Transcript Structural Family Therapy - Tavistock and Portman NHS

Structural Family Therapy
SIMON SHATTOCK &
JOANNE PEARCE, COVENTRY
1 3 TH J U N E 2 0 1 3
What is the structure in your family?
 In pairs interview each other and ask the following
questions of each other:
 What role did you play in your family?
 What is the structure of your family ( who is in charge, maternal led,
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paternal led, grandparents led, or siblings led, or other alternative
structures)
Were the boundaries overbearing or not strict enough?
Was there ever confusion about who was in charge?
Is there anything you would like to be changed about your family
structure whilst growing up?
How does this map of your family inform your work with families?
How much importance do you place on rules and boundaries with
your own family or relationships now presently in your life?
Research Evidence
 The research evidence suggest that if Parenting
approaches do not work for example WebsterStratton that Structural Family Therapy should be
considered for Conduct Disorders. ( Scott, 2003)
 Chronic physical illness in children, aggression and
non-compliance, and anorexia nervosa (Campbell &
Patterson, 1995)
 Multi-systemic therapy with challenging families
uses ideas/ techniques from Structural Family
Therapy
The contributions of the Structural Model
 Distinctions are made in this model from well –
functioning structures to dysfunctional family
systems
 “Salvador Minuchin and his colleagues in the 1960’s
and 1970’s made a simple and enduring point about
families: that children thrive when, parents, or other
caregivers, can collaborate in looking after them”
(Kraemer 1997: 47)
What happens when the structure is unclear
 In dysfunctional families, the hierarchy is unclear,
and parents either do not have or do not exercise the
power and authority required to carry out their
parental and executive functions
 For eg, if there is a diffuse boundary around the
spousal system, a cross generational coalition may
develop between one parent and a child. This
weakens the alignment between the spouses, in turn
reducing their parental power.
 (Goldenberg and Goldenberg, 1991)
The mind is connected as a system
 “ Consider a man felling a tree with an axe. Each
stoke of the axe is modified or corrected, according
to the shape of the cut face of the tree left by the
previous stroke. This self corrective.. Process is
brought about by a total system, tree-eyes-brainmuscles-axe-stroke: and is the total system that has
characteristics of ….mind” Gregory Bateson.
The development of ideas
 Families of the slums (1967). Focused on issues of
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parental authority in Black American woman who’s
children were in trouble with the law
Families and Family Therapy(1974) – enmeshment and
engagement
Psychosomatic Families(1978) – conflict avoidance and
physical illness and eating disorders
Family Therapy Techniques (1981)- detailed the change
techniques or interventions
Family Kaleidoscopes (1984)- broaden systemic thinking
to wider audience
Mastering Family Therapy (1996) – taking account of the
feminist critique
What is the Structural Model
 When looking at families from the outside we may
notice that the family has a way of making decisions
which follows a pattern and follows unsaid rules
 Structural family therapy helps the practitioner to
pay close attention to patterns in family life
 Problems arise in families when patterns of relating
become inflexible
Enmeshment
 Enmeshment describes relationships of particular
closeness
 In the life cycle many relationships can be described in
these terms – falling in love, mother and baby bonding.
 If enmeshment becomes the only way of relating, or gets
in the way of culturally appropriate developmental tasks
(like adolescent separation in some Western cultures)
then it is problematic, leading to communication of
distress in some family members
 Enmeshment can show itself as reluctance to tolerate
distress in others
Disengagement
 Disengagement describes relationships characterised
by distance and under- involvement
 In families where disengagement is a characteristic
the qualities of independence and individuality are
valued. This could be culturally appropriate, for eg,
as a way of helping a teenager take more
responsibility for him/herself as they move to
adulthood in Western cultures
Disengagement
 Disengagement may however become problematic,
for eg where it is not possible to communicate
distress and have this responded to in a timely
manner, then this might lead to particular
expressions of distress and unhappiness, such as
teenage suicide attempts and self harm, as they may
be limited emotional connections to understanding
distress in others.
 This is more modern terms maybe described as the
inability to mentalize about the mental state of the
other person/s (Fonagy, P)
Structural Concepts
 Structural family therapists build these ideas onto Bateson’s idea that
relationships manifest patterns of interactions which are
complementary,
symmetrical or reciprocal (that is, include elements of both complementarity and
symmetry).
 So we might understand a child’s silence as withdrawal from his/her
parents, as both
 disengagement, part of a complementary pattern,
 and a way of expressing anger (fighting back) against the parents
‘overly-controlling’ behaviour, and thus as part of a symmetrical pattern
 We might think of these two understandings as highlighting overt and
covert patterns of interaction. What is key to understanding
of the relational context
this is the emotional quality
Structural Model
 So far, the descriptions fit with dyadic relationship patterns - those which
require only two 'parties’ for a useful description. In families often more
complex relationship patterns emerge. These we might describe as triadic.
 Triangulation is the idea that a pattern of interaction between two people,
which might be in danger of escalating beyond tolerable limits, starts to involve
a third party. The difference between the two parties then becomes detoured
through the third party. Examples of this triadic detouring include children
becoming ‘caught up’ in their parents 'conflicts, a mother acting as a ‘go
between’ for the children and their father, etc.
 Again, these triadic patterns arise in all families some of the time. They only
become problematic when through repetition, they become ‘necessary’ for the
family to function.
The Structural Model
 In some cases it is important to notice when
professionals take up a triadic position in
relation to a family. For example, by stepping
into a couple’s dispute to ‘mediate’. Minuchin’s idea of
enactment is one way the professional can avoid such
patterns of family-professional relationships emerging.
Enactment de-centres the professional
Fatty Acid Study
 Minuchin and colleagues measured family members
Free Fatty Acid( a physiological marker for stress)
during a structured interview. Dede, 17 year old has
been diabetic fo 3 years and her sister Violet, 12
years old since birth
 Dede’s diabetes was affected by ‘superliable’, affected
by events in her life and dramatic ways which were
difficult if not impossible to medically manage (eg
insulin) and in three years she had 23 A &E
admissions
Fatty Acid Study
 Violet diabetes was easily medically managed.
 The interview was structured so that children
observed their parents talking and becoming
stressed (9am – 10am). Later the children joined
their parents in the interview(10 – 10.30am)
 Dede was observed to be caught between her
parents, with each seeking support in the parental
disagreement. Violet’s was not brought into these
conflicts.
Fatty Acid Study
 Minuchin and his team noticed that while both Dede and
Violet’s FFA levels showed a stress response during the
interview, and particularly when they were in the room
with their parents, only Dede’s level remained
significantly elevated after the interview (10.30-12am,
when testing stopped).
 The parents FFA levels peaked at 10am, when the
children joined the interview. Minuchin and his
colleagues argued that the parents’ stress level falls at
this point because they assumed parental functions, and
their couple difficulties could be ‘detoured’ through their
parental subsystem
Fatty Acid Study
Sub-systems
 In Healthy families. Boundaries in the family are
clear. Life cycle issues are easier to navigate.
Members are allowed space without being too
distant.
 Sub -systems are protected by boundaries,
For eg children should not participate in disputes
between the parents. Parents should not overly
intervene in sibling disputes
Sub-systems
 For eg, there may be times when an older sibling
joins the executive subsystem, perhaps when a
parents is ill. However, Structural practitioners
would argue that this should not be permanent.
 Subsytems should neither be too close, so others can
easily step into a subsystems it does not
belong(enmeshed/overinvolved)
Sub-systems
 And not to distant from each other, so that joining is
never a possibility ( disengaged/rigid)
 Problems arise when subsystems boundaries are
consistently operating with boundaries which do not
serve the family well.
Theory of change:
 “Patients move for 3 reasons. First, they are
challenged in their perception of reality. Second they
are given alternative possibilities that make sense to
them, and third, once they have tried out the
alternative transactional patterns, new relationships
appear that are self reinforcing” (Minuchin 1974:119)
Techniques
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Join, the family – engage in the family dance
Observe how the family are with each other
Intervene in dysfunctional pattern.
Direct using action orientated techniques:
Reframing
Enactment
Unbalancing
Boundary Making
Intensification
Challenging cognitive constructs
Enactment
 Enactment – a dance of 3 movements
 Enactment is a technique to promote adaptation and
change in the family functioning
 1.0 The therapist observers the spontaneous
transactions of the family and decides which
dysfunctional areas to highlight
Enactment
 2. The therapist organises scenarios in which the
family members dance their dysfunctional dance in
the practitioners presence
 3. The therapist suggest alternative ways of
transacting(or pushes the enactment pattern beyond
the point it would normally run, so the possibility of
new patterns emerge)
Intensification
 It is a type of enactment for eg
 Therapist : I do not believe that you are saying
what you really want to your dad. Come on be
honest: tell him what you want him to do.
 Daughter : I can’t . He will be upset
 Therapist: Of course he will be upset. That is what
parents are for isn’t it. To be upset by what their
children say. Tell me are you frightened that he will
go crazy or something?
 Daughter – No I
Intensification
 Therapist: Well what is it. Don’t let this feeling shut
you up.
 Daughter: I am not frightened about what he will
do, but what he will feel
 Therapist: You think he will sulk?
 Daughter: It will hurt him so bad he will start
drinking again.
Unbalancing
 Technique which challenges the family . Often the
therapist might support one member of the family in
order to create change in another part of the system
 Therapist Who the boss in the family?
 Sarah ( 6) Its me
 Therapist :I am glad we have sorted that out. So
let’s ignore mum and dad at the moment shall we?
You and I will work out what they have to do.
Question relating to the clip
 What is the structure of this family?
 What is the therapist doing?
 What are the rules of this family?
 What are the benefits and dangers of this style of
therapy?
 What does structural family therapy make you think
about your own family?
Reframing
 A Reframe involves retelling or reconstructing the
language used by a family about its problems. You
might choose to emphasise the interactive aspects
of the problem rather than its intrinsic nature
The theory behind the use of reframing
 Family therapist are very keen to attend to language
in a particular way. On one hand they listen for
phrases and language used by family members. They
do this so they can create alternative descriptions of
patterns, problems and persons that may be more
helpful to the family. Bateson called this process of
double description. In short if we only have one
way of seeing things we have little ability to change,
Once we have more than on description of a situation
alternatives become possible.
Reframing
 An anorexic girl can be relabelled as stubborn or
determined not sick
 An angry boy can be relabelled as sad as opposed to
angry or disruptive
 An arguing couple could be described as passionate,
as opposed to not getting along or dysfunctional
Reframing
 If a family member expresses over involvement by
saying:
 I have to do everything for you because you
can’t manage alone
Reframed:
 It sounds like you find yourself worrying a lot
about Bob’s future and wondering if he will
be able to fend for himself
Structural Family Therapy and 2nd Order
 In the 1980’s and 1990’s the model was criticised by
the feminist colleagues in the field such as Goldner
(1998)
 “When families come for help, I assume they have
problems not because there is something inherently
wrong with them but because they’ve gotten stuck –
stuck with a structure whose time has passed, and
stuck with a story that doesn’t work” ( Minuchin and
Nichols, 1993, p43)
Structural Family Therapy and 2nd Order
 The assumption of competence and uniqueness of
each family is different
 Having a second order mind whilst doing first order
therapy
 Far from being pathologizing, it is grounded is as
 The assumption of competence and uniqueness of
each family is different
 Having a second order mind whilst doing first order
therapy
 Far from being the expert about the clients situation
, it is grounded in seeing everything as everyone as
unique and competent