PRIMARY TECHNIQUES

Over the course of the years structural family therapists have developed and adapted a variety of techniques, to help themselves carry out their function as pre­scribed by the model. They can be clas­sified, according to their main purpose, into (a) those that are primarily used in the formation of the therapeutic system, and (b) the larger group of techniques more directly aimed at provoking disequi­librium and change.

(a) Joining Techniques

Joining is the process of “coupling” that occurs between the therapist and the family, and which leads to the formation of the therapeutic system. In joining, the therapist becomes accepted as such by the family, and remains in that position for the duration of treatment; although the joining process is more evident during the initial phase of therapy, the maintenance of a working relationship to the family is one of the constant features in the thera­pist’s job.

Much of the success in joining depends on the therapist’s ability to listen, his capacity for empathy, his genuine interest in his client? dramas, his sensitivity to feedback. But this does not exclude a need for technique in joining. The therapist’s empathy, for instance, needs to be disci­plined so that it does not hinder his ability to keep a certain distance and to operate in the direction of change. Contrary to a rather common misunderstanding, join­ing is not just the process of being ac­cepted by the family; it is being accepted as a therapist, with a quota of leadership. Sometimes a trainee is described as “good at joining, but not at pushing for change”; in these cases, what in fact hap­pens is that the trainee is not joining well. He is accepted by the family, yes, but at the expense of relinquishing his role and being swallowed by the homeostatic rules of the system. Excessive accommodation is not good joining.

Maintenance is one of the techniques used in joining. The therapist lets himself be organized by the basic rules that regu­late the transactional process in the speci­fic family system. If a four-generation family presents a rigid hierarchical struc­ture, the therapist may find it advisable to approach the great-grandmother first and then to proceed downward. In so doing, the therapist may be resisting his first em­pathic wish—perhaps to rescue the iden­tified patient from verbal abuse—but by respecting the rules of the system he will stand a better chance to generate a thera­peutic impact.

However, in order to avoid total sur­render the therapist needs to perform his maintenance operations in a way that does not leave him powerless; he does not want to follow the family rule that Kathy should be verbally abused whenever somebody remembers one of her misdo­ings. As with any other joining technique, maintenance entails an element of chal­lenge to the system. The therapist can for instance approach the great-grandmother respectfully but he will say: “I am very concerned because I see all of you strug­gling to help, but you are not being help­ful to each other.” While the rule “great-grandma first” is being respected at one level, at a different level the therapist is positioning himself one up in relation to the entire system, including grandmother. He is joining the rules to his own advan­tage.

While maintenance concentrates on process, the technique of tracking consists of an accommodation of the therapist to the content of speech. In tracking, the therapist follows the subjects offered by family members like a needle follows the record groove. This not only enables him to join the family culture, but also to become acquainted with idiosyncratic idioms and metaphors that he will later use to endow his directive statements with additional power—by phrasing them in ways that have a special meaning for the family or for specific members.

At times the therapist will find it neces­sary to establish a closer relation with a certain member, usually one that posi­tions himself or is positioned by the fam­ily in the periphery of the system. This may be done through verbal interventions or through mimesis, a nonverbal response where the therapist adopts the other person’s mood, tone of voice or posture, or imitates his or her behavior -crosses his legs, takes his jacket off, lights a cigarette. In most of the occasions the therapist is not aware of the mimetic gesture itself but only of his disposition to get closer to the mimicked member. In other cases however, mimesis is con­sciously used as a technique: for instance, the therapist wants to join the system via the children and accordingly decides to sit on the floor with them and suck his thumb.

(b) Techniques for Disequilibration

The second, larger group of techniques encompasses all interventions aimed at changing the system. Some of them, like enactment and boundary-making, are pri­marily employed in the creation of a dif­ferent sequence of events, while others like reframing, punctuation~ and unbal­ancing tend to foster a different percep­tion of reality.

Reframing is putting the presenting problem in a perspective that is both dif­ferent from what the family brings and more workable. Typically this involves changing the definition of the original complaint, from a problem of one to a problem of many. In a consultation (Minuchin, 1980) with the family of a 5-year-old girl who is described by her parents as “uncontrollable,” Salvador Minuchin waits silently for a couple of minutes as the girl circles noisily around the room and the mother tries to persuade her to behave, and then he asks the mother: “Is this how you two run your lives together?” If the consultant had asked something like “Is this the way she behaves usually?” he would be confirm­ing the family’s definition of the problem as “located” in the child; by making it a matter of two persons, the consultant is beginning to reframe the problem within a structural perspective.

ln the quoted example the consultant is feeding into the system his own reading of an ongoing transaction. Sometimes a structural family therapist uses informa­tion provided by the family as the build­ing materials for his frame. Minutes later in the same session, the mother com­ments: “But we try to make her do it,” and the father replies “I make her do it.” Minuchin highlights then this brief inter­change by commenting on the differences that the family is presenting: mother can not make her do it, father can. The initial “reality” described just in terms of the girl’s “uncontrollability” begins to be replaced by a more complex version in­v9lving an ineffective mother, an undisci­plined child, and maybe an authoritarian father.

The consultant is reframing in terms of complementarity, a typical variety of the reframing technique, in which any given individual’s behavior is presented as con­tingent on somebody else’s behavior. The daughter’s uncontrollability is related to her mother’s ineffectiveness which is maintained by father’s taking over— which, on the other hand, is triggered by mother’s ineffectiveness in controlling the daughter. Another example of reframing through complementarity is the question “Who makes you feel depressed?” ad­dressed to a man who claims to be “the” problem in the family because of his depression.

As with all other techniques employed in structural family therapy, reframing is based on an underlying attitude on the part of the therapist. He needs to be ac­tively looking for structural patterns if he is going to find them and use them in his own communications with the family. Whether he will read the 5-year-old’s mis­behavior as a function of her own “uncontrollability” or of a complemen­tary pattern, depends on his perspective. Also, his field of observation is so vast that he can not help but be selective in his perception; whether he picks up that “I make her do it” or lets it pass by, unno­ticed amidst the flow of communication, depends on whether his selective attention is focused on structure or not. As with joining, as with unbalancing, reframing requires from the therapist a “set” with­out which the technique can not be mas­tered.

The reframing attitude guides the struc­tural family therapist in his search of structural embeddings for “individual” problems. In one case involving a young drug addict, the therapist took advantage of the sister’s casual reference to the handling of money to focus on the fam­ily’s generosity toward the patient and the infantile position in which he was being kept. In another case, involving a de­pressed adolescent who invariably arrived late at his day treatment program, the therapist’s reframing interventions led to the unveiling of a pattern of overinvolve­ment between mother and son: she was actually substituting for his alarm-clock. In an attempt to help him she instead was preventing him from developing a sense of responsibility.

The intended effect of reframing is to render the situation more workable. Once the problem is redefined in terms of com­plementarity -for instance, the participa­tion of every family member in the thera­peutic effort acquires a special meaning for them. When they are described as mutually contributing to each other’s fail­ures, they are also given the key to the solution. Complementarity is not neces­sarily pathological; it is a fact of life, and it can adopt the form of family members helping each other to change. Within such a frame, the therapist can request from the family members the enactment of alternative transactions.

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Enactment is the actualization of transactional patterns under the control of the therapist. This technique allows the thera­pist to observe how family members mutually regulate their behaviors, and to determine the place of the problem behav­ior within the sequence of transactions. Enactment is also the vehicle through which the therapist introduces disruption in the existent patterns, probing the system’s ability to accommodate to dif­ferent rules and ultimately forcing the ex­perimentation of alternative, more func­tional rules. Change is expected to occur as a result of dealing with the problems, rather than talking about them.

In the case of the uncontrollable girl, the consultant, after having reframed the problem to include mother’s ineffective­ness and father’s hinted authoritarianism, sets up an enactment that will challenge that “reality” and test the family’s possi­bilities of operating according to a dif­ferent set of assumptions. He asks the mother whether she feels comfortable with the situation as it is—the grown ups trying to talk while the two little girls run in circles screaming and demanding every­body’s attention. When mother replies that she feels tense, the therapist invites her to organize the situation in a way that will feel more comfortable, and finishes his request with a “Make it happen” that will be the motto for the following se­quence.

The purpose of this enactment is multi­leveled. At the higher, more ambitious level, the therapist wants to facilitate an experience of success for the mother, and the experience of a successful mother for the rest of the family. But even if mother should fail to “make it happen” the enactment will at least fulfill a lower-level goal: it will provide the therapist with an understanding of the dysfunctional pat­tern and of the more accessible routes to its correction.

In our specific example, the mother begins to voice orders in quick succession, overlapping her own commands and hence handicapping her own chances of being obeyed. The children seem deaf to what she has to say, moving around the room and only sporadically doing what they are being asked to do. The consultant takes special care to highlight those mini-successes, but at the same time he keeps reminding the mother that she wanted something done and “It is not happen­ing—make it happen.” When father, fol­lowing the family rule, attempts to add his authority to mother’s, the consultant blocks his intervention. The goal of the enactment is to see that mother “makes it happen” by herself; for the same reason, the consultant ignores mother’s innumer­able violations to practically every prin­ciple of effective parenting. To correct her, to teach her how to do it would defeat the purpose of the enactment.

The consultant keeps the enactment go­ing on until the mother eventually suc­ceeds in organizing the girls to play by themselves in a corner of the room, and then the adults can resume their talk. The experience can later be used as a lever in challenging the family’s definition of their reality.

If mother had not succeeded, the con­sultant would have had to follow a dif­ferent course—typically one that would take her failure as a starting point for another reframing. Sometimes the struc­tural family therapist organizes an enact­ment with the purpose of helping people to fail. A classical example is provided by the parents of an anorectic patient who undermine each other in their competing efforts to feed her. In this situation the therapist may want to have the parents take turns in implementing their respec­tive tactics and styles, with the agenda that they should both fail and then be reunited in their common defeat and anger toward their daughter—now seen as strong and rebellious rather than weak and hopeless.

Whether it is aimed at success or at fail­ure, enactment is always intended to pro­vide a different experience of reality. The family members’ explanations for their own and each other’s behaviors, their no­tions about their respective positions and functions within the family, their ideas about what their problems are and how they can contribute to a solution, their mutual attitudes are typically brought in-to question by these transactional micro-experiences orchestrated by the therapist.

Enactments may be dramatic, as in an anorectic’s lunch (Rosman, Minuchin & Liebman, 1977, pp. 166—169), or they can be almost unnoticeably launched by the therapist with a simple “Talk to your son about your concerns, I don’t know that he understands your position.” If this re­quest is addressed to a father that tends to talk to his son through his wife, and if mother is kept out of the transaction by the therapist, the structural effects on behavior and perception may be power­ful, even if the ensuing conversation turns out to be dull. The real power of enact­ment does not reside in the emotionality of the situation but rather in the very fact that family members are being directed to behave differently in relation to each other. By prescribing and monitoring transactions the therapist assumes control of a crucial area—the rules that regulate who should interact with whom, about what, when and for how long.

Boundary making is a special case of enactment, in which the therapist defines areas of interaction that he rules open to certain members but closed to others. When Minuchin prevents the husband from “helping” his wife to discipline the girls, he is indicating that such specific transaction is for the mother and daugh­ters to negotiate, and that father has nothing to do at this point; this specific way of making boundaries is also called blocking. Other instances of boundary making consist of prescriptions of phy­sical movements: a son is asked to leave his chair (in between his parents) and go to another chair on the opposite side of the room, so that he is not “caught in the middle”; a grandmother is brought next to the therapist and far from her daughter and granddaughters who have been re­quested to talk; the therapist himself stands up and uses his body to interrupt visual contact between father and son, and so forth.

Boundary making is a restructuring maneuver because it changes the rules of the game. Detouring mechanisms and other conflict avoidance patterns are disrupted by this intervention; under­utilized skills are allowed and even forced to manifest themselves. The mother of the 5 year old is put in the position of ac­complishing something without her hus­band’s help; husband and wife can and must face each other without their son acting as a buffer; mother and daughter continue talking because grandma’s inter­vention, which usually puts a period to their transactions, is now being blocked; father and son can not distract one another through eye contact.

As powerful as the creation of specific events in the session may be, their impact depends to a large extent on how the therapist punctuates those events for the family.

Punctuation is a universal characteristic of human interaction. No transactional event can be described in the same terms by different participants, because their perspectives and emotional involvements are different. A husband will say that he needs to lock himself in the studio to escape his wife’s nagging; she will say that she can not help protesting about his aloofness. They are linked by the same pattern, but when describing it they begin and finish their sentences at different points and with different emphases.

The therapist can put this universal to work for the purposes of therapeutic change. In structural family therapy punctuation is the selective description of a transaction in accordance with the therapist’s goals. In our example of enact­ment, the consultant organized a situation in which the mother was finally suc­cessful, but it was the consultant himself who made the success “final.” Every­body—the mother included—expected at that point that the relative peace achieved would not last, but the consultant has­tened to put a period by declaring the mother successful and moving to a dif­ferent subject before the girls could misbehave again. If he had not done so, if he had kept the situation open, the usual pattern in which the girls demanded mother’s attention and mother became in­competent would have repeated itself and the entire experience would have been labeled a failure. Because of the facts of punctuation, the difference between suc­cess and failure may be no more than 45 seconds and an alert therapist.

Later in the same session the consultant asked the parents to talk without allowing interruptions from their daughter. The specific prescription was that father should make sure that his wife paid atten­tion only to him and not to the girl. Given this context for the enactment, whenever mother was distracted by the girl the therapist could blame father for the fail­ure—a different punctuation from what would have resulted if the consultant had just asked mother to avoid being dis­tracted.

A variety of punctuation is intensity, a technique that consists of emphasizing the importance of a given event in the session or a given message from the therapist, with the purpose of focusing the family’s attention and energy on a designated area. Usually the therapist magnifies something that the family ignores or takes for granted, as another way of challenging the reality of the system. Intensity is achieved sometimes through repetition: one therapist put the same question about 80 times to a patient who had decided to move out of his parents’ home and did not do so: “Why didn’t you move?” Other times the therapist creates intensity through emotionally charged interven­tions (“It is important that you all listen, because your sister can die”), or confron­tation (“What your father did just now is very disrespectful”). In a general sense, the structural family therapist is always monitoring the intensity of the thera­peutic process, so that the level of stress imposed on the system does not become either unbearable or too comfortable.

Unbalancing is a term that could be used to encompass most of the therapist’s activity since the basic strategy that per­meates structural family therapy is to create disequilibrium. In a more restricted sense, however, unbalancing is the tech­nique where the weight of the therapist’s authority is used to break a stalemate by supporting one of the terms in a conflict. Toward the end of the consultation with the family of the “uncontrollable” girl, Minuchin and the couple discuss the wife’s idea that her husband is too harsh on the girls:

Minuchin. Why does she think that you are such a tough person? Because I think she feels that you are very tough, and she needs to be flexible because you are so rigid. I don’t see you at all as rigid, I see you actually quite flex­ible. How is that your wife feels that you are rigid, and not understanding?

Husband:          I don’t .know, a lot of times I lose my temper I guess, right? That’s probably why.

Wife: Yeah.

Minuchin: So what? So does she. I have seen you playing with your daughter here and I think you are soft and flexible, and that you were playing in a rather nice and accepting way. You were not authoritarian, you had ini­tiative, your play engaged her. . . . That is what I saw. So why is that she sees you only as rigid and authoritarian, and she needs to de­fend the little girls from your (punches father’s knee)? I don’t see you that way at all.

Husband: I don’t know, like I say, the only thing I can think of, really, is because I lose my temper with them.

Wife: Yes, he does have a short fuse.

Minuchin: So what? So do you.

Wife: No, I don’t.

Minuchin: Oh you don’t. Okay, but that doesn’t mean that you are authoritarian, and that doesn’t mean that you are not under­standing. Your play with your daughter here was full with warmth and you entered very nicely, and as a matter of fact she enjoyed the way in which you entered to play. So, some way or other your wife has a strange image of you and your ability to understand and be flexible. Can you talk with her, how is that she sees that she needs to be supportive and de­fending of your daughter? I think she is protecting the girls from your short fuse, or something like that. Talk with her about that, because I think she is wrong.

Wife: That’s basically what it is, I’m afraid of you really losing your temper on them, because I know how bad it is, and they are lit­tle, and if you really hit them with a temper you could really hurt them; and I don’t want that, so that’s why I go the other way, to show them that everybody in the house doesn’t have that short fuse.

Husband. Yes, but I think when you do that, that just makes it a little worse because that makes her think that she has somebody backing her, you know what I mean?

Minuchin (shakes husband’s hand): This is very clever, and this is absolutely correct, and I think that you should say it again because your wife does not understand that point.

In this sequence the consultant un­balances the couple through his support of the husband. His focus organizes him to disregard the wife’s reasons, which may seem unfair at first sight. But it is in the nature of unbalancing to be unfair. The therapist unbalances when he needs to punctuate reality in terms of right and wrong, victim and villain, actor and reac­tor, in spite of his knowing that all the comings and goings in the family are regu­lated by homeostasis, and that each per­son obliges with his and her own contribu­tion; because the therapist also knows that an equitable distribution of guilt’s and errors would only confirm the existing equilibrium and neutralize change poten­tialities.

While unbalancing is admittedly and necessarily unfair, it is not arbitrary. Diagnostic considerations dictate the direction of the unbalancing. In the case of our example, the consultant chooses to support the husband rather than the wife because in so doing he is challenging a myth that both spouses share: initially the husband agrees to his wife’s depiction of him, and it is only through the intensity of the consultant’s message that he begins to challenge it. At different points in the same session, the consultant supports the wife as a competent mother and questions the idea of her unremitting inefficiency—

again, a myth defended not only by her husband but by herself as well. In the last analysis unbalancing—like the entire structural approach—is a challenge to the system rather than an attack on any member.