Introduction

Structural Family Therapy is a method for understanding and treating behavioral problems within the context of the family. Its characteristic features are an emphasis on interactional context as the organizer of individual behaviors, the central role assigned to the family as the protagonist of therapy, and the reliance on “making change happen” in the therapy room.

Prominent Associated Figures

SFT is the brainchild of Dr. Salvador Minuchin. He recognized Braulio Montalvo as his “most influential teacher” (Minuchin 1974, p. iv). Other authors associated with the model are Harry Aponte, Jorge Colapinto, Charles Fishman, Jay Lappin, Patricia Minuchin, Michael Nichols, George Simon, and Wai-Yung lee.

Theoretical Framework

Core Concepts

Structural Family Therapy poses that individual behaviors are shaped by the relational context within which they occur. If a father screams at her son, the structural therapist wants to know what is happening between and around them. What is the father screaming about? What is the son doing before the screaming? How does he respond? Does the screaming bring father and son closer or more distant from each other? Are there other people present – a mother, a grandmother, a social worker? Do they participate, and how? Do father and son relate differently when in other situations?

The model’s emphasis on context goes hand in hand with its conceptualization of the individual self as multifaceted. In the example above, a structural therapist would not try to assess what the father “is” (an angry or violent person), but what are his various ways of being – with his son, with his wife, with his parents. He may be angry at home, but a team player in his job. Similarly, his wife may seem weak in his presence, but be an effective leader of the children when he is not.

Complementarity designates the concordance of behaviors and roles between family members. The screaming father and his cowering son fit each other, like pieces in a puzzle: the more the father screams, the more the child cowers – and vice versa. Other examples of complementarity are the dominant and the submissive spouses, the pursuer and the evader, the protector and the protected.

Coupled with the concept of a diversified self, the notion of complementarity questions the fixedness of individual behaviors. The father who screams at his son may be seen by others and even himself as primitive and incapable of self-control, but a structural therapist may note that those traits are sustained and reinforced by the son who cowers and the mother who tries to put some distance between the two males. The therapist can then count on the father’s latent capacity for flexibility and softness, attributes that may have no place within the established relational patterns but may surface if those patterns shift.

In describing family patterns, the model focuses on two relational dimensions: horizontal (closeness/distance among family members) and vertical (the family’s hierarchical arrangement). The horizontal dimension identifies which members are close to each other, and which are more distant; who are included in what situations, and who are left out. For example, if a wife criticizes her husband’s habits at the table and he defends himself, their daughter may or not intervene with her opinions in the discussion. If she does, the distance between her and the parents is shorter than if she does not; in the terminology of the model, the boundary around the spouse subsystem is weak.

Subsystems are groupings of family members defined by gender, generation, common interests, or functions. They partially overlap: a husband and wife form the spouse subsystem, whose function is to provide mutual support, and are also part of the parental subsystem, which includes the children and is organized around issues of nurturance, guidance, and discipline. Within the sibling subsystem, children learn to make friends, handle conflict, and provide and receive support.

A boundary can be depicted as a line that encircles two or more family members and differentiates them from the rest, making it possible for them to self-regulate their relationship. In the example above, the girl’s intervention in the conflict between the spouses prevent them from solving that conflict on their own. In another example, a boy is engaged in disruptive behavior that the mother unsuccessfully tries to stop, until the father intervenes with a stern admonition and the boy ceases his disruptive behavior. At first glance, the father appears to be supporting his wife. From a structural perspective, however, he is entering a territory that belongs to the mother and son, interfering with the development of their own relationship.

While boundaries should be firm enough to make room for the members of a subsystem to negotiate their relationship autonomously, they also need to be flexible enough to allow for participation of the subsystem members in other subsystems. If mother and son are closely knit together, drawing a rigid boundary around them, and the father is relegated to a peripheral position, both the spouses subsystem and the father-son subsystem remain underdeveloped.

When two family members – for instance a parent and child – are excessively close to each other, they are considered over involved. If on the other hand, they are too distant from each other, they are under involved. A family is said to be enmeshed when all its members are over involved with each other, and disengaged when under involvement is generalized. Enmeshed families are characterized by high mutual reactivity, loyalty expectations, and lack of individual autonomy. Disengaged families exhibit low mutual reactivity, excessive tolerance of deviant behavior, and lack of mutual support.

The concept of hierarchy refers to the vertical organization of the family – the differential of power among its members. In well-functioning families, the parents initially occupy a higher position than the children – not as arbitrary authoritarians but as providers of nurturance, protection, and guidance and protection. As children grow and their need for parental leadership decreases, the hierarchical differential between parents and children should also decrease.

Families can function with a variety of hierarchical arrangements. For instance, an older child in a single parent family may function in a parental capacity, provided there is a clear delineation of responsibilities and the child is not constantly promoted and demoted in the hierarchy.

Behavioral problems in children are often associated with dysfunctional hierarchical arrangements. These include flat hierarchies, where children hold the same power as the parents; reversed hierarchies, where children are in charge; and excessively rigid hierarchies, which do not make room for the children’s emotional growth and autonomy. A particular kind of hierarchical dysfunction is the cross-generational coalition, for instance, a parent allied with a child in opposition to the other parent. Cross-generational coalitions play a stabilizing role in families where adults cannot resolve their conflicts, Spouses avoid confronting each other directly by recruiting children as allies; for instance, a mother and daughter join in opposition to the husband/father, while he supports their coalition by adopting the stance of the common enemy. In families with a single parent, the cross-generational coalition may include another relative, for instance a grandparent, who joins the grandchild in criticizing the parent.

Theory of Change

The relational structure of a family is the result of “years of explicit and implicit negotiations among family members, often around small daily events” (Minuchin 1974, p. 52.). To explain how family patterns originate, are maintained, and eventually change, Structural Family Therapy resorts to the complementary notions of homeostasis and adaptation. On the one hand the family needs to maintain some kind of internal organization that prescribes how its members must relate to each other. These transactional rules restrict individual freedoms: for instance, family members must accept some degree of interdependency (e.g., between spouses) and some form of hierarchy (e.g., between parents and children). On the other hand, transactional rules need to change over time, to adapt to the demands posed by the changing needs of their developing members, and by idiosyncratic external events such as a move to another city, changed financial circumstances, or illnesses. Well-functioning families are not defined by the absence of stress and conflict but by their capacity to respond to them in ways that do not interfere with the well-being and growth of its members or with the family’s fluent interaction with its social milieu. These families succeed in maintaining their identity as such while allowing their members to differentiate.

Conversely, families become dysfunctional when they persevere in maintaining relational patterns that are no longer adaptive; for instance, a family with adolescent children continues functioning as it did when the children were younger; or a widowed father and his daughter continue to have the same distant relationship as when the mother was alive. Dysfunctional structures tend to perseverate: it is difficult for the family members to risk abandoning their respective roles – the “ineffective mother,” the “authoritarian father,” the “rebellious child,” – because the arrangement represents the best point of equilibrium that the family has been able to achieve. A therapeutic intervention is then needed, to help the family members deconstruct the patterns that imprison them and mobilize their capacity to develop healthier patterns.

In Structural Family Therapy, individual behaviors and internal experiences improve as a result of better relational patterns, rather than the other way around. It is not necessary for the “inefficient” mother to work through the historical roots of her low self-esteem before she can be and feel competent as a parent; if the “authoritarian” husband ceases interfering in her relationship with their son, she can actualize her latent competency.

Rationale for the Model

Like the individuals and families that it endeavors to serve, Structural Family Therapy was shaped by the contexts where it developed. In the early 1960s, Salvador Minuchin set up a family-oriented treatment program at the Wiltwyck School for Boys, a correctional facility located in upstate New York and serving young delinquents. The typical client was “the ghetto-living, urban, minority group member who is experiencing poverty, discrimination, fear, crowdedness, and street living” (Minuchin et al. 1967, p. 22). Improvements achieved during the youngsters’ stay at the institution tended to dissipate when they returned to their families. On the other hand, families from the same neighborhoods that did not have delinquent children showed more stable, consistent, and predictable interactions and were more connected to others. The observation that families contribute to organize (or disorganize) the behavior of their members justified a therapeutic approach aimed at families rather than isolated individuals.

The Wiltwick experience also provided the initial rationale for relying on action as the main vehicle for therapeutic change. Verbal, insight-oriented treatments did not fit the concrete and action-oriented style of the clients’ families. Role playing, in-home treatments and other nontraditional, “more doing than talking” approaches served as models for the development of alternative techniques.

For instance, in one family session a therapist found himself under heavy attack. He then changed his seat and sat among the family members. Pointing to the empty chair, he said, “It was very difficult to be there being attacked by you. It makes me feel left out.” The therapist might have described in words alone that he felt left out of the family; instead, he changed his seat to be among the family members and then commented on his feelings. He sensed that although his verbal statement would pass unnoticed by all but the most verbal members of the family, his “movement language” would be attended to by everyone. (Minuchin et al. 1967, p. 247)

In 1965, Minuchin left Wiltwyck to assume the directorship of the Philadelphia Child Guidance Clinic. Serving a heterogeneous urban population, the facility made Structural Family Therapy available to a wider spectrum of families and problems. The Clinic’s association with a children’s hospital provided a context for the application of the structural approach to the treatment of psychosomatic conditions including asthma, diabetes, and anorexia (Minuchin et al. 1978). Unlike the disorganized and unstable families of Wiltwyck, families with psychosomatic children tended to be too rigidly organized and too stable. In therapy, it was necessary to deconstruct the family’s patterns, to allow for greater flexibility. Action techniques, originally adopted in Wiltwyck to facilitate communication with “nonverbal” clients, were now used to challenge clients who talked too much. Thus Structural Family Therapy moved further away from the classical conception of therapy as a reflective, calm endeavor, protected from the untidiness of everyday relational life, and towards a more committed practice, where the therapist actively participated in the family drama, raising the emotional temperature as necessary to facilitate the transformation of established interactional patterns.

Populations in Focus

During the initial Wiltwyck years, Structural Family Therapy was utilized in the treatment of delinquent children from economically deprived areas. The move to the Philadelphia Child Guidance Clinic made it possible to apply the model to the treatment of children and families presenting a wide range of problems and coming from various socioeconomic backgrounds.

In the mid-1980s, Minuchin left the Philadelphia clinic and founded the Family Studies Institute in New York, from where he endeavored to apply the structural paradigm to the work with the larger systems that impact the lives of low-income families. The key structural notions of boundaries, coalitions, and conflict resolution were put to the task of changing the relationship between families and agencies, so that the families could retrieve their autonomy and resume responsibility for the well-being of their children (Minuchin et al. 2007).

Strategies and Techniques Used in Model

In Structural Family Therapy the family is not a mere recipient of the treatment but the main protagonist – its own change agent. Regardless of how much or little responsibility it has for creating the problem, the family is seen as possessing the keys to the solutions. The job of the structural therapist is to catalyze change, by helping family members utilize their “hidden strengths” to change each other. He or she

confirms family members and encourages them to experiment with behavior that has previously been constrained by the family system. As new possibilities emerge, the family organism becomes more complex and develops more acceptable alternatives for problem solving. (Minuchin and Fishman 1981, p. 16)

Structural therapists engage in three kinds of activities: joining, assessment, and restructuring.

Joining designates the activities of the structural therapist oriented to gaining acceptance from the family as a temporary member. Those activities include simple rules of etiquette, such as establishing contact with all family members, as well as more deliberate interventions, such as recognizing feelings of concern, sadness, anger, fear, or even rejection of therapy.

More than a technique, joining is a stance maintained throughout the treatment.

Joining is letting the family know that the therapist understands them and works with them and for them. Only under this protection can the family have the security to explore alternatives, try the unusual, and change. Joining is the glue that holds the therapeutic system together. (Minuchin and Fishman 1981, pp. 31–32)

To assess the family, structural family therapists rely on family maps and tracking. The first draft of a family map may be drawn on the basis of the referral information. Who live in the household? What are their genders and ages? How are they related to each other? This gives the therapist a basic sense of the “shape” of the family: “multigenerational,” “blended,” “single parent,” “one-child.” The referral information may also include data on the larger system: individuals and organizations that are relevant for the family, such as extended family, school, church, child protection agency.

More detailed information about the nature of the relationships among family members is obtained when the therapist has the opportunity to observe the family in action.

The family map indicates the position of family members vis-à-vis one another. It reveals coalitions, affiliations, explicit and implicit conflicts, and the ways family members group themselves in conflict resolution. It identifies family members who operate as detourers of conflict, and family members who function as switchboards. The map charts the nurturers, healers, and scapegoaters. Its delineation of the boundaries between subsystems indicates what movement there is and suggests possible areas of strength or dysfunction. (Minuchin and Fishman 1981, p. 69)

Structural therapists use symbols to represent these different relations in the family map. For instance:

figure bfigure b

The primary tool for creating a map of family interaction is tracking, an operation comparable to the action of a phonograph needle following the groove of a disc. As the structural therapist listens to and observes the family, he or she pays attention to the interaction process, rather than the verbal content: “When a family member is talking, the therapist notices who interrupts or completes information, who supplies confirmation, and who helps” (Minuchin and Fishman 1981, p. 146).

Tracking interactions in the therapy room is complemented with an inquiry about events at home, the “there-and-now.” For instance, if a child is not going to school, the therapist may explore how does that happen: Who or what wakes him up in the morning? Who does or does not do something when he stays in bed? Is there a struggle? When do the parents finally accept that the child is not going to school that day? What does the child do when he stays home, and how do the parents respond to that? What time did the child go to bed the night before, and if it was late, what was he doing instead of going to sleep, and how did the parents respond then?

Structural family therapists are not interested just on descriptions of how problems occur. They also look for strengths that family members may possess but not recognize as such. A mother expresses frustration about her daughters: “I’ve always had a problem with them. I even had them separated for a while. Ruby is more introverted than Miranda. Miranda is outgoing and tomboyish. She used to be very tomboyish. Ruby used to be more domesticated and always playing with tea cups and dolls and everything, but she’s been with the boys longer. And Miranda stays to herself a lot more than she used to.” The therapist reflects: “The mother’s description is highly differentiated; she is clearly a sensitive person who is observant of the children’s individual developmental processes” (Minuchin and Fishman 1981, p. 106).

Structural family therapists are not neutral observers; they aim to restructure the family’s relational patterns by challenging family members to expand their experience of each other and the ways in which they interact with each other.

The first challenge is to the family’s perception of their reality. While the family may look at the problem as located in one individual, the structural therapist highlights the complementary fit between family members’ behaviors. If a girl labeled as hyperactive is running around the room while her mother begs her to sit down, the therapist may ask the mother, “Is that how the two of you spend your time together?” If the father then succeeds in quieting the girl, the therapist may note that she is more or less hyperactive depending on who she is interacting with. Asking questions like “Is this how you and your father talk about your drug use?” or “When you criticize your wife for being too lenient with the children, does that make her more assertive?” relocate problems in relationships, rather than on specific individuals.

The main technique utilized by structural family therapists to elicit changes in problematic relationships is the enactment, where the therapist asks family members to interact differently from how they usually do. The therapist does not prescribe specific behaviors, but rather operates as a play director or stage manager, assigning topics (“Tell your husband what worries you about his treatment of your son”), and asking family members to physically change their positions (“Sit facing each other”) and their stances (“Talk to your brother as his sister, not as his nurse”). If a mother appears unable to quiet her hyperactive daughter, the therapist neither models how to manage the girl nor gives the mother parenting skills tips; instead, the therapist may give the mother the task of playing with the girls, or organizing them to play by themselves so that the mother and therapist can talk.

Once the enactment is set up, the therapist abstains from intervening unless it becomes necessary, for instance when participants appear to have reached a dead end (“Keep trying to convince your mother, don’t take her first “no” for an answer”), veer off track (“You are again apologizing to each other, go back to discuss how to make sure that your daughter stays in school tomorrow”), or a violation of boundaries occurs (“I know you want to help your husband and son communicate, but let them find their own way.”). Depending on the outcome of the enactment, the therapist can comment on how the family members were able to get through to each other, or what they are doing that keeps them stuck.

The purpose of an enactment is not necessarily to solve a problem but to provide family members with the experience of a better relationship. New relational patterns need to be experienced repeatedly until they hold; each successful enactment contributes to the expansion of the family’s repertoire, showing that change is possible and what it may look like.

Research about the Model

Research on Structural Family Therapy has been conducted in the areas of juvenile delinquency (Minuchin et al. 1967), psychosomatics (Minuchin et al. 1978), and substance abuse (Stanton and Todd 1982). Structural theory on the family and on the process of therapy also inform Brief Strategic Family Therapy (Szapocznik et al. 2012), an evidence based intervention for the reduction of adolescent risk behavior.

Case Example

Fourteen-year-old Jessica had been repeatedly suspended from school due to her fighting with schoolmates and disrespect of her teachers. Jessica lived with her mother, Barbara; her stepfather, Anthony; and 16-year-old sister, Angela.

Barbara, Anthony, and Jessica attended the first therapy session. Mother and daughter shared a sofa, while Anthony took a chair next to the therapist. Jessica claimed that it was the other girls who started the fights, and then the teachers picked on her. Barbara agreed and reported that she had complained to the teachers and the principal about what she saw as unfair treatment of her daughter. Anthony said that he did not think that the problem was the teachers and schoolmates, and that he and Barbara disagreed on how to raise the children. Barbara confirmed this and added that since her ex-husband left, when Jessica was 5 years old, she has always relied on her church community for guidance.

The therapist learned that Jessica’s biological father currently lived in another state and only talked to his daughters occasionally. He was also told that Jessica and Angela often quarreled with each other. In drawing the family’s map, the therapist attention was attracted primarily to two triangles where Jessica was involved. One was her relationship with her mother (close) mother and stepfather (distant), and the other was the conflictive relationship that both she and her mother had with the school.

figure cfigure c

Angela joined the rest of the family for the next session. The three women sat together on one side of the room and Anthony again took the chair next to the therapist. From there, Anthony criticized Barbara’s parenting of Jessica (“She is too soft on her.”). Barbara responded “I am her mother,” and Jessica said to Anthony “You are not my father.”

The therapist asked Anthony and the girls to switch positions, then directed Barbara and Anthony to discuss their differences about parenting and instructed the girls to observe but not participate. Anthony complained that he was not allowed “to be a father to the girls.” Barbara replied that Anthony was “more interested in other things than in playing the father role”; Jessica nodded.

Therapist (to Jessica): Do you know what your mother means by “other things”?

Jessica: Anthony has another woman.

Therapist: How do you know?

Jessica: My mom told me.

Barbara: No, that’s not it. It’s that Anthony still spends a lot of time talking to his ex.

Therapist: We can talk about this later, with just the two of you (points at Barbara and Anthony). Right now I am curious about how it came to happen that Jessica knows so much about your life.

Barbara explained that when her ex-husband left, Jessica clangs to her while Angela turned more to her friends. She remembers that when Anthony moved in 5 years ago, Angela “didn’t care much” while Jessica was upset, so Barbara did not try to impose Anthony on the girls. “To protect the girls’s feelings, or to protect your relationship with Anthony?” the therapist asked. “Both,” replied Barbara.

The therapist asked Barbara if it was okay for Anthony and Jessica to talk about her relationship with the teachers, right now in the session. Although looking skeptical, Barbara agreed. Anthony then began lecturing Jessica about the importance of education, while Jessica looked bored. After a quick glance at Barbara, Jessica said to Anthony: “You expect too much from me.” Anthony threw up his arms-, “I give up.” The therapist challenged Anthony: if he gave up, he could not claim that Barbara was impeding his relationship with Jessica. Barbara said that Anthony had been comfortable with the arrangement because “he is really not that committed to us.” Responding to this new reference to conflict in the couple, the therapist asked to meet with Barbara and Anthony alone.

It came up that Anthony spent time on the phone with an ex-girlfriend, who according to Anthony was still a friend and was going through rough times. Barbara said she did not suspect Anthony of cheating, but his ongoing relationship with the ex-girlfriend was a sign of lack of commitment that made her even more hesitant about letting Anthony play a “father’s role” with the girls. Anthony countered that Barbara seemed more involved with her church than with him. They argued back and forth until the therapist interrupted to point out that while their conflict was important, Jessica’s problems could not wait for them to resolve it. She needed their guidance now.

The next few sessions were dedicated to working on Jessica’s relationships with peers and teachers. The family members took turns pairing up to discuss the relational challenges that Jessica was facing and possible solutions: sometimes Jessica and one of the parents talked while the other parent and Angela observed; other times the sisters observed the parents agreeing or disagreeing on how Jessica could respond to provocations from schoolmates or to teachers’ demands. At the sisters’ request, they met without the parents so they could talk “in private” about peer relationships. The therapist supported this enforcement of the sibling subsystem’s boundaries, and let the girls decide what parts of their conversation they would feel comfortable sharing with the parents. The family was also given “homework”: at least twice a week Jessica was to discuss specific situations at school with a family member of her choice – not the same family member every time.

Regarding the alliance of Barbara and Jessica against the school, the therapist insisted on the need to change the relationship between the mother and the school, from one of confrontation to one of collaboration. When Barbara objected (“I don’t trust the school, I still feel they are unfair to Jessica”), Anthony countered “But we need their help,” and Angela noted: “It doesn’t help us when you fight the school.” Eventually Barbara accepted some coaching from Anthony and even from the girls about how to be more “diplomatic” with the teachers and the principal.

Two months into the treatment, there had been no more suspensions or complaints from the teachers about Jessica, or from Jessica about the teachers. Jessica also stopped fighting with her schoolmates; however, she had accomplished this by isolating herself from them. The rest of the treatment focused on helping Jessica make friends. Angela played an important role in this endeavor, and Barbara and Anthony collaborated by encouraging Jessica to invite children to their home. The more Jessica became involved with her own friends, the less she quarreled with Angela.

Although the couple conflict was never addressed directly, their relationship became stronger as Anthony increasingly took the role of caretaker, and not just Barbara’s partner. He took more distance from his former girlfriend. Barbara continued her involvement with the church community, but she “took the parenting stuff out of it.”

Cross-References