise: every family has a *family structure*, which is "an invisible set of functional demands that organize the ways in which family members interact." It is impossible to tell what a family's structure is unless the family is active and one is able to observe repeated interactional patterns. Structure influences families for better or worse. In some families, structure is well organized in a hierarchical pattern, and members relate to each other. In others, there is little structure, and few arrangements are provided in which family members can easily and meaningfully interact. Developmental/situational events increase family stress, rigidity, chaos, and dysfunctionality, throwing the family into crisis. The most therapeutically relevant cause of a member's behavior is the here-and-now experience of other family members' behavior. Dysfunction results from the development of dysfunctional sets, which are *"family reactions, developed in response to stress, that are repeated without modification whenever there is family conflict."* In some dysfunctional units, coalitions arise. *Coalition* is "an alliance between specific family members against a third member." The dysfunctional couple is one whose external boundary is excessively diffuse or rigid. A diffuse boundary deprives the couple subsystem of integrity, resulting in partners' lack of identity as a couple. A rigid boundary cuts the couple off from its environment. Minuchin conceptualized child behavior as a response to parental behavior.

Single-minded focus on systemic structure. Emphasizes the family as a whole, as well as interactions between subunits of family members. A person's symptoms are best understood as rooted in the context of family transaction patterns. The family is seen as the client. The hope is that through restructuring the system, all members of the family and the family itself will become stronger. Families are viewed as living systems: they operate in an ever-changing environment in which communication and feedback are important. Lasting change is dependent on altering the balance and alliances in the family so that new ways of interacting become realities. Subsystems are smaller units of the system. They exist to carry out various family tasks. Without subsystems, the overall family system would not function. Defined by boundaries and rules connected with them. Formed when family members join together to perform various functions. Some are temporary (e.g., painting a room). Others are more permanent (e.g., parenting). Subsystems can provide the family with internal resources to negotiate the demands of the outside world.

Of particular significance are the *spousal, parental, and sibling subsystems.* Spousal subsystem works best when there is complementarity of functions. *Parental subsystem* is the *executive system of the family.* A cohesive, collaborative parental system is critical for healthy family functioning. Boundaries are the physical and psychological factors that separate people from one another and organize them. For proper family functioning, boundaries of subsystems must be *clear.* Major types of boundaries: *clear, rigid (i.e., disengaged), and diffuse (i.e., enmeshed).* *Triangulation* is a system process in which a child becomes involved in parents' conflictual interactions by taking sides, distracting parents, and carrying messages to avoid or minimize conflict between the parents.

Parentified child is one who is given privileges and responsibilities that exceed what would be considered developmentally consistent with age. Alignments are the ways family members join together or oppose one another in carrying out a family activity. Structural family therapy is based also on roles, rules, and power. Therapists need to understand roles, or the positions under which the family is operating. Roles may be outdated or ineffective. Rules provide the family with structure. Rules may be explicit or implicit; *functional families generally have more explicit* than implicit rules. Rules may be adhered to regardless of changes that have occurred in the family's lifestyle or outside circumstances. Power is the ability to get something done; related to authority and responsibility. *In dysfunctional families, power is vested in only a few members.*

Structural assessment of the couple subsystem entails examining boundaries around the subsystem and how differentiation is handled. "Enactment" in the therapy room is used to assess the couple's relationship. (See description of "enactment" in techniques section below.) *Enactments demonstrate subsystem functioning and structure. Assessment includes:* -family members' preferred transactional patterns and available alternatives -flexibility and the capacity to change -family members' sensitivity to members' needs, behaviors, attitudes, etc. -developmental issues, tasks, and requirements -the meaning and relational significance of symptomatic behavior -the context of family life (i.e., sources of social support, family stressors)

They are divided into *two major groups of techniques:* (1) are primarily used in the formation of a therapeutic system (i.e., *joining*), and those that (2) are more directly aimed at provoking disequilibrium and change. *Group I: Joining* = the process of "coupling" that occurs between therapist and family, leading to development of the therapeutic system. Therapist makes contact and allies with each family member through expressing interest in them as individuals and working with and for them. Four ways to join: *1. Tracking:* therapist follows content of the family (i.e., the facts); open-ended questions. *2. Mimesis:* therapist becomes like the family in manner/content of their communications (e.g., joking with a jovial family; talking slowly or sparsely with a slow-talking family). *3. Confirmation:* use affective words to reflect a feeling of a family member (i.e., a nonjudgmental description of the present behavior of the family member). *4. Accommodation:* the therapist makes personal adjustments in order to achieve a therapeutic alliance. The therapist needs to know when and how to *"push the envelope" of the family functioning by introducing new ideas*, or whether he or she should *accommodate* to *family ideas* to maintain or strengthen the therapeutic alliance.

*Group II. Disequilibrium & Change Techniques:* Eleven Interventions for changing a family system *Reframing* - involves changing a perception by explaining a situation from a different context (i.e., meaning of a situation is examined from a new perspective). Ex: viewing a negative situation in a more favorable light. *Punctuation* - the way a person describes a situation, that is, begins and ends a sentence, due to a selective perspective or emotional involvement in an event. By punctuating a particular situation, the perception of everyone involved is changed. Punctuation enhances possibilities for new competencies and behaviors in the future. Ex: a therapist trying to show that a mother has competence in controlling her child's behavior may declare her competent when she corrects/disciplines her kid.

*Unbalancing* - the therapist siding with one member of the family *Enactment* - when the therapist "invites client-system members to interact directly with each other." *Enactment* consists of families bringing problematic behavioral sequences into treatment by showing them to the therapist in a demonstrative transaction. Uses the relationship between the family members as the agent of change. Like a director, the therapist assumes responsibility for setting dramatic scenes, designating which family members will be involved, what they'll talk about, how they'll talk about it. *Working with spontaneous interaction -* focusing attention on some particular behavior. Occurs whenever families display actions in sessions that are disruptive (members yelling at one another or parents withdrawing from their children)

*Boundary making* - a boundary is an invisible line that separates people or subsystems from each other psychologically. Families may need rigid boundaries when children are young, in order to make sure that everyone is taken care of, and more flexible boundaries during the time when there are teenagers in the house. *Intensity* - changing maladaptive transactions by using strong affect, repeated intervention, or prolonged pressure. The tonality, volume, pacing, and choice of words by the therapist can raise the affective intensity of statements. *Restructuring* - changing the structure of the family by altering the existing and hierarchy and interaction patterns so that problems are not maintained. Accomplished through the use of enactment, unbalancing, directives, and boundary formation. *Shaping competence* - the therapist highlights and reinforces positive behaviors in order to make the family more functional.

*Diagnosing* - involves describing (i.e., diagnosing) the systemic interrelationships of all family members. Ex: noting disruptive coalitions or triangles among family members *Adding cognitive constructions* - Advice, information, pragmatic fictions, paradox. *Pragmatic fiction* - pronouncements that help families/family members change. Ex: Therapist telling the child that they are acting younger than their years. *Paradox* - a confusing message meant to frustrate or confuse families and motivate them to search for alternatives

The fundamental task of the therapist is to help the couple replace dysfunctional structure. Structural family therapist is an observer and an expert who is active, like a *theater director, in making interventions to modify and change the underlying structure of the family.* Successful structural family therapists require high energy and precise timing so that in-session interactions among client-families result in new family organization. Therapist's role changes over the course of therapy. In the first phase, therapist joins the family and takes a leadership position. In second phase, therapist mentally maps out the family's underlying structure. In the final phase, therapist helps transform family structure.

*The mechanism of change in Structural Couple Therapy is the production of new relational experiences for clients.* It is the experience of receiving different behavior from his or her partner that induces a couple member to behave differently toward each other. In SCT, clients change each other by behaving differently toward each other. The job of the therapist is to facilitate this internal change process within or between subsystems. The *enactment is the central piece of the assessment process.* Technical Aspects of the Therapeutic Process (theatrically-thinking, "act" terminology): First, there is a Prologue before Two Main Acts (think of the Prologue as the Assessment Period). *Act 1: Destabilizing the Old Structure* - the client's predominant experience (what is relationally familiar is abandoned). *Act 2: Nurturing the New Structure* - Client surrenders the "old script." The therapist functions primarily as an audience for new relational enactments.

Demographic variables are also not correlated with outcome. However, the model has proven helpful in work with all social classes, with families and couples representing numerous ethnic groups, with homosexual and heterosexual couples, and in numerous countries. The model can be applied to divorcing and divorced couples, as well as to engaged or married couples, and to unmarried couples whose commitment to each other is not in question.

https://www.youtube.com/watch?v=VOjqL3p-dSo