General systems theories emerged in the biological and social sciences following World War II. This led to the conceptualization of the individual as an interdependent part of larger social systems. Systemic therapy does not focus on how problems start, but rather on how the dynamics of relationships influence the problem. The therapist’s goal is to alter the dynamics of the relationships rather than to focus only on the behavior or internal dynamics of individuals. For example, if a child is having temper tantrums, attention would be given to the stage of family development, the quality of communication between its members, and the clarity and flexibility of family roles. In the family, the executive subsystem is that of the parents; the sibling subsystem is that of the children. Invisible boundaries–unspoken rules about who does what with whom–are drawn around each (and around the immediate family itself) so that each subsystem can carry out its family-stabilizing tasks while remaining connected to the others.
One of the most common family problems is a weak boundary between subsystems. A woman making several calls a day from work to instruct her teenagers on how to dress for school, what to say when they turn in homework, and so forth indicates over-involvement with the sibling subsystem; a man who calls or visits his mother every time he argues with his wife shows a weak boundary between the immediate and extended families. In therapy it’s quite common to see a little boy suddenly make everyone laugh at precisely the moment the therapist is asking the uncomfortable parents how their marriage is going. Without knowing it, the boy, usually prompted by some subtle signal from his parents, protects the family by taking the heat off them and their fragile relationship. The therapist, seeing the family operating as a whole (self-preservation through distraction) rather than as isolated individuals (Mom, Dad, the son), might then comment. In alcoholic families the member who drinks controls the whole family with his/her behavior. His/Her unavailability, bad health, violence, unpredictability, and self-contempt distort every interaction between family members.
The whole family learns to adapt itself to his/her drinking with maneuvers like denial, bailing him out of jail if he drinks and drives, calling in sick for him if he’s hung over, walking carefully when he’s drunk and angry, unconsciously nominating one child to stand in for him and parent the family. Family therapists use the term IP, meaning Identified Patient, because a dysfunctional family member generally means a destabilized family system. Whatever its components, unresolved stress between parents reverberates down through all family interrelations and normally results in coalitions, emotional parent-child alignments against the other parent and perhaps other children. For example a mom is a verbally abusive, so when she explodes, dad and brother console one another and perhaps agree that she’s nuts. A linear approach would emphasize mom’s upbringing and lack of anger management skills and thereby ignore the coalition process itself and reinforce its tendency to scapegoat, whereas a systems approach would focus on the present-time context of mom’s explosions, looking at the interactions leading up to it and encouraging dad and mom to work out new, non-escalating ways to talk and negotiate. Perhaps the couple could enter into couples therapy, rather than blaming her or him or failing to confront, and thus defuse alliances forming elsewhere in the family. When a couple in session argues about how it started, the therapist can let them know that there is more interest in where it’s going: “How will you resolve this here?” With specific reference to alcoholics, many have inherited biological and family stresses and have low self-esteem and other dynamics which can all play a part. What counts for the alcoholic isn’t looking for causes so much as cutting the feedback circles that maintain drinking.
A good clinician will refer the client to AA, consider hospitalization, assess for suicidal intent, advise a physical, ask about weapons in the home, and work on both family and individual levels with interventions aimed at interactions (arguments, nagging, money problems, abuse) that presently maintain the alcoholism. A typical situation as described by Neil Jacobson in 1995, an un-intense family with a cool emotional atmosphere unconsciously selects a member to turn up the heat; brother and sister start fighting. This turns into an argument between the parents, the drama escalates, and then, before it gets too hot, a child who plays the role of family ambassador calms everybody down. In that family, the bias, the emotional level setting, is too low. Many drug and alcohol counselors know that when one member of the family stops drinking or using, the family will subtly try to push him back into his old vices, not because they want him sick, but because families, like other organisms, naturally resist changes that might further destabilize the system.
So one day the husband says to his abstaining wife, “Why not skip your AA meeting tonight so we can catch a movie?” Or the mother of a teen who’s quit using congratulates him on finding a job, in a restaurant with a bar and grill. Introducing positive feedback (system-changing) loops into these families might include warning them about enabling, relapses and resistance to change and examining what family members gain from having a malfunctioning member (control? A scapegoat? Distraction from other conflicts? Someone to rescue?). Constructive intensity might re-calibrate the bias and make explosions unnecessary. Battery normally begins with emotional or verbal abuse (name-calling, shouting, intimidation, shaming) and escalates over the years from pushing and shoving to beatings and even murder. Abuse gives rise to more abuse, violence to more violence: destructive synergy. In theory of constructive synergy, however, a batterer uses a batterer’s group to learn and master rage-control techniques; those enhance his self-esteem; his wife praises his efforts and trusts him more; he feels good about that and shows her more empathy; the two get problems out on the table instead of hiding them; both grow; their affection deepens; their children carry the resulting relationship blueprint into their own relationships. Therapists begin this process by helping clients consciously relate and capitalize on growth-producing thoughts, feelings, and interactions (“Now that you stopped drinking, he feels safer telling you about his sadness; you empathized, so he is listening to you more often and with greater care…good work! How will you keep this going?”)
Even twins eventually take different roads, grow into individuals with their own insights and values, habits and preferences. (Jacobson, 1995) Consciousness guarantees that what we choose to make of our original conditions is more important than the conditions themselves. The abuse survivor who owns the pain moves on; the one who won’t becomes a chronic victim and will probably get into re-victimizing situations. Therapists who realize this assume that a client can and should take full responsibility for the work of healing no matter how dangerous or abusive that client’s environment may have been.
Families are likeliest to be conflicted and symptomatic when key horizontal transitions like marriage, the birth of children, children going to school, children moving away from home, changes of jobs, et cetera coincide with a resurfacing of stressors like old emotional baggage. For example, a workaholic husband driven to succeed by high internalized standards (Rogers’s “conditions of worth”) that equate esteem with production (vertical stressor) puts in even more overtime to stuff the loneliness he feels when his eldest son leaves for college (horizontal stressor).(Jacobson, 1995) Worried about his health, escalating stress, and increasing distance from her, his wife suggests that they see a family therapist. Part of the therapeutic agenda would include giving the family tools for negotiating the “empty nest syndrome” while helping the husband get in touch with his mourning, examine his expectations of himself, and reconnect with his family. Teaching family members how to use “I” statements and listen empathically demonstrate first-order changes that enhance the family’s current functioning. Coaching a widow through the loss of her husband, helping a couple let go of the last child to leave the nest, and restructuring an alcoholic family to eliminate drinking are second-order changes that alter the family fundamentally, bringing it to an entirely new structure and psychological place. Yes, there really are families–and extended families and neighborhoods and even companies–that work this way: members are clear about what to expect from one another and neither intrude nor distance themselves, they speak openly and affectionately to one another, they know who’s in charge of what, they know and can talk about what is permitted and what is not, their roles and favorites are flexible and changing, and they feel comfortable and safe getting problems and hurt feelings out in the open where everyone can work on them. When enough families succeed at this, perhaps the systemic impact on whole nations will become irresistible.
Born and raised in Argentina, Salvador Minuchin began his career as a family therapist in the early 1960’s when he discovered two patterns common to troubled families: some are “enmeshed,” chaotic and tightly interconnected, while others are “disengaged,” isolated and seemingly unrelated. When Minuchin first burst onto the scene, his immediate impact was due to his dazzling clinical artistry. This very creative man would provoke, seduce, bully, or bewilder families into changing, as the situation required, setting a standard against which other therapists still judge their best work. But even Minuchin’s legendary dramatic flair didn’t have the same long lasting impact as his structural theory of families.
In his text, Families and Family Therapy (Minuchin, 1974) Minuchin taught family therapists to see what they were looking at. Through the lens of structural family theory, previously puzzling interactions suddenly appeared in focus. Where others saw only chaos and cruelty, Minuchin helped people to understand that families are structured in “subsystems” with “boundaries,” their members shuffling to steps they do not see. In 1962 Minuchin formed a productive professional realtionship with Jay Haley, who was then in the famous Palo Alto symposium. In 1965 Munuchin became the director of the Philadelphia Child Guidance Clinic, which eventually became the world’s leading center for family therapy and training. At the Phiadelphia Clinic, Haley and Minuchin developed a training program for members of the local black community as paraprofessional family therapists in an effort to more effectively related to the urban blacks and Latinos in the surrounding community.
In 1969, Minuchin, Haley, Braulio Montalvo, and Bernice Rosman developed a highly successful family therapy training program that emphasized hands-on experience, on-line supervision, and the use of videotapes to learn and apply the techniques of structural family therapy. Minuchin stepped down as director of the Phildelphia Clinic in 1975 to pursue his interest in treating families with psychosomatic illnesses and to continue writing some of the most influential books in the field of family therapy. In 1981, Minuchin established Family Studies, Inc., in New York, a center committed to teaching family therapists. Minuchin retired in 1996 and currently lives with his wife Patricia in Boston. (Miller 1992)
FAMILY THERAPY AS DESCRIBED BY SALVADOR MINUCHIN
To understand family functioning Minuchin looks at family interaction patterns or rules. Family structure is the invisible set of functional demands that organizes the way in which family members interact. The family system differentiates and carries out its functions through subsystems. Subsystems can be made up of individuals or dyads and can be formed by generation, sex, interest or functions. Each person belongs to a multiplicity of subsystems with different levels of power and in which differentiated skills are learned. Subsystem boundaries must be clear for proper family functioning. They must be defined well enough to prevent intrusion or interference but must also permit emotional contact among members. Interactive patterns are the ways that family member’s behaviors define who is aligned with whom. (Minuchin, 1981)
The process of assessment for the structural therapist includes the mapping the structure of the family, location and permeability of the boundaries, and the identification of the subsystems. The patterns of communication must be assessed, and the character and flexibility of alignments and alliances (joining together of 2 or more members in a common interest or task) recognized. Minuchin also assesses coalitions, which are joint actions directed against one or more members. He also looks at distributions of power, sources of stress and environmental support (Minuchin, 1981).
Minuchin believes that it is normal for appropriate alliances to be formed. Parents should form an alliance with each other rather than with one or more of the children. Also children should be treated age appropriately. But some alliances are inappropriate. When there is too much or too little power, or the family members are over involved on one hand or too distant on the other hand, problems with family boundaries arise.
Enmeshment is the term Minuchin uses when member’s involvement is intrusive. In enmeshment, boundaries and personal space are weak and change rapidly. These changes impact all subsystems. Autonomy and competence are inhibited and perceptions of self and others are poorly differentiated. The family floods with anxiety in times of stress and poorly adapts to change (Minuchin, 1981).
Disengagement is the term Minuchin uses when member’s involvement is too distant. In disengagement, family members have rigid boundaries and communication between subsystems is poor. Supportive contact is minimal. The family members may function autonomously but have a skewed sense of independence, lack feelings of loyalty and belonging and a capacity for interdependence. They have a poor response to stress in other subsystems or members of the family (Minuchin, 1974).
The structural therapist sees a family as a system that operates through transactional patterns. Repeated transactions establish patterns of how, when, and to whom to relate and these patterns determine whether the system is functional or dysfunctional. Minuchin sees the family as a system with norms and structures such as coalition patterns that continuously change as members age and deal with a changing environment.
Minuchin notes the importance of recognizing the physical, social, and sociocultural environment within which any family exists since family members respond at least partly in response to these.
The long range treatment goals of the structural therapist is to change dysfunctional family structures. Some of these structures include, inappropriate coalitions, enmeshment, and disengagement. The short range goals are to change patterns, even if they are still dysfunctional, since this at least gets the family moving. The therapist tries to help family members to realize that they can think, feel, and act differently to achieve more effective family communication and environmental improvement (Friedman, 1981)
The initial treatment strategies used by structural therapists are joining strategies. The therapist joins with or accommodates to a family’s set of rules. They almost become a part of the family. In doing this they establish good relationships with the family members and experience the family’s rhythms and demands. The therapist makes internal adjustments to move with a family rather than disrupt it. He gives members respect and support but also challenges family members to create hope that change can occur (Minuchin,1974).
Minuchin believes that the amount of knowledge needed about the family to diagnose and begin restructuring dysfunctional interactions is available quickly. Structural family therapy does not explore or interpret the past. It is active and immediate (Minuchin, 1981). The structural therapist uses restructuring techniques to transform dysfunctional transactional patterns that maintain symptomatic behavior. Various strategies are used to intervene to change dysfunctional patterns. Some of these strategies include: enacting transactional patterns, marking of both individual and subsystem boundaries, escalating stress, assigning tasks, using symptoms, manipulating the family’s mood and the use of education and guidance.
FAMILY DATA: MINUCHIN’S THEORY APPLIED
A graduate nursing student participated in family therapy for 4 weeks with the C. family.(Gwin, 1996) The C’s were referred for counseling by a crisis intervention center as the result of alleged child molestation and wife abuse. Reluctantly, the husband agreed to participate in family therapy sessions with his wife. The young children of the family, a 2 year old girl and a 6 year old boy, were also present, playing in the room where the sessions were held at Peninsula Hospital. The children were present in order to observe the interaction of the whole family. The structural therapist sees a family as a system that operates through transactional patterns. Repeated transactions establish patterns of how, when, and to whom to relate and these patterns determine whether the system is functional or dysfunctional. The subsystems of the family must be observed interacting together in order to make this assessment. Both verbal and nonverbal behaviors were observed. The children climbed all over the mother rather than the father and asked her to identify pictures in a book. The wife looks up and shouts at the husband and he in turn looks down and mutters a barely audible derogatory remark. To get a more complete picture of the violence, the spouses were asked about their parental home life. Both husband and wife came from homes where beatings were common between husband and wife and of children.
One Minuchin joining strategy that was used with the C. family was “respecting the family’s values and hierarchies”. In this treatment strategy communication is addressed through a dominant spouse or switchboard for the family. During the early sessions, communication was addressed through Mrs. C. the dominant spouse. This accommodated to the structure of the family system and thereby the sessions moved with the family rather than disrupting it. “Mirroring and mimicking”, other Minuchin joining strategies, were used as the family’s mood, pace, and communication patterns were matched by the therapist. Internal adjustments were made by the therapist so that if the family became somber so did the therapist. He experienced the rhythms and demands of the family.
The mood of Mr. C. was mirrored by the therapist in the following exchange(Gwin 1996):
Wife: You can’t tell him anything. He just sits there. I don’t really expect him to do much work around the house. But I’d like just once of he’d ask if I wanted help.
Therapist: Ted, I feel pretty uncomfortable right now, kind of frustrated. I sense this is the way you may be feeling just now.
If the therapist has done a good job in the process of joining, the stage is set for therapeutic restructuring efforts. The mother is assessed to be in a subsystem alliance or enmeshed with the children and needs to be weaned away from this tight bond. Her autonomy and competence are inhibited and her perception of self is poorly differentiated. This enmeshment pattern was validated by asking the children to “See what your parents say about staying up this late?” Their communication was directed solely to the mother.
The husband-wife subsystem have one-way communication. This was validated by observation of both verbal and nonverbal communication patterns between the husband and wife during the therapy sessions. One restructuring technique that was used in this situation is to “escalate stress” by baiting the conversation to establish this one-way communication and quickly point this out to the family. Escalating stress is one of
Minuchin’s more radical techniques that forces members to develop alternative more functional ways of resolving stress. This stress escalation can be accomplished by blocking usual transactional patterns, siding with only one family member, identifying previously unidentified symptom bearers by pointing out previously unnoticed symptoms, or by asking for opinions. In this case previously unidentified symptom bearers were identified by pointing out the one-way communication pattern initiated by the wife and labeling this as dysfunctional. This also blocks usual transactional patterns forcing the development of newer more functional communication patterns. By baiting the conversation to produce the one-way communication pattern and relabeling this symptom negatively, the therapist has used this symptom to increase its intensity and thereby mobilize family resources to cope with the increased stress produced.
Data was gathered. Family patterns assessed and plans of intervention therapy made by staging the family drama. The therapist is looking for a specific confirmation, and having obtained it, he shares his finding with the family. The wife was told she “sets up” an argument by anticipating her husband’s response before he gives it to her. An example of the one-way communication patterns used.
According to Minuchin, each family has its own unique map or patterns of behavior (Minuchin, 1974). Change can take place, but to accomplish this goal, an initial assessment of family boundaries is necessary. Both individual and subsystem boundaries should be assessed. These boundaries establish the relative individuality or autonomy of family members. In Minuchin’s concept of enmeshment, boundaries and personal space are weak and change rapidly. In Minuchins’s concept of disengagement, family members have rigid boundaries and communication between subsystems is poor.
In the family studied, the wife and husband exhibit patterns of behavior that fit the criteria of disengagement. Both husband and wife work in administrative positions in retail sales. Both of them partake of the materialistic benefits of the wife working. The husband feels that he deserves everything that he has attained and easily and quickly blames others if the need arises. The wife places the victim role. She anticipates trouble, stores resentment, walks a tightrope, and is easily thrown off balance. The children further separate the couple with there enmeshment with their mother and ineffective relationship with their father.
The goal of therapy was to open the boundaries that separate the husband and wife and reduce the enmeshment of the mother and the children. This was addressed by rearranging family space and positioning during the therapeutic sessions. In the third session the graduate nurse therapist took the favorite seat of the husband. Due to the arrangement of the other seating during the session, the husband was forced to sit next to his wife on the sofa. The co-therapists played with the children during the session thus also pushing the couple closer together. The nonverbal behavior that was observed was an indication of the success of the intervention. The husband at first was with his wife seated on the sofa and nothing more. He looked nervous and disconcerted. He spoke little and looked more at the children playing than at his wife. Later in the session as the wife talked about how difficult it was to deal with her anger, the husband reached out for her hand on the back of the couch and held and occasionally squeezed it.
Another restructuring technique used with the C family was the “assigning of tasks”. This is done inside or outside of sessions and structures the setting for alternative interactions and behavior to occur between family members. All critically involved members should be give a portion of the task to complete. The task assigned was to have the father spend at least 15 minutes each day he was home playing with the 2 year old girl. The wife could be present, but she was not to participate. She was to keep the 6 year old son occupied during this time. This task was to improve the relationship between the father and daughter and decrease the enmeshment between the mother and the children. The other task assigned was for the couple to discuss the anger the wife was feeling about the lack of help her husband offered at home. The couple was instructed not to spend more than 20 minutes on just one occasion talking about this, If it seemed that an argument might ensue, the couple could stop for a minute or so, but neither should leave the room or the house. This task addressed their communication patterns. The task assignment was evaluated by the therapists. The husband stated he really enjoyed the four 15 minute periods he spent with his daughter and felt a little guilty about not spending more time with her. The couple were not as successful at completing their assigned task. The co-therapists pointed out that it is sometimes very difficult to face a sensitive issue. It was pointed out that better communication was needed to avert continuing anger.
The C. family was exposed to a comparatively brief therapeutic process. During this time the therapist dealt with anger, one-way, incomplete communication and disengagement of the couple and enmeshment of the mother and children. Their therapy is continuing. Hopefully the dramatization of their problems and the restructuring techniques utilized will assist the couple to accomplish the long term goal of structural therapy of changing dysfunctional family structures such as inappropriate coalitions, enmeshments, and disengagements. The C. family was assisted to see that they can think, feel, and act differently to achieve more effective family communication and improve their family environment.
Both husband and wife came from homes where beatings were common between husband and wife and of children. Mr. C’s father was an alcoholic and died of the complications of the disease. Mr. C and his mother had a very conflictural relationship. He maintains little contact with her. Mrs. C. came from a very rigid parental setting. She had little to do with her father and was dominated by her mother. The conflict and poor patterns of communication that the C’s are now experiencing has led to the disengagement between Mr. and Mrs. C. Mrs. C’s over involvement with her children mirrors the pattern of her mother and her relationship with her father is also reflected in her relationship with her husband.