Brief Strategic Family Therapy

U.S. Department of Justice Office of Justice Programs Office of Juvenile Justice and Delinquency Prevention

John J. Wilson, Acting Administrator April 2000

engthen tr ing S S ly e i r m ie Brief Strategic a s F From the Administrator Just as a child is influenced by his or Family Therapy her family, the child’s family, in turn, is affected by the culture of which it is an integral part. If we are to succeed in preventing and combating delinquency, we must work to strengthen the role of the family within the com- Michael S. Robbins and José Szapocznik munity in which it resides. The Office of Juvenile Justice and Delin- One of the first challenges the Spanish This Bulletin features a family- quency Prevention (OJJDP) is dedicated to Family Guidance Center’s clinical program strengthening strategy—brief strate- preventing and reversing trends of increased encountered involved identifying and de- gic family therapy—that integrates delinquency and violence among adoles- veloping a culturally appropriate and ac- theory with decades of research and cents. These trends have alarmed the pub- ceptable treatment intervention for Cu- practice at the University of Miami in lic during the past decade and challenged ban youth with behavior problems. To an intensive, short-term, problem- the juvenile justice system. It is widely ac- understand Cuban culture and how it re- focused intervention, generally cepted that increases in delinquency and sembled, and differed from, mainstream lasting 3 months. violence over the past decade are rooted in culture, the Center’s staff conducted a a number of interrelated social problems— comprehensive study on value orienta- The Bulletin also describes the therapy’s implementation by the child abuse and neglect, alcohol and drug tions. The study determined that the abuse, youth conflict and aggression, and Cuban community expected a family- Spanish Family Guidance Center. The Center, which was established early sexual involvement—that may origi- oriented approach in which therapists nate within the family structure. The focus take active, directive, present-oriented by the University of Miami’s School of Medicine, serves the local His- of OJJDP’s Family Strengthening Series is to leadership roles (Szapocznik, Scopetta, provide assistance to ongoing efforts across et al., 1978). panic community, consisting largely the country to strengthen the family unit by of Cuban immigrants. In adapting discussing the effectiveness of family inter- The Center’s second challenge involved brief strategic family therapy to the vention programs and providing resources developing interventions to help recent needs of its clients, the Center took to families and communities. immigrant Hispanic families work to- into account the strengths and weak- gether to deal with the stress of accul- nesses these minority youth and The 1970’s witnessed a tremendous in- turation. In these families, it was quite families bring to therapy, and those crease in the number of Hispanic adoles- common for conflicts to emerge or inten- special risk and protective factors cents involved with drugs. In response to sify when the children or adolescents are also highlighted in these pages. this problem, the University of Miami (FL) began to behave in ways that were not The needs of families are addressed School of Medicine, Department of Psy- consistent with the families’ traditional chiatric and Behavioral Sciences, estab- cultural values. Typically, these conflicts most effectively within the social and cultural milieus of those families. lished the Spanish Family Guidance Cen- occurred as children and adolescents as- ter in Miami to provide services to the similated more rapidly than their parents Brief strategic family therapy is a time-tested approach to that end. local Hispanic community, which was pre- to the bicultural environment in which dominately recent immigrants from Cuba. they were living, and often involved a clash John J. Wilson The Center was initially funded by the between the American value of individual- Acting Administrator U.S. Department of Health, Education, and ism and the Hispanic value of familism. Welfare, Office of Economic Opportunity. Such intergenerational (parent versus adolescent) and cultural differences often yielded intense conflict within the family and resulted in parents and adolescents feeling alienated from one another. In 1975, the Spanish Family Guidance Center adopted structural family therapy (SFT) as its core approach, and SFT has been at the heart of the Center’s efforts to develop interventions for use in culturally diverse contexts (Szapocznik and Kurtines, 1993). Over time, the structural approach of SFT has been refined to meet the needs of the Hispanic community in Miami. For example, SFT uses treatment methods that are both strategic (i.e., problem focused and pragmatic) and time limited. Thus, the structural approach has evolved into a time-limited, family-based approach that combines both structural and strategic interventions. This and cultural/contextual factors that influ- one parent, usually the mother, to come approach, called brief strategic family ence youth behavior problems. BSFT is to the United States alone to establish a therapy (BSFT), has become the most com- based on the fundamental assumption place and economic means for the family, mon intervention used by the Spanish that the family is the “bedrock” of child and then bring the children to this coun- Family Guidance Center for families that development; the family is viewed as the try. For many families, this process is pro- include youth with behavior problems. primary context in which children learn tracted, and they are separated for many BSFT evolved from more than 25 years of to think, feel, and behave. Family rela- years. Moreover, the reunification process research and practice at the University of tions are thus believed to play a pivotal often fails to meet family members’ expec- Miami. The structural orientation of BSFT role in the evolution of behavior problems tations. Children are often disappointed draws on the work of Minuchin (Minuchin, and, consequently, they are a primary tar- when they arrive in the United States and 1974; Minuchin and Fishman, 1981; and get for intervention. see that they are living in an impover- Minuchin, Rosman, and Baker, 1978), and ished, dangerous, inner-city community. BSFT recognizes that the family itself is part the strategic aspects of BSFT are influenced Likewise, parents are often disappointed of a larger social system and—as a child is by Haley (1976) and Madanes (1981). By when they are confronted with angry and influenced by her or his family—the family integrating theory, research findings, and emotionally detached children. As a re- is influenced by the larger social system clinical practice, BSFT has been continu- sult, treatment often involves attempting in which it exists. Sensitivity to contextual ously refined to improve its effectiveness to reestablish parent-child bonds and cre- factors begins with an understanding of with youth with behavior problems. ate new family structures that include the the influence of peers, schools, and neigh- parent who was separated from the family. Since its modest beginning in a small store- borhoods on the development of children’s front location, the Spanish Family Guid- behavior problems. However, BSFT also High conflict. Intense and persistent ance Center has grown in response to the focuses on parents’ relationships with conflict is a common characteristic of needs of the minority community in Mi- children’s peers, schools, and neighbor- families of youth with behavior prob- ami. In particular, work with youth with hoods and on the unique relationships lems. High levels of conflict interfere behavior problems has expanded to in- that parents have with individuals and with parents’ ability to resolve problems, clude minority families from a variety of systems outside the family (e.g., work or communicate effectively, nurture, and backgrounds, including both Hispanic groups such as Alcoholics Anonymous). guide their children. BSFT focuses on (from the Caribbean Islands and Central assessing the family’s conflict resolution and South America) and African American style and developing specific interven- youth and families. To accommodate this Program Objectives tions to help families negotiate and re- expansion, the Center for Family Studies BSFT has been revised to respond to the solve their differences more effectively. was established as an umbrella organiza- unique strengths and weaknesses minor- Inner city. The powerful influence of tion to serve inner-city minority youth ity youth and families in Miami bring to neighborhoods cannot be ignored when and families in Miami. The mission of the therapy. Several of these risk and protec- working with inner-city youth and fami- Center for Family Studies is to identify the tive factors are described below. lies. In fact, accumulating evidence needs of minority families and develop shows that the positive changes made in and refine culturally appropriate interven- Mitigating Risk Factors family therapy are often overwhelmed tions to meet those needs. The Center for Immigration. Many of the families served by the harsh and deteriorated conditions Family Studies uses BSFT to help children by the Spanish Family Guidance Center of the inner city. As a result, the focus of and adolescents with conduct, delin- have recently immigrated to the United BSFT has expanded from individual fami- quency, and other behavior-related prob- States. The immigration process creates lies to include the relationship between lems, including alcohol and substance specific problems that must be addressed families and the multiple systems that in- abuse. To improve youth behavior, BSFT in treatment. For example, many families fluence children. Developments in the attempts to change family interactions emigrate in stages; it is not uncommon for clinical model have been heavily influenced

2 by the theoretical work of Urie Bronfen- BSFT has been implemented as a preven- system’s structure. This view of structure brenner (1977, 1979, 1986) and the tion, early intervention, and intervention is evident in the following assumptions: groundbreaking clinical work of Scott strategy for delinquent and substance- ◆ Structure refers to the repetitive pat- Henggeler and his colleagues (Henggeler abusing adolescents. and Borduin, 1990; Henggeler, Melton, terns of interactions that characterize the family system. and Smith, 1992). In particular, BSFT has expanded to include attention to the rela- Theoretical ◆ Repetitive interactions (i.e., ways fam- tionship between families, on one hand, Underpinnings ily members behave with one another) are either successful or unsuccessful and schools, peers, juvenile justice agen- The goal of BSFT is to improve youth cies, and neighborhoods, on the other. behavior by: in achieving the goals of the family or its individual members. ◆ Enhancing Protective Improving family relationships that ◆ BSFT targets repetitive patterns of in- Factors are presumed to be directly related teraction (i.e., the habitual ways in to youth behavior problems. Extended families. One of the most effec- which family members behave with ◆ tive protective factors is the availability of Improving relationships between the one another) that are directly related strong extended family networks. It is not family and other important systems that to the youth’s behavior problems. uncommon, for example, for treatment to influence the youth (e.g., school, peers). include grandparents, aunts, uncles, cous- To understand the specific way in which Strategy ins, or even close friends (“fictive kin”) who BSFT produces changes in these relation- BSFT believes in a strategic approach that grew up with the child’s parents. Although ships and subsequent changes in behavior uses pragmatic, problem-focused, and these networks may also be sources of problems, it is necessary to understand planned interventions. This strategic ap- problems for the family, they are frequently some of the basic principles on which BSFT proach emerged from an explicit focus on sources of strong support. In BSFT, these is based. developing an intervention that was quick networks are often used to bolster or serve and effective in eliminating symptoms. In the important functions of the family. For Systems BSFT, this strategic approach is evident example, extended family members are in the following assumptions: frequently engaged in treatment to help BSFT assumes that each family has its ◆ monitor the children while parents are at own unique characteristics and proper- Interventions are practical. That is, work. At times, members of the extended ties that emerge and are apparent only interventions are tailored to the unique family or fictive kin assume primary lead- when family members interact. This fam- characteristics of families and are ership roles in the family when parents are ily “system” influences all members of the implemented to achieve attainable unable or unwilling to perform these tasks. family. Thus, the family must be viewed as treatment goals. In most instances, BSFT seeks to strengthen a whole organism rather than merely as ◆ Interventions are problem focused. A social connections by increasing mutual the composite sum of the individuals or problem-focused approach targets first support and decreasing tension and con- groups that compose it. In BSFT, this view those patterns of interactions that most flict between the family and the extended of the family system is evident in the fol- directly influence the youth’s psycho- support network. lowing assumptions: social adjustment and antisocial behav- ◆ iors and targets one problem at a time. Family focus. A second protective factor The family is a system with interde- that has helped minority families in Miami pendent/interrelated parts. ◆ Interventions are well planned, meaning is their strong sense of family unity. High- ◆ The behavior of one family member can that the therapist determines what seem lighting the needs of the family above the only be understood by examining the to be the maladaptive interactions (i.e., needs of individual family members moti- context (i.e., family) in which it occurs. interactions that are directly related to vates many adults to participate in inter- ◆ the youth’s behavior problems), deter- Interventions must be implemented at mines which of these might be targeted, ventions. In fact, the Spanish Family Guid- the family level and must take into ac- ance Center initially selected a family and establishes a plan to help the fam- count the complex relationships within ily develop more effective patterns of approach because of the Cuban (the target the family system. population in the 1970’s) emphasis on fam- interaction. ily values. As the Center reached out to Structure many different Hispanic populations in the Process Versus Content 1980’s and to African Americans in the BSFT also focuses on “structure.” While As noted above, BSFT is primarily con- the concept of a system is useful, one 1990’s, the emphasis on the importance of cerned with identifying and ameliorating families remained consistent. Minority must understand the system’s basic patterns of interaction in the family system structure to recognize the mechanism groups in the United States generally place that are presumed to be directly related to great value on their natural reference group through which it operates. Thus, as behavioral symptoms. This focus on pat- noted above, the existence of a system (e.g., family, extended network, or tribe). terns of interactions is also referred to as a explains how the behaviors of family “process” focus. Rather than focusing sim- members are interdependent. These in- ply on what happens in the family (e.g., Target Population terdependent or linked behavioral inter- what dad said when he yelled at the chil- actions among individuals tend to recur BSFT targets children and adolescents be- dren), BSFT focuses on how interactions tween the ages of 8 and 17 who are display- and create patterns of interactions occur (e.g., who was involved in the con- among family members. In BSFT, these ing or are at risk for developing behavior flict, when it occurred, who responded to problems, including substance abuse. repetitive patterns compose a family whom, what preceded and followed the

3 incident). This important distinction be- A number of specific techniques can be For example, youth interactions at school tween process (patterns of interaction) and used to join the family, including mainte- or with peers and the nature of the neigh- content (specific and concrete information) nance (e.g., supporting the family’s struc- borhood may serve as powerful risk or pro- is a fundamental concept of BSFT. This pro- ture and entering the system by accepting tective factors. In addition, one’s parents, cess focus is evident in the following their rules that regulate behavior), track- extended family, friends, or career may assumptions: ing (e.g., using what the family talks about serve as sources of strength or stress that (content) and how their interactions un- may or may not contribute to the problems ◆ Process refers to what behaviors are fold (process) to enter the family sys- experienced by the youth. involved in an interaction and how tem), and mimesis (e.g., matching the they occur. Secondarily, process refers tempo, mood, and style of family member Restructuring to the message that is communicated interactions). by the nature of interactions or by the As therapists identify what a family’s pat- style of communication, including all terns of interaction are and how these fit that is communicated nonverbally, Diagnosis with individual and social factors, they such as emotion, tone, and the under- In BSFT, diagnosis refers to identifying inter- make judgments about the relationship be- lying power relationship. actional patterns (structure) that allow or tween the family’s pattern of interactions ◆ Content refers to the specific and con- encourage problematic youth behavior. In and the youth’s problem behaviors. Based other words, diagnosis determines how the on these judgments, therapists develop crete facts used in the communication. Content includes such things as the nature and characteristics of family interac- specific plans for changing the family inter- tions (how family members behave with actions and individual and social factors reasons that family members offer for a given interaction. one another) contribute to the family’s that are directly related to the child’s prob- failure to meet its objective of eliminating lem behavior. The ultimate goal of treat- ◆ BSFT is process oriented at all times. youth problems. To derive complex diag- ment plans in BSFT is to change family The emphasis is on identifying the na- noses of the family, therapists carefully ex- interactions that maintain the problems ture of the interactions in the family amine family interactions along five interac- to more effective and adaptive interac- and changing those interactions that tional dimensions (see the table on pages tions that eliminate the problems. BSFT are maladaptive. 6 and 7): structure, resonance, develop- therapists use a range of techniques that mental stage, identified patient, and con- fall within three broad categories: flict resolution. Components of ◆ Working in the present. Intervention Assessment refers to the systematic review ◆ Reframing. There are three intervention compo- of the detailed or molecular aspects of family interaction to identify specific qualities ◆ Working with boundaries and alliances. nents in BSFT: joining, diagnosis, and restructuring. in the patterns of interaction of each family Working in the present. While some types along the five dimensions presented in the of counseling focus on the past, BSFT fo- table. In contrast, clinical formulation refers cuses primarily on the present interactions Joining to the process of integrating the informa- that occur between family members and Individuals from families that include youth tion obtained through assessment into are observable to the therapist. For ex- with behavior problems are very difficult to larger patterns or processes that character- ample, enactments are a critical feature of engage in treatment. For the past 15 years, ize the family’s interactions. In family sys- BSFT. Enactments encourage, help, and/or the Center’s staff have focused explicitly on tems therapy, clinical formulation explains allow family members to behave or interact family resistance and have developed spe- the patient’s presenting symptom in rela- as they would if the therapist were not cialized procedures for engaging families in tionship to the family’s characteristic pat- present. Very frequently, family members treatment. These procedures, which are terns of interaction. For example, a child’s will spontaneously behave in their typical described in more detail below (see “Engag- acting out may be seen as resulting from a way when they fight, interrupt, or criticize ing Hard-To-Reach Families” on page 8), are lack of parental supervision and monitoring one another. Therefore, when families be- based on two fundamental assumptions: that, in turn, are influenced by a poor mari- come rigidly focused on speaking to the tal relationship and disagreement about ◆ Engagement or joining begins from the therapist, the therapist should systemati- parenting practices. very first contact with the family. cally redirect communication to encourage interactions between session participants. ◆ Resistance can be understood in the In addition to the family interactional factors that are central to BSFT, individual and so- same way as any other pattern of There are two reasons for encouraging en- family interaction. cial factors must be considered for a com- actments. The first is to permit the thera- plete clinical formulation. At the individual In BSFT, joining occurs at two levels. First, pist to observe problematic interactions level, psychological factors (e.g., beliefs, atti- directly rather than relying on stories at the individual level, joining involves es- tudes, intelligence, and psychopathology) tablishing a relationship with each partici- about what happens when the therapist and biological factors (e.g., family predispo- is not present. Clinical experience shows pating family member. Second, at the level sition toward alcohol abuse or bipolar dis- of the family, the therapist joins with the that families’ stories about how they inter- order) must be considered when evaluating act are often very different from their ac- family system to create a new therapeutic the impact of family interactions on the tual interactions. system. Joining thus requires both sensi- problems experienced by youth. Moreover, tivity and an ability to respond to the other social systems that the family comes The second reason for enactments, and unique characteristics of individuals and into contact with may have a profound im- a central tenet of BSFT, is that the thera- quickly discern the family’s governing pact on the family, and consequently, must pist is responsible for restructuring (or processes. be considered in the clinical formulation. transforming) interactions. Frequently,

4 interactions are transformed when the changing the patterns of alliance. A common attempts to include the entire family in therapist allows family members to inter- situation of drug-using youth is a strong alli- treatment. In fact, therapists are very active act and then intervenes in the midst of ance with only one parent. The resulting in trying to engage reluctant family mem- these interactions to facilitate the occur- alliance may cross generational lines and bers, particularly during the early phase of rence or emergence of a different, more work against the traditional parental hierar- therapy. The basic philosophy is that thera- positive set of interactions. It is important chy. For example, there may be a strong pists will be able to understand family prob- to remember that in BSFT, therapists are bond between a youth and her or his lems and treat youth behavior problems not interested in having the family simply mother (or mother figure). Whenever the more effectively if they view the family’s “talk about” behaving differently. Rather, youth is punished by the father (or father patterns of interaction directly. they are interested in having the family figure) for inappropriate behavior, the behave differently during and following youth may solicit sympathy and support Although BSFT therapists are active and directive, they never do what the family the intervention sessions. from the “mother” to undermine the “father’s” authority and remove the sanc- members can do for themselves. The Reframing. Perhaps one of the most inter- therapist’s goal is to move in and out of tion. In a single-parent family, it may be the esting, useful, subtle, and powerful tech- grandmother who overprotects the youth family interactions, creating opportunities niques in BSFT is reframing. Reframing in the session that will propel the family’s and undermines the parent’s attempts at creates a different sense of reality; it gives discipline. Shifting of boundaries involves: interactions in a new, more positive direc- family members the opportunity to per- tion. Even in these circumstances, the ceive their interactions or situation from ◆ Creating a more solid bond between therapist moves briefly into a centralized a different perspective. Reframing is a re- the parents so they will make execu- role and quickly moves out of it. Ideally, structuring technique that typically does tive decisions together. when the therapist leaves the system, the not cause the therapist to lose his or her ◆ Removing the inappropriate parent- family will be able to respond positively to rapport with the family. For this reason, child alliance and replacing it with an internal and external challenges. Excep- reframing should be used liberally through- appropriate alliance between both par- tions are allowed when crises occur or out the treatment process, especially at the ents or parent figures and the youth when situations arise that require expert beginning of treatment when the therapist that meets the youth’s needs for sup- intervention (e.g., suicidal thoughts or be- needs to bring about changes but is still in port and nurturance. haviors, family violence/abuse). the process of building a working relation- A fundamental assumption of BSFT is that ship with the family. Reframing serves two extremely important functions. First, it is a Implementation families enter treatment with their own, naturally occurring, informal networks, tool for changing negative and apparently “uncaring” emotions into positive and car- Philosophy including friends, extended family members, schools, and work. BSFT therapists examine ing interactions. This is achieved, for ex- BSFT is based on the assumption that the ample, by redefining anger and frustration these networks to identify potential prob- family—one of the most important and influ- lems or areas of strength on which to capi- as the bonds that tie a family together; the ential systems in the lives of children and therapist may help a parent recognize that talize in therapy. Thus, rather than attempt- adolescents—provides the foundation for ing to hook family members into formal his or her anger toward a child is based child development. As a result, BSFT con- on love. The other important function is systems, like social services, that tend to be ceptualizes and intervenes to change youth transient in nature, BSFT tries to improve to shift from a blaming or castigating ap- behavior problems at the family level. Al- proach to developing a team spirit that al- naturally occurring relationships so the though BSFT also uses unique interventions family is more likely to maintain positive lows family members to acknowledge that to work with individual family members (see changes when the therapist (or social they are in therapy because they care about “One-Person Family Therapy” on page 7), it one another. One major goal of all restructuring interventions is to create the opportunity for the family to behave in construc- tive new ways. That is, when the family is unable to break out of its maladaptive interactions, the therapist’s job is to help the family interact in a new, more positive, way. Working with boundaries and alliances. The lives of youth who use drugs are likely to include a complex set of alliances that require intervention. The alliances between the drug user and other users and sellers need to be severed, and alliances with individuals who can encourage prosocial behaviors need to be established. Boundaries are the social “walls” that exist around groups of people who are allied with one another and that stand between individuals and groups that are not allied with one another. Shifting boundaries refers to

5 Dimensions of Family Functioning* Addressed in Brief Strategic Family Therapy

Structure Resonance

Hierarchy/Leadership Executive Subsystem Enmeshment One parent is more active than the Decisionmaking subsystem is absent. Emotional, psychological, or physical other. Sibling Subsystem boundaries between family members Child is more powerful than the parents. are excessively close. Relationship between siblings is poor Behavior Control (e.g., high conflict or disengagement). Disengagement Parents are not engaging in behavior Triangulation Emotional, psychological, or physical control when needed or are engaging boundaries between family members Child is stuck in the middle of a in ineffective behavior control (e.g., are excessively distant. conflict between adults. inappropriate consequences, lack of followthrough, unclear expectations, Communication inconsistency, or excess emotion). Family lacks direct verbal communica- Guidance/Nurturance tion or uses ineffective communication (e.g., vagueness, sermonizing, or Parents do not nurture children. excess emotion). Parents are poor role models (e.g., One family member serves as a engaged in illegal activity, substance switchboard operator or gatekeeper. abuse, or violence). Spousal Alliance Marital relationship is poor (e.g., high conflict or disengagement).

* Examples of problems in family interaction are listed under each of the five dimensions. services agency) is no longer involved resources (e.g., transportation, money) to specifically designed to ameliorate the with the family. make it to the office. BSFT does not believe acculturation-related stresses confronted that home- or community-based treatment by two-generation immigrant families Length of Treatment is required for all youth with behavior (Szapocznik et al., 1984). problems, but finds that it may be re- BSFT is a short-term, problem-focused in- A clinical trial1 investigated the relative effec- quired for more severe cases. Therapists tervention. The average treatment includes should never allow the location of treat- tiveness of bicultural effectiveness training approximately 12–15 sessions and lasts in comparison with BSFT (Szapocznik, ment (e.g., home, office, schoolyard) to about 3 months. For more severe cases, become an obstacle to treatment. Santisteban, et al., 1986b) in improving be- such as substance-abusing adolescents, the havior problems in early adolescence and average number of sessions and length of family functioning. (Drug-abusing adoles- treatment may be doubled. It is important Development of a cents were excluded from this study because to note, however, that BSFT is not a fixed they were considered beyond the reach of “package.” Treatment continues until the Culturally Specific the intervention.) The results of this study family achieves changes in key behavioral Family Approach indicated that bicultural effectiveness train- criteria rather than until it completes a Applying BSFT to Hispanic families revealed ing was as effective as structural family predetermined number of sessions. how profoundly the process of immigration therapy in improving adolescent and family and acculturation could affect the family functioning. These findings suggested that Location of Treatment and each member. To meet this challenge, bicultural effectiveness training could ac- complish the goals of family therapy while Most BSFT work with children with behav- an intervention was specifically designed to focusing on the cultural content that made ior problems occurs in the office. How- address the special stressors and clinical the therapy attractive to Hispanic families. ever, some treatment of substance-abusing problems faced by this population. adolescents and their families is conducted in the home or community. The Bicultural Effectiveness Family Effectiveness Training movement to “home-based” treatment re- Training Subsequently, BSFT and bicultural effec- sults from many factors; therapists must The Center for Family Studies developed the tiveness training were combined into a deal with families that are highly disorga- bicultural effectiveness training intervention nized and/or unmotivated to attend treat- to enhance bicultural skills in all family mem- ments and families that lack the necessary bers. Bicultural effectiveness training is 1 This study was funded by National Institute of Mental Health (NIMH) grant #MN31226.

6 Developmental Stage Identified Patient Conflict Resolution

Parenting Negativity Denial/Avoidance Parent is immature. Family members are critical about and Family members deny or avoid negative toward the identified patient. conflict. Children Child is treated as/acts too young (e.g., Centrality Diffusion overly restricted, low requirement/ Identified patient is almost always the Family members jump from conflict to opportunity for responsible behavior, central topic of conversation. conflict without achieving any depth or no negotiation allowed). regarding one particular issue. Family members are organized around Child is treated as/acts too old (e.g., the identified patient and her/his Emergence Without Resolution overloaded with adult tasks or exhibits problem behaviors. parentlike behavior). Family engages in an indepth discus- Support sion about a particular conflict but is not able to resolve the problem. Extended Family Family members protect or support Extended family usurps parental power identified patient. Negativity/Conflict or treats the parent like a child. Family interactions are openly critical or hostile.

package called family effectiveness training cultural context that was dominated by therapy without having the whole family (Szapocznik, Santisteban, et al., 1986a). A Cuban immigrants and Caucasian Ameri- present was an important challenge. study2 investigated the value of family cans. However, by the 1990’s, Miami in- effectiveness training as a prevention/ cluded Cuban Americans, Cuban immi- To meet this challenge, it was necessary to question some basic theoretical assump- intervention strategy for Hispanic families grants, Caucasian Americans, Latin of children ages 6–11 who presented emo- Americans from nearly all countries in tions of conventional family systems practice. Family systems theory postulates that tional and behavioral problems (Szapocznik, the Western Hemisphere, African Ameri- Santisteban, et al., 1989). The results of this cans, and Haitian immigrants. In response the youth’s behavior problems are a symptom of flawed patterns of family interaction. study indicated that families in the family to these changes, the bicultural effec- effectiveness training treatment group tiveness training intervention was rede- As such, interventions must change family interactions that produce problem behav- showed significantly greater improvement signed into the multicultural effective- than did control families on measures ness training (Mancilla and Szapocznik, iors in the child. Conventional family systems theorists assume that to change these of family functioning, problem behaviors, 1994) program that helps non-Cuban and child self-concept. Thus, the interven- Hispanic parents understand the com- interactions, the entire family must be present in therapy. Thus, the challenge in- tion was able to improve both child plex cultural context in which they live. and family functioning. The improvements In multicultural effectiveness training, the volved developing an approach, One-Person Family Therapy, that seeks to change family were still in effect at 6-month followup. challenges faced by non-Cuban Hispanic families who find themselves in a culture interactions while working with only one person (Szapocznik, Kurtines, et al., that is heavily influenced by Cuban Ameri- Multicultural Effectiveness 1990; Szapocznik and Kurtines, 1989). Training cans are considered for the first time. One-person family therapy applies the prin- Recently, the cultural context in Miami has ciple of complementarity, which suggests become more complex. When bicultural One-Person Family that a change in the behavior of one family effectiveness training and family effective- Therapy member will lead to corresponding changes ness training were developed in the 1970’s, in the behavior of other family members. the targeted Cuban-born families lived in a Engaging the whole family in treatment is one of the most challenging aspects of One-person family therapy uses this prin- working with youth with behavior problems ciple deliberately and strategically to direct the identified patient to change his or 2 This study was funded by National Institute on Drug and their families. Thus, developing a pro- Abuse (NIDA) grant #1E0702694. cedure that can achieve the goals of family her behavior in ways that will lead to

7 adjustments in the behavior of other family members toward him or her. Figure 1: Differential Engagement and Retention Rates for Strategic A clinical trial3 examined the effectiveness Structural Systems Engagement Experimental Group and of one-person family therapy, comparing Engagement-as-Usual Control Group the entire family format with the one-person 100 format of BSFT (Szapocznik, Kurtines, et al., 1983, 1986). Both conditions were designed to use the BSFT framework so that 80 only the number of people would differ. Results indicated that one-person family 60 therapy was as effective as the group format not only in improving behavior and 40 reducing drug abuse in the youth, but also in improving and maintaining significant improvements in family functioning. 20

The results of this study demonstrated of Families Percentage that it is possible to change family inter- 0 actions even when the whole family is not Engagement Retention present at most sessions. It is important to note, however, that one-person family Strategic Structural Systems Engagement Experimental Group therapy was most effective when it was implemented by expert BSFT therapists. Engagement-as-Usual Control Group To implement one-person family therapy, therapists must be proficient with family and individual BSFT techniques. One- (status quo) which, in the case of drug- To test the effectiveness of strategic struc- person techniques are very complex and abusing youth with behavior problems, can tural systems engagement in engaging and sophisticated and thus require a therapist be accomplished by avoiding therapy. Sec- retaining Hispanic families with drug- with extensive training and experience in ond, while the presenting symptom may be abusing youth in treatment, a major clini- changing family interactions. drug abuse, the initial obstacle to change is cal trial4 was conducted (Szapocznik, resistance to treatment. The same struc- Perez-Vidal, et al., 1988). In this study, tural principles that apply to family strategic structural systems engagement Engaging Hard-To- functioning and treatment also apply to was compared to an engagement-as-usual Reach Families understanding and handling the family’s control condition. Clients in the control resistance to treatment (Szapocznik, condition were approached in a way that Although it is possible to conduct family Perez-Vidal, et al., 1990). The solution to resembled as closely as possible the kind therapy through one person, getting indi- overcoming the undesirable “symptom” of of engagement that usually takes place in viduals to begin treatment continues to be a resistance is to restructure the family’s pat- outpatient centers. There were two basic problem. For example, in the clinical trial terns of interaction that permit the symp- findings from the study (Szapocznik, Perez- discussed above, only 250 of approximately tom of resistance to continue to exist. It is Vidal, et al., 1988). First, as figure 1 shows, 650 families who met intake criteria on the here that one-person family therapy tech- the effects of the experimental condition basis of a telephone screening began the niques become useful because the person were dramatic. More than 57 percent of intake process. Of this number, 145 com- requesting help becomes the person the families in the engagement-as-usual pleted the intake procedure and only 72 through whom therapy can work to im- condition failed to participate in treat- completed treatment. Clearly, a very large prove the family’s pattern of interaction. ment. In contrast, only 7.15 percent (four proportion of families who initially seek Having accomplished the first phase of families) in the strategic structural sys- treatment never participate in therapy. the therapeutic process in which resis- tems engagement condition failed to par- tance has been overcome and the family, ticipate in treatment. The differences in Strategic Structural Systems including the drug-abusing youth, have the retention rates were also dramatic. In Engagement agreed to participate in therapy, the the engagement-as-usual condition, 41 Strategic structural systems engagement therapist may shift the focus of the inter- percent of cases did not complete treat- was developed to more effectively engage vention toward the removal of behavior ment; whereas, in the treatment condition, drug abusers and their families in treatment problems and drug abuse. 17 percent of cases did not complete (Szapocznik, Perez-Vidal, et al., 1990; treatment. Thus, of all cases assigned to Clinical work suggests that the patterns Szapocznik and Kurtines, 1989). It is based therapy, 25 percent in the engagement- of interaction that permitted the symp- on the premise that resistance to change as-usual condition and 77 percent in the toms to exist may be the same patterns within the family results from two systems strategic structural systems engagement of interaction that keep the families from properties. First, the family is a self- condition were successfully completed. entering treatment. Hence, to have the regulatory system—that is, the family will For families that completed treatment in opportunity to intervene in these hard-to- attempt to maintain structural equilibrium both conditions, behavioral improvements reach families, the therapist using strategic structural systems engagement must

begin the intervention with the first phone 4 3 This study was funded by NIDA grant #DA0322. This study was funded by NIDA grant #DA2059. call rather than the first office session.

8 by adolescents were highly significant and widely used clinical interventions. Two the two treatment conditions, with more these improvements were not significantly such studies are described below. than two-thirds of dropouts belonging to different across the engagement conditions. the control group. Second, the two forms The critical distinction between the con- BSFT Versus Individual of therapy were equally effective in reduc- ditions was in the rates of participation Psychodynamic Child ing behavior and emotional problems. and completion. Therapy A third finding demonstrated the greater A second major finding of the project The first study6 compared the effective- effectiveness of BSFT over child therapy in (Szapocznik et al., 1988) was the identifi- ness of a structural family therapy group protecting family integrity in the long term cation of a number of resistant family (Minuchin, 1974; Minuchin and Fishman, (see figure 2). In this study, psychodynamic types and the development of interven- 1981) with an individual child therapy therapy was found to be effective in reduc- tion strategies for engaging these families group and a recreational activity control ing symptoms and improving child psycho- (Szapocznik and Kurtines, 1989). group for children with behavior prob- dynamic functioning, but it was also found lems. In addition, this study investigated to result in undesirable deterioration of Replication Study the mechanisms for change used by each family interactions. The findings supported the BSFT assumption that treating the An additional study5 was designed to repli- type of therapy. Both theoretical ap- whole family is important because it re- cate these findings and to further explore proaches assume underlying causes of duces the symptoms and protects the fam- the elements of effective interventions symptoms and try to eliminate or reduce ily, versus treating just the child, which may (Santisteban et al., 1996). This study, which symptoms. However, each form of therapy cause family interactions to deteriorate. included a large multicultural sample, dem- uses a different approach to reducing onstrated the overall effectiveness of the symptoms. The individual child approach specialized engagement interventions dis- postulates that the child’s internal (i.e., Structural Family Therapy cussed above. Significant differences in emotional, cognitive) functioning needs to Versus Group Counseling be modified to eliminate the symptoms. rates of engagement were found between A second clinical trial compared the effec- BSFT, on the other hand, postulates that the treatment group and the control group. tiveness of BSFT with that of a control family interactions need to be modified In the treatment group, 81 percent of the condition delivered in a group format to eliminate the symptoms. Because of families were successfully brought into (Santisteban et al., 1996). This study also these important theoretical differences, treatment. In contrast, 60 percent of the investigated whether changes in family this study explored the impact of each families assigned to the two control groups functioning were responsible for the form of therapy on child psychodynamic were successfully brought into treatment. changes observed in youth behavior. functioning and family interactions. In addition to investigating the overall effec- Youth who received BSFT showed signifi- The analysis revealed several important tiveness of the specialized engagement cantly greater improvement in behavior findings. First, members of the recreational intervention, the study also investigated (p<.05) than youth assigned to group coun- activity (control) group were significantly the influence of culture/ethnicity on the seling. In fact, youth in BSFT showed signi- more likely to drop out than members of multicultural Hispanic sample. The data ficant improvements in conduct disorder suggested varying rates of engagement and socialized aggression, while youth in across Hispanic groups. Among the non- 6 This study was funded by NIMH grant #DA34821. group counseling did not. Cuban Hispanics (primarily Nicaraguan, but also including Colombian, Puerto Rican, Peruvian, and Mexican) assigned to the Figure 2: Comparison of Family Functioning at Pretest, Posttest, and treatment group, the rate of intervention 1-Year Followup for Youth Assigned to Brief Strategic Family failure was extremely low (3 percent). Fully Therapy, Individual Child Therapy, and Recreational Control 97 percent of the non-Cuban Hispanic families were successfully treated. In contrast, Group among the Cuban Hispanic sample assigned 18 Brief Strategic to the treatment group, the rate of interven- Family Therapy tion failure was relatively high at 36 percent, with 64 percent of the Cuban Hispanic 17 families successfully treated. 16 Control Group Comparing Structural Family Therapy With 15 Individual Child Therapy Other Types of Therapy Earlier research concentrated on the de- Functioning* of Family Level 14 velopment, refinement, and testing of Timepoint BSFT theory and strategies. The next challenge was to compare the relative Note: The three points on each line designate the following events: pretest, posttest, effectiveness of BSFT with that of other and 1-year followup, in that order. *Numbers on this axis reflect the family’s functioning on five dimensions of family interaction. Higher numbers represent healthier, more adaptive family functioning. 5 This study was funded by NIDA grant #DAO5334.

9 A Structural Approach several ongoing ecosystemic prevention Conclusion and intervention projects are being to Changing the Social implemented in schools and neighbor- In the evolution of BSFT, the Center for Fam- Context of Families hoods to address children’s behavior ily Studies has sought to integrate theory, application, and research. The Center’s work As the needs of families change, the problems. In place of a review of each of these programs, one program that exem- began in the 1970’s to address an issue of theoretical and clinical work of the Cen- growing concern: promoting culturally ter for Family Studies continues to plifies the ecosystemic philosophy is described below. competent therapists and therapies to ad- evolve. The Center has expanded and dress behavior and drug abuse problems adjusted its interventions in response to The Family Alliance Project.7 The Fam- among Miami’s Hispanic youth. Since then, declining inner-city social conditions, the ily Alliance Project study is investigat- the Center has achieved important break- multiple problems faced by minority ing the effectiveness of ecosystemic throughs in assessment, engagement, treat- families, and the complex contextual fac- family therapy compared with tradi- ment, and prevention, which have provided tors that affect behavior problems. The tional family therapy and a community a solid foundation from which to pursue new Center is developing a structural ap- control group. The experimental inter- advances in the field. Refinement of struc- proach for changing the social context of vention, structural ecosystems therapy, tural family theory strategies and goals in families that works more effectively with organizes the life context of the drug- BSFT, in turn, enabled the Center to modify minority youth with behavior problems abusing youth using Bronfenbrenner’s these strategies to achieve the same goals and their families. social ecology framework and the theo- without having the entire family in therapy, retical principles of BSFT—that is, pat- thus making one-person family therapy pos- Theoretical Background terns of interaction are examined within sible. Changing family interactions by work- The Center for Family Studies uses and outside the family. Structural eco- ing primarily with one person led to a break- the theoretical work of Bronfenbrenner systems therapy includes a full dose of through in engaging hard-to-reach families (1977, 1979, 1986) and the multisystemic, BSFT (e.g., alliance, hierarchy, communi- in treatment. service-oriented approach of Henggeler and cation flow, personal and subsystem boundaries, developmental stage, iden- The work of the Center for Family Studies colleagues (Henggeler and Borduin, 1990; will help therapists develop new strate- Henggeler, Melton, and Smith, 1992). tified patient, conflict resolution style, and abilities). However, interventions go gies to support minority families. As the Bronfenbrenner examined the complexity needs of families change, work in the field of contexts, especially the relationships beyond the family to target other critical youth interactions. In particular, the needs to continue to evolve to address between various systems that affect an the multiple problems minority families individual. In doing so, he identified and youth’s relationships with school au- thorities and prosocial versus antisocial will continue to confront. The Center oper- defined “microsystems” as those systems ates under the assumption that “it takes a that have direct contact with the individual. peers are examined. At the mesosystem levels, the relationships between par- village to raise a child.” It is necessary For a child, microsystems include the family, both to create a “village,” or community, school, and peers. He defined “mesosys- ents and school, parents and their children’s peers, and parents and the that can support healthy child develop- tems” as those systems that occur when ment and to modify policies and systems microsystems interact. One example of a juvenile justice system are considered. At this mesosystem level, the extent to that provide services to the community. mesosystem occurs when the parents and Bronfenbrenner (1979) wrote, “Seldom is school collaborate on a child’s education. which the different systems support one another, or are in conflict with one an- attention paid to the person’s behavior in Another example of a mesosystem occurs more than one setting or to the way in when parents and peers interact (e.g., when other, is critical. For example, in the parents-peers mesosystem, parents may which relations between settings can af- parents organize and supervise peer activi- fect what happens within them” (p. 18). ties). “Exosystems” are defined as those know the peers, organize supervised peer activities, and know the parents of He suggested that an individual’s environ- systems that affect family members and, ment is composed of a complex set of through their impact on family members, their child’s peers. Parents may participate in community organizations that nested structures. Scientists involved in affect the child. Examples of exosystems intervention must consider the social and are a mother’s workplace or her natural provide organized, supervised peer activities. cultural context in which treated families support network. live. The Center for Family Studies’ devel- Bronfenbrenner’s theory highlights the Results of the interventions suggest that opment of theory, research, and services pivotal role of context in the life of a it is possible to affect youth conduct within the complex community is based child and her or his family members. problems at home and school by correct- on this priority. Moreover, this theory helps to explain ing patterns of interaction in the family how culture influences all other social and school microsystems and the family- contexts and provides a framework for school mesosystem; reducing youth drug References developing culturally sensitive interven- abuse also requires improving inter- Bronfenbrenner, U. 1977. Toward an ex- tions that take into account the complex actions in the peer microsystem and perimental ecology of human develop- influence that cultural factors have on family-peer mesosystem. ment. American Psychologist 32:513–531. minority families. Bronfenbrenner, U. 1979. The Ecology of Most of the current work at the Center 7 This study was originally funded as a treatment de- Human Development. Cambridge, MA: for Family Studies reflects an increasing velopment project by Center for Substance Abuse Harvard University Press. understanding of ecosystemic influences Treatment grant #1 HD7 TI00417; it is currently funded on youth behavior problems. In fact, by NIDA grant #1 RO1 DA10574.

10 Bronfenbrenner, U. 1986. Ecology of the to differential effectiveness. Journal of Szapocznik, J., Rio, A.T., Murray, E.J., family as a context for human develop- Family Psychology 10(1):35–44. Cohen, R., Scopetta, M.A., Rivas-Vasquez, ment: Research perspectives. Develop- A., Hervis, O.E., Posada, V., and Kurtines, Szapocznik, J., and Kurtines, W.M. 1989. mental Psychology 22(6):723–742. W.M. 1989. Structural family versus psy- Breakthroughs in Family Treatment. New chodynamic child therapy for problem- Haley, J. 1976. Problem-Solving Therapy. York, NY: Springer. atic Hispanic boys. Journal of Consulting San Francisco, CA: Jossey-Bass. Szapocznik, J., and Kurtines, W.M. 1993. and Clinical Psychology 57(5):571–578. Henggeler, S.W., and Borduin, C.M. 1990. Family psychology and cultural diversity: Szapocznik, J., Santisteban, D., Kurtines, Family Therapy and Beyond: A Multi- Opportunities for theory, research and W.M., Perez-Vidal, A., and Hervis, O.E. systemic Approach to Treating the Be- application. American Psychologist 1984. Bicultural Effectiveness Training havior Problems of Children and Adoles- 48(4):400–407. (BET): A treatment intervention for en- cents. Pacific Grove, CA: Brooks/Cole. Szapocznik, J., Kurtines, W.M., Foote, F., hancing intercultural adjustment. His- Henggeler, S.W., Melton, G.B., and Smith, Perez-Vidal, A., and Hervis, O.E. 1983. panic Journal of Behavioral Sciences L.A. 1992. Family preservation using Conjoint versus one person family 6(4):317–344. multisystemic therapy: An effective alter- therapy: Some evidence for the effective- Szapocznik, J., Santisteban, D., Rio, A.T., native to incarcerating serious juvenile ness of conducting family therapy through Perez-Vidal, A., and Kurtines, W.M. 1986a. Journal of Consulting and Clini- Journal of Consulting and Clini- offenders. one person. Family Effectiveness Training for Hispanic cal Psychology 60:953–961. cal Psychology 51:889–899. families: Strategic Structural Systems In- Madanes, C. 1981. Strategic Family Szapocznik, J., Kurtines, W.M., Foote, F., tervention for the Prevention of Drug Therapy. San Francisco, CA: Jossey-Bass. Perez-Vidal, A., and Hervis, O.E. 1986. Abuse. In Cross Cultural Training for Men- Conjoint versus one person family tal Health Professionals, edited by H.P. A Mancilla, Y., and Szapocznik, J. 1994. therapy: Further evidence for the effec- Lefley and P.B. Pedersen. Springfield, IL: Manual for a Community Based, Multifam- tiveness of conducting family therapy Charles C. Thomas. ily Strategic Structural Systems Intervention through one person. Journal of Consulting for Strengthening Hispanic Immigrant Fami- Szapocznik, J., Santisteban, D., Rio, A.T., and Clinical Psychology 54:395–397. lies of Behavior Problem Adolescents at Perez-Vidal, A., Kurtines, W.M., and Hervis, Risk for Gang Involvement. Technical Re- Szapocznik, J., Kurtines, W.M., Perez- O.E. 1986b. Bicultural effectiveness training port. Miami, FL: University of Miami, Vidal, A., Hervis, O.E., and Foote, F. 1990. (BET): An intervention modality for families Spanish Family Guidance Center. One person family therapy. In Handbook experiencing intergenerational/intercultural of Brief Psychotherapies, edited by R.A. conflict. Hispanic Journal of Behavioral Families and Family Minuchin, S. 1974. Wells and V.A. Gianetti. New York, NY: Sciences 8(4):303–330. Therapy. Cambridge, MA: Harvard Univer- Plenum, pp. 493–510. sity Press. Szapocznik, J., Santisteban, D., Rio, A.T., Szapocznik, J., Perez-Vidal, A., Brickman, Perez-Vidal, A., and Kurtines, W.M. 1989. Minuchin, S., and Fishman, H.C. 1981. A.L., Foote, F.H., Santisteban, D.A., Hervis, Family effectiveness training: An interven- Family Therapy Techniques. Cambridge, O.E., and Kurtines, W.H. 1988. Engaging tion to prevent problem behaviors in His- MA: Harvard University Press. adolescent drug abusers and their fami- panic adolescents. Hispanic Journal of Be- Minuchin, S., Rosman, B.L., and Baker, L. lies into treatment: A strategic structural havioral Sciences 11:4–27. Journal of Consulting 1978. Psychosomatic Families: Anorexia systems approach. Szapocznik, J., Scopetta, M.A., Aranalde, and Clinical Psychology 56: 552–557. Nervosa in Context. Cambridge, MA: M.A., and Kurtines, W.M. 1978. Cuban Harvard University Press. Szapocznik, J., Perez-Vidal, A., Hervis, value structure: Clinical implications. Santisteban, D.A., Szapocznik, J., Perez- O.E., Brickman, A.L., and Kurtines, W.M. Journal of Consulting and Clinical Psychol- Vidal, A., Kurtines, W.M., Murray, E.J., and 1990. Innovations in Family Therapy: ogy 46(5):961–970. LaPerriere, A. 1996. Engaging behavior Overcoming Resistance to Treatment. problem drug abusing youth and their Handbook of Brief Psychotherapy, edited families into treatment: An investigation by R.A. Wells and V.A. Gianetti. New York, Points of view or opinions expressed in this of the efficacy of specialized engagement NY: Plenum, pp. 93–114. document are those of the authors and do not interventions and factors that contribute necessarily represent the official position or policies of OJJDP or the U.S. Department of Justice. Acknowledgments The Office of Juvenile Justice and Delin- This Bulletin was written by Michael S. Robbins, Ph.D., Research Assistant quency Prevention is a component of the Of- Professor, and José Szapocznik, Ph.D., Professor and Director, Center for Family fice of Justice Programs, which also includes Studies, Affiliation University of Miami School of Medicine, Department of the Bureau of Justice Assistance, the Bureau Psychiatry and Behavioral Sciences. of Justice Statistics, the National Institute of Photograph page 2 copyright © 1999 Artville; photograph page 5 copyright © 1999 Justice, and the Office for Victims of Crime. PhotoDisc, Inc.

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