Structural

23 rd May 2011 Structural Family Therapy Outline -

1. Key Figures 2. Key Concepts 3. Therapy Goals 4. Therapist’s functions Salvador Minuchin • Born in Argentina in 1921 to Russian-Jewish immigrant parents • Oldest of three children • Son of a successful businessman • Family went into poverty during the Great Depression • Fascination with psychology began in High School • Became interested in the works of the philosopher Rousseau • Began medical school at age 18 • Involved with the political movement that sought to overthrow the dictator Juan Peron which landed him in jail for three months • Ultimately he graduated from medical school and went into pediatric psychology Salvador Minuchin

• Founder of Structural Family Therapy • Author of the classic Families and Family Therapy (1974) • Concepts developed by Minuchin are used to train family therapists to this date Salvador Minuchin

“society acts as if all family violence is instrumental, and the response therefore is to increase control. But it is clear to us as family therapists that most cases of family violence are the products of generations of powerlessness. When we try to intervene by controlling the parents or with concern for the child alone, we can only produce a continuation of the pattern.”

Salvador Minuchin Structural Family Therapy - Salvador Minuchin

• Focus is on family interactions to understand the structure, or organization of the family • Symptoms are a by-product of structural failings • Structural changes must occur in a family before an individual’s symptoms can be reduced • Techniques are active, directive, and well thought-out • Focus on the how, when, and to whom family members relate Key Concepts Structural Family Therapy of Salvador Minuchin • Family Structure: invisible set of functional demands or rules that organize way family members relate to one another- • Observe family to see the structure: – who says what to whom, – in what way, – with what result Family Subsystems

• Spousal: wife & husband • Parental: mother & father • Sibling: children • Extended: grandparents, other relatives • Family member play a different role in each of the subsystems they belong • Structural difficulty when one subsystem takes over or intrude another Boundaries

• Emotional barriers that protect & enhance the integrity of individuals, subsytems & families • Extremes of boundaries • Disengagement -overly detached -rigid • Enmeshment-very involved as one- diffuse-fosters dependency on parents • Clear healthy boundaries-attain sense of personal identity yet allow sense of belongingness within family system Structural Family Therapy Goals

• Reduce symptoms of dysfunction • Bring about structural change by: – Modifying the family’s transactional rules – Developing more appropriate boundaries – Creation of an effective hierarchical structure – It is assumed that faulty family structures have: – Boundaries that are rigid or diffuse – Subsystems that have inappropriate tasks and functions Structural Family Therapist Function

• To actively engage family as unit to initiate structural change by: 1. Joining the family in a position of leadership 2. Mapping its underlying structure 3. Intervening in ways designed to transform an ineffective structure • The Therapeutic Endeavor is challenging rigid transactional patterns 1. Pushing for clearer boundaries 2. Increasing degree of flexibility in family interactions 3. Modifying dysfunctional family structures Structural Family Techniques

• Joining: build & maintain therapeutic alliance with family • Family Mapping: draw map to identify boundaries , transactional styles • Enactments : family engages in conflict situation that would happen at home • Reframing: new light or different interpretation on problem situation in family Strategic Family Therapy

11 th October 2010 Introduction:

• There are two models within the strategic school of family therapy: the brief/communication model developed at the Mental Research Institute, and a blend of the structural/strategic model developed by Haley and Madanes. • We have already looked at the MRI approach and therefore we will now focus on the work of Jay Haley. Strategic Family Therapy

• Jay Haley – Worked with Milton Erickson, & Salvador Minuchin • Started the Family Therapy Institute in DC • Helped Minuchin start the Philadelphia Child Guidance Center in 1967 • Retired in 1995 to La Jolla, CA • Died in 2007 Jay Haley

• Dominant figure in strategic family therapy • Studied under three of the most influential pioneers in the evolution of family therapy - Gregory Bateson, Milton Erickson, and Salvador Minuchin • Combined ideas taught to him into own form of family therapy Jay Haley

• Trained under hypnotist Milton Erickson • Developed a brief therapy model which focused on the context and function of symptoms • Utilized directives to instruct patients to act in ways that were counterproductive to their maladaptive behavior • Focus was on patients actively doing something about their problems • Instrumental in bridging the gap between strategic and structural approaches to family therapy • Explored concepts related to triangular and intergenerational relationships Jay Haley

• Haley conducted research at the Mental Research Institute in Palo Alto • In 1967 joined Salvador Minuchin at the Philadelphia Child Guidance Clinic in 1967 • Interests were in training and supervision in family therapy • In 1976, Haley moved to Washington D.C. and founded the Family Therapy Institute with Cloe Madanes, which has become one of the major training institutes in the country • Haley retired in 1995 Jay Haley

• Has written 19 books on therapy • Writings are clear and concise and illustrate his ideas • Publications include Problem-Solving Therapy , Uncommon Therapy , Leaving Home , and l earning and Teaching Therapy • In collaboration with his wife, Madeleine Richeport-Haley, Jay Haley has produced a number of therapist training videotapes Haley’s Family Therapy

• The first axiom states that people are always communicating • It is important to remember that the framework of all behavior is communicative • Communication still takes place in situations where there is an absence of mutual understanding; or if it was done unconsciously or unintentionally • The second axiom states that all messages contain two functions: report and command Theoretical Formulations

• The presence and utilization of Command messages within a family, results in the individuals accepting these messages as rules. • This phenomenon can be witnessed from the observation of the redundancy of interactions between family members • Don Jackson used the term family rules to describe regularity, and not regulation. • There isn’t a specific individual who sets the rules; as a matter of fact, family members often fail to recognize their presence. Theoretical Formulations

• Communication researchers hold that families are inherently goal-oriented • Researchers decided avoided searching for basic motives • Instead they chose to assume circular causality, in order to investigate specific modes of communication bonded by additive chains of stimulus and response as feedback loops • For example if a member of the family elicits a response in reaction to a challenging behavior or situation exhibited by another member of the family, this response chain is defined as a positive feedback loop Theoretical Formulations:

• The benefit of this procedure lies in its focus on specific relationships which cause various difficult situations • These interactions can then be modified and altered, instead of making various assumptions about the causes; which are very resistant to change. • Strategic therapists employ the concept of the positive feedback loop as the primary component of their models. Key Concepts:

• Patient's symptoms seen as the result of incongruence between manifest and covert levels of communication • Symptoms seen as giving a patient a sense of control in their interpersonal relationships • Therapy focuses on patient taking responsibility for their actions (i.e. therapeutic paradox) Theoretical Formulations

• The rules which govern family interaction function as a method of ensuring the maintenance and preservation of family homeostasis . • Homeostasis is responsible for bringing the family back to its original state (equilibrium) when experiencing any type of disturbance; making the family very resistant to change • Jackson’s definition of homeostasis closely resembles the conservative idea of a family system; as well as, bearing a very close resemblance to the concept of negative feedback. Theoretical Formulations

• The majority of family behaviors are controlled and regulated by unspoken rules • Rules promote and encourage inappropriate solutions to problems; it turns out that it isn’t only the behavior needing to be altered, but the rules need to be changed as well • First-Order Change occurs when only a particular behavior within the system changes • Nichols defines First –order changes as temporary or superficial changes within a system that do not alter the basic organization of the system itself • Nichols defines Second-order changes as basic changes in the structure and functioning of a system • Second-Order Change takes place when there is a modification or alteration to the rules within the system Key Concepts:

A central underlying theme of strategic family therapy is that families are ambivalent about change, usually because family problems serve some important interpersonal protective function for some family members, and so therapists must carefully design specific directives to undermine this ambivalence or resistance and so help families resolve their presenting problems, while also providing the family with an opportunity to deal with the complex interpersonal problem that the symptom was designed Key concepts: Healthy Families:

• Healthy families have clearly defined intergenerational hierarchies, so that it is quite clear that for important issues, parents are in charge and have the final veto on major family decisions. • When healthy families move from one stage of the family lifecycle to the next, they are flexible enough to modify their rules, roles and routines sufficiently to meet the demands of the new lifecycle stage. Key Concepts: Healthy Families:

Within family relationships there is a mix of complementary and symmetrical transactions . Complementary: a process in which the increasing dominant behaviour of one member (or faction) of a system invariably elicits increasing submissive behaviour from another member (or faction), and over time the intensity of the complementary behaviour pattern increases until the members (or factions) separate. (Aggressive-Passive) Symmetrical: a process in which the behaviour of one member (or faction) of a system invariably elicits a similar type of behaviour from another member (or faction), and over time the intensity of the symmetrical behaviour patterns escalate until the members (or factions) separate. Key Concepts: Healthy Families:

• Healthy families select love rather than violence as the central value and distribute love within the family in a non-intrusive, non- violent way. • Have clearly defined intergenerational hierarchies, so that it is quite clear that for important issues, parents are in charge and have the final veto on major family decisions. • It is also assumed that when families move from one stage of the family lifecycle to the next, they are flexible enough to modify their rules, roles and routines sufficiently to meet the demands of the new lifecycle stage. • A third assumption is that within family relationships there is a mix of complementary and symmetrical transactions. Key Concepts: Problematic Family:

Problems occur when the hierarchical structure of the family is unclear; when there is lack of flexibility in moving from one lifecycle stage to the next; and when family relationships are characterised exclusively by complementary or symmetrical transactions. Haley argues that when there are differing overt and covert hierarchical structures within a family or social system and this difference is denied, problems occur. Key Concepts: Problematic Family:

Haley also argues that when these type of pathological triangles occur, they prevent families from moving smoothly from one stage of the family lifecycle to the next. Incongruous hierarchies may also occur within the marital relationship. Marital relationships which are characterized exclusively by symmetrical transactions (such as persistent oppositional arguments) and relationships characterised by exclusively complementary transactions (such as caregiving and caretaking) inevitably become seriously problematic. Key Concepts: Problematic Family:

• Symptoms may be conceptualized as metaphorical messages about problems in other domains. • Family difficulties are conceptualised within Madanes’s (1991) formulation of strategic therapy as arising from attempts to dominate and control; to be loved; to love and protect; or to repent and forgive. Assessment in Strategic Therapy:

• Involves identifying the specific problem with which the family want help; clarifying the pattern of interaction around the problem; and clarifying the role of hierarchical incongruities, lifecycle stage ‘stuckness’, and exclusive reliance on symmetrical or complementary transactions in this cycle. • The way the family manage the issues of power, the need to be loved, to love and protect, and to repent and forgive is also addressed. Assessment in Strategic Therapy:

• The assessment interview is segmented into four parts:

– Social Stage – Problem Stage – Interaction Stage – Goal- Setting Stage The Haley and Madanes Approach Social Stage • Initially family members display defensiveness when they first come to therapy; as a result, of not knowing what to expect, or a fear that the therapist will place all the blame on them for their problems • So Haley utilizes the first couple minutes of the session to help everyone calm down The Haley and Madanes Approach Problem Stage

• Haley asks each individual to describe their personal perspectives • He asserted that since mothers are generally assume a more focal role than fathers, Haley preferred to speak with the fathers first in efforts of increasing their participation • Haley makes a special effort to actively listen and understand the manner used by each individual in describing the problem; making it a point to prevent any interruptions before each person has had their turn • Haley uses this stage to locate and uncover various clues about triangles and hierarchy • Haley resists providing his comments and opinions about these observations, to avoid running the risk of a particular family member interpreting his comments in a defensive manner The Haley and Madanes Approach Interaction Stage

• When everyone has spoken, Haley instructs the family members to talk to each other and discuss the statements and arguments each of them made

• This stage provides the therapist with the opportunity to observe, rather than just listen to the discussions and conversations which surround the problem

• As the individuals converse, specifically looks to locate any coalitions between the family members against one another

• Haley states that the definition of a truly effective therapist is not someone who tells people what to do, but one who gets them to do it Treatment:

• Conceptualising or formulating problems within the therapeutic team • Reframing problems for clients • Giving directive to clients that will disrupt the pattern of interaction which maintains the presenting problem. Treatment:

• An truly unique aspect about Haley’s technique is his concentration on interpersonal payoff of psychiatric symptoms • The notion that individuals receive something from their symptoms was rejected by the majority of schools of family therapy because it was seen as a method of placing blame on the victim • The point that Haley was trying to emphasize, was that the development of problems such as anxiety; contained the possibility of influencing, promoting and maintaining interpersonal struggles within the family Treatment

• The primary goal of Haley’s treatment technique is to understand the heart of the family drama that symptoms revolve around • Haley declares that people’s hardships carry a deeper meaning with it, and in turn suggest the ability of discovering reasonable solutions • The solution lies in providing assistance to families with finding new methods and approaches they can utilize to resolve their issues Treatment:

 Cloe Madens illustrated the method by which one relationship can metaphorically imitate another  Madens also focused on attending to the issue of power balance in couples, and the effects brought upon the role it plays on numerous symptoms  Her concentration focused upon the lives of couples, where there is a regulation of power; including issues of money, education, control of children, coalition with in-laws, religion and sex  What Maden discovered was that the partner who held the least amount of power developed the most emotional problems  Symptoms included: depression, headache, substance abuse, eating disorders, and phobias  Madanes made the observation that individuals will exhibit behaviors they wouldn’t normally perform, if the behaviors are framed as play to develop an entire range of pretend techniques Treatment:

• The current name for Haley/Madanes therapeutic approach is strategic humanism • Its still entails giving directives, however the directives are geared more towards encouraging and strengthening the family members capabilities to provide love and comfort to each other, Skills Guide

Structural & Strategic Family Therapy • The following are four skills or techniques that can be derived from the first phase of systemic family therapy. • They embody some of the core contributions of the first phase and they are of enduring value. • Many therapists continue to employ these skills. Skills:

• Family Sculpting • Family tree and • Time line (or family chronology) • Reframing