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Structural therapy is primarily associated with the work of who?

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Salvador Minuchin

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What is the general approach of structural therapists in helping their clients?

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They map family structure—boundaries, hierarchies, and subsystems—, then they restructure the family, realigning boundaries and hierarchies to promote growth and resolve problems.

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Structural family therapists hold an attitude of what?

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Strengths--never seeing families as dysfunctional but rather as people who need assistance in expanding their repertoire of interaction patterns to adjust their ever changing developmental and contextual demands.

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Boundaries

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rules for managing physical and psychological distance between family members, for defining the regulation of closeness, distance, hierarchy, and family roles

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Although boundaries may sound static

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they are organic, living processes.

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Structural therapists identify three basic types of boundaries

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Clear Boundaries, Diffuse Boundaries, and Rigid Boundaries

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Clear Boundaries

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"normal" boundaries that allow for close emotional contact with others while simultaneously allowing each person to maintain a sense of identity and differentiation.

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Diffuse Boundaries

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lead to relational enmeshment. Families with overly diffuse boundaries do not make a clear distinction between members, creating a strong sense of mutuality and connection at the expense of individual autonomy

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When talking with an enmeshed family, therapists typically see family members doing the following:

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■■Interrupting one another or speaking for one another ■■Mind reading and making assumptions ■■Insisting on high levels of protectiveness and over concern ■■Demanding loyalty at the expense of individual needs ■■Feeling threatened when there is disagreement or difference

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Rigid Boundaries

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these type of boundaries lead to relational disengagement. Autonomy and independence are emphasized at the expense of emotional connection, creating isolation that may be more emotional than physical. These families have excessive tolerance for deviation, often failing to mobilize support and protection for one another.

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Therapists working with disengaged families notice the following:

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■■Lack of reaction and few repercussions, even to problems ■■Significant freedom for most members to do as they please ■■Few demands for or expressions of loyalty and commitment ■■Consistently using parallel interactions (e.g., doing different activities in the same room) as substitutes for reciprocal interactions and engagement

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systemic reframing

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It usually involves removing the blame from one person (the identified patient) and "spreading" blame equally by describing how each person's response contributes to the problem dynamic. Once this is done, blame becomes a moot point.

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How to Generate Systemic reframes

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• assess broader interactional patterns (complementary relationships, hierarchy, boundaries, etc.) • redescribe the problem (use interactional patterns to describe the problem in a larger context).

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Boundary making is

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a special form of enactment that targets over- or underinvolvement to help families soften rigid boundaries or strengthen diffuse boundaries

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Boundary making may involve several different directives:

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• Asking family members to change seats • Asking family members to move seats further or closer together or turn toward one another • Having separate sessions with individuals or subsystems to strengthen subsystem boundaries • Asking one or more members to remain silent during an interaction • Asking questions that highlight a problem boundary area (e.g., "Do you always answer for your son when he is asked a question?") • Blocking interruptions or encouraging pauses for less dominant persons to speak

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Challenging the family's worldview and unproductive assumptions typically involves

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verbally questioning operational assumptions in the family system, whether overtly spoken or covertly acted upon

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Common assumptions that create problems for individuals, couples, and families include the following:

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• "Kids' needs come first." • "It's better to keep the peace than start conflict." • "It is easier to sacrifice my needs than ask for what I want." • "If I give here, you should give there." • "It's better for the kids for us to stay in this unhappy marriage."

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Intensity and crisis inductions are interventions that

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use affect to create structural shifts in hierarchy and boundaries, especially when the family is having trouble "hearing" the therapist with other interventions

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Intensity involves

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turning up the emotional heat by using tone of voice, pacing, and word choice to break through rigid and stuck interactional patterns.

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An example of intensity would be

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example, a therapist may say to a couple who claims to have no time for a weekly date because of their children's numerous after-school activities, "Do you think your children would prefer to be in soccer and have divorced parents or to have fewer activities and an intact family?"

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crisis induction in structural therapy is used with families who

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chronically avoid a conflict or problem

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The point of using a crisis induction is

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So The therapist can then help the family develop new interactions and patterns.

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An example of a crisis induction would be

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in families with anorectic children, the therapist may bring the symptom into the room by staging a meal and having the family deal with it. Similarly, with alcohol or substance abuse issues, the therapist often induces a crisis so that the family will acknowledge and finally address the problem.

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When is unbalancing used?

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for more extreme difficulties in hierarchy or when the identified patient is being scapegoated. This intervention is used to realign boundaries between subsystems

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explain how a therapist might use unbalancing in session

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Therapists use their expert position to temporarily "join sides" with individuals who are being scapegoated or with subsystems that need to develop stronger boundaries by arguing their cause or helping to explain their perspective to others.

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When working with a highly rigid family structure, structural therapists directly challenge these beliefs and realities in order to do what?

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expand the family's functioning in new directions.

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Describe one possible way a therapist could use to expand a family's rigid worldview:

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Rather than introduce an entirely foreign concept, the structural therapist takes the family's fundamental premise that has been supporting the problem and redirects its logic to support an alternative set of behaviors and interactions, allowing the family to maintain its core beliefs but use them in new ways.

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Compliments are used to

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bolster behaviors that support families in moving toward their goals, and shaping competence involves noticing small successes along the way to reaching goals.

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Minuchin and Fishman strongly recommend that therapists take what type of approach or view to psychopathology?

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therapists should identify and accentuate family strengths and positive interaction patterns, and therapists should augment and reinforce the family's natural positive patterns and strengths.

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Harry Aponte, a structural therapy proponent, has been a leading voice in the field of family therapy on issues of

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spirituality, race, and poverty.

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What kind of approach does structural family therapy take?

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employs an active, engaged approach in which the therapist often takes an expert stance in relation to the family, an approach that often fits with the values of traditional cultures.

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Jose Szapocznik and his colleagues at the Center for Family Studies developed which form of therapy?

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brief strategic family therapy (BSFT) which is an evidence based structural family approach

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Brief strategic family therapy is based on three central concepts:

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systems, structure (patterns of interaction), and strategy.

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Brief strategic family therapy has two goals:

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• Reduce or eliminate child drug use • Change family interactions that are supporting the problem behaviors (youth drug use)

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Ecosystemic structural family therapy (ESFT), an empirically supported adaptation of structural family therapy (Minuchin, 1974), was developed by

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Marion Lindblad-Goldberg and her colleagues at the Philadelphia Child and Family Training Center (formerly the Philadelphia Child Guidance Clinic)

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Ecosystemic structural family therapy (ESFT), an empirically supported adaptation of structural family therapy (Minuchin, 1974), was developed to treat

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children and adolescents with severe emotional or behavioral problems and their families within the context of their communities

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Ecosystemic structural family therapy is a bio/developmental/systemic trauma-informed clinical model that examines

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the biological and developmental influences of family members as well as current and historical familial, cultural, and ecological influences.

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Ecosystemic structural family therapy therapists are guided by five interrelated constructs:

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• Family structure • Family emotion regulation • Individual differences (historical, biological, cultural, developmental) • Affective proximity (emotional attachment between parent and child and between parents) • Family development

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The primary targets of therapeutic change in Ecosystemic structural family therapy are the following:

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• Parental executive functioning • Child coping skills • Co-parent alliances • Nonadaptive emotional attachment patterns • Emotional regulation • Extrafamilial supports to family members

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Minuchin (1974) identifies three main phases of structural therapy:

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1. Join the family and accommodate to its members' style (build an alliance) 2. Map the family structure, boundaries, and hierarchy (evaluate and assess) 3. Intervene to transform the structure to diminish symptoms (address the problems they identified in the assessment)

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Who Attends Therapy?

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To be able to assess the system, structural therapists prefer to begin therapy with the entire family, but they do not insist on it. However, once the family system has been assessed, the therapist often meets with specific subsystems and individuals to achieve structural goals.

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Structural family therapists have a unique term for the therapeutic relationship:

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joining

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accomodating

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Therapists "join" the system in the sense that they accommodate to its style: how people talk, what words they use, how they walk, and so forth. This technique is used in building the therapeutic alliance.

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The attitude of joining requires

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(a) a strong, clear sense of connection and affiliation (e.g., curiosity, openness, sensitivity, acceptance) and (b) an equally clear sense of distance and differentiation (e.g., questioning, dissenting, promoting change).

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Therapeutic spontaneity

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Structural therapists strive to cultivate this and it refers to the ability to flow naturally and authentically in a variety of contexts and situations.

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How does a therapist cultivate therapeutic spontaneity?

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is cultivated and shaped through the training process, which increases therapists' repertoire for "being natural" in a wide range of clinical situations.

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Therapist's use of self

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According to Minuchin, therapists must use themselves to relate to the family, varying from being highly involved to professionally detached.

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Making it happen

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According to Minuchin, it is the therapist's job to do (almost) whatever it takes to help a family make the desired change. Therefore, a therapists' roles can vary widely: they can be the "producer" who ensures conditions that make therapy possible, the "stage director" who pushes the family toward more functional patterns, the "protagonist" who directly uses himself/herself to alter stuck family interactions, or the "narrator" or "co-author" who collaboratively helps the family revise their script. Thus therapists need to be open to playing whichever role will be most beneficial for a particular family in a given session, rather than being wedded to their own favorite roles.

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Structural family therapists conceptualize and assess the following factors:

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• role of symptom in the family • Subsystems • Cross-generational coalitions • Boundaries • hierarchy • Complementarity • Family development • Strengths

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Structural therapists identify three possible relationships between the symptom and the family system

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1. Family as Ineffectual Challenger of Symptom: The family is passive. In order to maintain a highly enmeshed or disengaged family structure, it fails to challenge the symptomatic member. 2. Family as "Shaper" of Individual's Symptoms: The family structure shapes the individual's experience and behaviors. 3. Family as "Beneficiary" of the Symptom: The symptom performs a regulatory function in maintaining the family structure.

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How does a structural therapist view the identified patient in the family system?

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He or she is never seen as the sole source of the problem, and instead the family interaction patterns are targeted for intervention.

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subsystems

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Some subsystems can be found in almost every family: couple, parental, sibling, and each individual as a separate subsystem. In addition, in some families other influential subsystems develop along gender lines, hobbies, interests (sports, music), and even personalities (serious versus fun loving). When assessing a family, generally the most important subsystem issues to consider are (a) whether there is a clear distinction between the parental and couple subsystems and (b) whether there is a clear boundary between the parental and child/sibling subsystems.

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Define cross-generational coalitions

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A problematic subsystem that forms between a parent and child against the other parent or other key caretaker.

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The goal of this model is to prevent unhealthy sequences from repeating, by

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interrupting the family hierarchical structure This includes the distribution of power shifting to others to by changing the style of interaction.

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When working with reported problems in child behavior, therapists must first assess the parental hierarchy so

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they know how to intervene

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There are three basic forms of parental hierarchy:

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effective, insufficient, excessive

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effective parent boundaries

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When the parental hierarchy is appropriate and effective, parents can set boundaries and limits while still maintaining emotional connection with their children.

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insufficient parent boundaries

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When the parental hierarchy is insufficient, parents are not able to effectively manage the child's behavior and often adapt a permissive parenting style.

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examples of insufficient parent boundaries illustrated

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This style is easy to identify in the therapy office: the parents are not able to keep younger children from tearing up the waiting room and office, or their teens act as though they have the right to set their own curfews and rules. Often the parents hope that the therapist will "teach" their children to listen, but this often requires intervening more with the parents than the children.

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Excessive parental boundaries:

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When there is excessive hierarchy, the rules are developmentally too strict and unrealistic and consequences are too severe to be effective. In this situation, there is almost always a rigid boundary between children and parents. These parents need assistance in developing age-appropriate rules and expectations and in developing a stronger emotional bond with their children.

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Minuchin and Fishman (1981) identify four major stages in family development:

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1. Couple formation 2. Families with young children 3. Families with school-age or adolescent children 4. Families with grown children At each stage, the members need to renegotiate boundaries to define the levels of closeness and differentiation that will support individual members' growth needs. Families often get stuck transitioning from one stage to another if they fail to renegotiate boundaries and hierarchy as the family develops.

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Structural therapists target similar goals for all families

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• Clear boundaries between all subsystems that allow for connectedness and differentiation congruent with the family's cultural contexts. • Clear distinction between the marital/couple subsystem and the parental subsystem. • Effective parental hierarchy and the severing of cross-generational coalitions. • A family structure that promotes the development and growth of individuals and the family.

Gehart Chapter 5: Structural Family Therapy – Flashcards

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