Structural Family Therapy
DEFINITION
Structural family therapy is a model
of treatment based on systems theory that was developed primarily at the Philadelphia Child Guidance Clinic, under the leadership of Salvador
Minuchin, over the last 15 years. The model’s distinctive features are its emphasis on structural change as the main goal of therapy, which acquires preeminence over the details of individual change, and
the attention paid to the therapist as
an active agent in the process of restructuring the family.
HISTORICAL DEVELOPMENT
Structural family therapy was
the child of necessity, or so the
student may conclude in tracing the origins of the movement back to the early l960s, to the time when Salvador Minuchin was doing therapy, training, and research at the Wiltwyck School for Boys in New York. Admittedly, our historical account does not need to start precisely there, but the development of a
treatment model—no less than the development of an individual or a family—can only be told by introducing a
certain punctuation and
discarding alternative ones.
It would be possible to choose a more distant
point in time and focus on Minuchin’s experience in the newborn Israel,
where families from all over the world
converged carrying their
bits of common purpose and their lots of regional
idiosyncrasies, and found a unique opportunity
to live the combination of cultural universals
and cultural specifics. Or, reaching
further back, one could think of Minuchin’s
childhood as the son of a Jewish
family in the rural Argentina of
the 1920s, and wonder about the influence of this early exposure to alternative
cultures— different rules, different
truths—on his conception of human
nature. Any of these periods in the life of the creator of structural
family therapy could be justified as a starting point for an account
of his creation. The experiences provided
by both are congruent with
philosophical viewpoints deeply rooted in the architecture of the model; for instance, that we are more human than otherwise,
that we share a common range of potentialities which each of us displays differentially as a function
of his or her specific context.
But the Wiltwyck experience stands out as a powerful
catalyst of conceptual production because of a peculiar combination of circumstances.
First of all, the population at Wiltwyck consisted of delinquent boys from
disorganized, multi-problem, poor families. Traditional psychotherapeutic
techniques, largely developed to fulfill the demands of verbally articulate,
middle-class patients besieged by intrapsychic conflicts, did not appear to
have a significant impact on these youngsters. Improvements achieved
through the use of these and other techniques in the residential setting of
the school tended to disappear as soon as the child returned to his family
(Minuchin, 1961). The serious concerns associated with delinquency, both from
the point of view of society and of the delinquent individual himself, necessarily
stimulated the quest for alternative approaches.
The
second circumstance was the timing of the Wiltwyck experience: it coincided
with the consolidation of an idea that emerged in the 1950s—the idea of
changing families as a therapeutic enterprise (Haley, 1971). By the early 60s,
family therapy thinking had become persuasive enough to catch the eye of Minuchin
and his colleagues in their anxious search for more effective ways of dealing
with juvenile delinquency. Finally a third fortunate circumstance was the
presence at Wiltwyck of Braulio Montalvo, whom Minuchin would later recognize
as his most influential teacher (Minuchin, 1974, p.vii).
The enthusiastic group shifted the focus of attention from the
intrapsychic world of the delinquent adolescent to the dynamic patterns of the
family. Special techniques for the diagnosis and treatment of low
socioeconomic families were developed (Minuchin & Montalvo, 1966, 1967),
as well as some of the concepts that would become cornerstones in the model exposed
a decade later.
Approaching delinquency as a family issue proved more helpful than
defining it as a problem of the individual; but it should not be inferred that Minuchin
and his collaborators discovered the panacea for juvenile delinquency. Rather,
they experienced the limitations of therapeutic power, the fact that
psychotherapy does not have the answers to poverty and other social problems
(Malcolm, 1978, p. 70).
Nowadays
Families of the Slums (Minuchin, Montalvo, Guerney, Rosman &
Schumer, 1967), the book that summarizes the experience at Wiltwyck, will more
likely be found in the Sociology section of the bookstore than in the Psychotherapy
section. But the modalities of intervention developed at Wiltwyck, and even
the awareness of the limitations of therapy brought about by their application,
have served as an inspirational paradigm for others. Harry Aponte, a disciple
of Minuchin, has worked on the concept of bringing organization to the underorganized
family through the mobilization of family and network resources (Aponte, 1976b).
From
the point of view of the historical development of Minuchin’s model, the major
contribution of Wiltwyck has been the provision of a nurturing and stimulating.
environment. The model spent its childhood in an atmosphere of permissiveness,
with little risk of being crushed by conventional criticism. Looking retrospectively,
Minuchin acknowledges that working in “a no man’s land of poor families,”
inaccessible to traditional forms of psychotherapy~ guaranteed the tolerance of
the psychiatric establishment—which had not accepted Nathan Ackerman’s approach
to middle-class families (Malcolm, 1978, p. 84).
The
possibility to test the model with a wider cross-section of families came in
1965, when Minuchin was appointed Director of the Philadelphia Child Guidance
Clinic. The facility was at the time struggling to emerge from a severe institutional
crisis—and, as Minuchin himself likes to remind us, the Chinese ideogram for
“crisis” is made of “danger” and “opportunity.” In this case the opportunity
was there to implement a systemic approach in the treatment of a wide variety
of mental health problems, and also to attract other system thinkers to a
promising new pole of development for family therapy. Braulio Montalvo also
moved from New York,
and Jay Haley was summoned from the West Coast.
Haley’s
own conceptual framework differs in significant aspects from that of Minuchin,
but undoubtedly the ideas of both men contributed a lot to the growth and
strengthening of each other’s models, sometimes through the borrowing of concepts
and techniques, and many times by providing the contrasting pictures against
which the respective positions each became better defined. Together with
Montalvo, Haley was a key factor in the intensive training program that
Minuchin wanted and had implemented at Child Guidance Clinic. The format of the
program, with its emphasis on live supervision and videotape analysis,
facilitated the discussion and refinement of theoretical concepts and has been
a continuous primary influence on the shaping of the model. The preface to Families
and Family Therapy (Minuchin, 1974) acknowledges the seminal value of the
author’s association with Haley and Montalvo.
While
Minuchin continued his innovative work in Philadelphia, the clinical and research data
originating in different strains of family therapy continued to accumulate, up
to a point in which alternative and competitive theoretical renderings became
possible. The growing drive for a systemic way of looking at behavior and
behavior change had to differentiate itself from the attempts to absorb family
dynamics into a more or less expanded version of psychoanalysis (Minuchin,
1969, pp. 179—187). A first basic formulation of Minuchin’s own brand of
family therapy was almost at hand and it only needed a second catalyst, a
context comparable to Wiltwyck.
The
context was provided by the association of Philadelphia Child Guidance Clinic
with the Children’s Hospital
of Philadelphia, which
brought Minuchin to the field of psychosomatic conditions. The project started
as a challenge, in many ways similar to the one posed by the delinquent boys of
Wiltwyck. Once again the therapist had to operate under the pressures of
running time. The urgency, of a social nature at Wiltwyck, was a medical one at
Philadelphia.
The patients who first forced a new turn of the screw in the shaping of
Minuchin’s model were diabetic children with an unusually high number of
emergency hospitalizations for acidosis. Their conditions could not be explained
medically and would not respond to classical individual psychotherapy, which
focused on improving the patient’s ability to handle his or her own stress.
Only when the stress was understood and treated in the context of the family
could the problem be solved (Baker, Minuchin, Milman, Liebman & Todd,
1975). Minuchin’s team accumulated clinical and research evidence of the
connection between certain family characteristics and the extreme
vulnerability of this group of patients. The same characteristics—enmeshment,
over protectiveness, rigidity, lack of conflict resolution—Were also observed
in the families of asthmatic children who presented severe, recurrent attacks
and/or a heavy dependence on steroids (Liebman, Minuchin & Baker, 1974;
Minuchin, Baker, Rosman, Liebman, Milman & Todd, 1975; Liebman, Minuchin,
Baker & Rosman, 1976, 1977, pp. 153—171).
The
therapeutic paradigm that began to evolve focused on a push for clearer
boundaries, increased flexibility in family transactions, the actualization of
hidden family conflicts and the modification of the (usually overinvolved) role
of the patient in them. The need to enact dysfunctional transactions
in the session—prescribed by the model so that they could be observed and
corrected—led therapists to deliberately provoke family crises (Minuchin &
Barcai, 1969, pp. 199-220), in contrast with the supportive, shielding role
prescribed by more traditional approaches. If the under organized families of
juvenile delinquents invited the exploration of new routes, the hovering overconcenied
families of psychosomatic children led to the articulation of a first version
of structural family therapy.
In an early advance of a new conceptual model derived from the
principles of general systems theory (Minuchin, 1970), the clinical material
chosen as illustration is a case of anorexia nervosa. Although Minuchin’s
involvement with this condition was practically simultaneous with his work
with diabetics and asthmatics, anorexia nervosa provided a special opportunity
because in this case the implementation of the model aims at eliminating the
disease itself, while in the other two cases it can not go beyond the
prevention of its exacerbation. In both diabetes and asthma, the emotional link
is the triggering of a somatic episode, but it operates on a basic preexistent
physiological vulnerability—a metabolic disorder, an allergy. Thus, the terms
“psychosomatic diabetic” and “psychosomatic asthmatic” do not imply an
emotional etiology for any of the two conditions. In anorexia nervosa, on the
other hand, the role of such vulnerability is small or inexistent. Emotional
factors can be held entirely responsible for the condition, and then the
therapeutic potential of the model can be more fully assessed. Clinical and research
experience with anorexia is the most widely documented of the model’s
application (for instance Liebman, Minuchin & Baker, 1974a, l974b;
Minuchin, Baker, Liebman, Milman, Rosman & Todd, 1973; Rosman, Minuchin
& Liebman, 1975; Rosman, Minuchin, Liebman & Baker, 1976, 1977, pp.
341—348).
During
the first half of the 1970s, with the Philadelphia
clinic already established as a leading training center for family therapists,
Minuchin continued his work with psychosomatics. In 1972 he invited Bernice Rosman,
who had worked with him at Wiltwyck and coauthored Families of the Slums, to
join the clinic as Director of Research. Minuchin, Rosman, and the pediatrician
Lester Baker became the core of a clinical and research team that culminated
its work 6 years later with the publication of Psychosomatic Families (Minuchin,
Rosman & Baker, 1978).
Also in 1972 Minuchin published the first systematic formulation of his
model, in an article entitled, precisely, “Structural Family Therapy” (Minuchin,
1972). Many of the basic principles of the current model are already present
in this article: the characterization of therapy as a transitional event,
where the therapist’s function is to help the family reach a new stage; the
emphasis on present reality as opposed to history; the displacement of the
locus of pathology from the individual to the system of transactions, from the
symptom to the family’s reaction to it; the understanding of diagnosis as a constructed
reality; the attention paid to the points of entry that each family system offers
to the therapist; the therapeutic strategy focused on a realignment of the
structural relationships within the family, on a change of rules that will
allow the system to maximize its potential for conflict resolution and individual
growth.
During
this same period of time, the clinical experience supporting the model went far
beyond the psychosomatic field. Under Minuchin’s leadership, the techniques
and concepts of structural family therapy were being applied by the clinic’s
staff and trainees to school phobias, adolescent runaways, drug addictions and
the whole range of problems typically brought for treatment to a child clinic.
The model was finally reaching all sorts of families from all socioeconomic
levels and with a variety of presenting problems.
In 1974 Minuchin presented structural family therapy in book form
(Minuchin, 1974) and the Philadelphia Child Guidance Clinic moved to a modern
and larger building complex together with Children’s Hospital. A process of fast
expansion started: the availability of services and staff increased
dramatically and a totally new organizational context developed. The visibility
of Philadelphia Child Guidance Clinic, which reached international renown,
brought a new challenge to the model in the form of increasing and not always
positive attention from the psychiatric establishment. In 1975 Minuchin chose
to step down from his administrative duties and to concentrate on the teaching
of his methods and ideas to younger generations, at the specially created
Family Therapy Training Center.
This move signaled the beginning of the latest stage in the development
of the model, a period of theoretical creation driven by the need to develop a
didactically powerful body of systemic concepts consistent with the richness
of clinical data. The current status of structural family therapy (Minuchin
& Fishman, 1981) is characterized by an emphasis on training and
theoretical issues. In the delivery of training, increasing attention is being
paid to the therapist’s epistemology—concepts, perspectives, goals, attitudes—as
a “set” that conditions the learning of techniques. In the development of
theory, the trend is to refine the early systemic concepts that served as
foundations of the model, by looking
Into ideas developed by systems thinkers in other fields.
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