family therapy chp.7

Michael P. Nichols

Richard C. Schwartz

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Concepts and Methods, 6/E

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FAMILY THERAPY

Structural Family TherapyThe Underlying Organization of Family Life

One of the reasons family therapycan be difficult is that families oftenappear as collections of individualswho affect each other in powerful but unpre-dictable ways. Structural family therapy offersa framework that brings order and meaning tothose transactions. The consistent patterns offamily behavior are what allow us to considerthat they have a structure, although, of course,only in a functional sense. The boundaries andcoalitions that make up a family’s structure areabstractions; nevertheless, using the concept offamily structure enables therapists to intervenein a systematic and organized way.Families who seek help are usually con-cerned about a particular problem. It might bea child who misbehaves or a couple who don’tget along. Family therapists typically look be-yond the specifics of those problems to the fam-ily’s attempts to solve them. This leads them tothe dynamics of interaction. The misbehavingchild might have parents who scold but neverreward him. The couple may be caught up in apursuer–distancer dynamic, or they might beunable to talk without arguing.

What structural family therapy adds to theequation is a recognition of the overall organi-zation that supports and maintains those inter-actions. The “parents who scold” might turnout to be two partners who undermine eachother because one is wrapped up in the childwhile the other is an angry outsider. If so, at-tempts to encourage effective discipline arelikely to fail unless the structural problem is ad-dressed and the parents develop a real partner-ship. Similarly a couple who don’t get alongmay not be able to improve their relationshipuntil they create a boundary between them-selves and intrusive children or in-laws.The discovery that families are organizedinto subsystems with boundaries regulat-ing the contact family members have witheach other turned out to be one of the de-fining insights of family therapy. Perhapsequally important, though, was the introduc-tion of the technique of enactment, inwhich family members are encouraged to dealdirectly with each other in sessions, permit-ting the therapist to observe and modify theirinteractions.176

7

When he first burst onto the scene, SalvadorMinuchin’s galvanizing impact was as an in-comparable master of technique. His most last-ing contribution, however, was a theory offamily structure and a set of guidelines to orga-nize therapeutic techniques. This structural ap-proach was so successful that it captivated thefield in the 1970s, and Minuchin built thePhiladelphia Child Guidance Clinic into aworld-famous complex, where thousands offamily therapists have been trained in struc-tural family therapy.Sketches of Leading FiguresMinuchin was born and raised in Argentina.He served as a physician in the Israeli army,then came to the United States, where hetrained in child psychiatry with Nathan Acker-man in New York. After completing his studiesMinuchin returned to Israel in 1952 to workwith displaced children—and became ab-solutely committed to the importance of fami-lies. He moved back to the United States in1954 to begin psychoanalytic training at theWilliam Alanson White Institute, where hestudied the interpersonal psychiatry of HarryStack Sullivan. After leaving the White Insti-tute, Minuchin took a job at the WiltwyckSchool for delinquent boys, where he suggestedto his colleagues that they start seeing families.

At Wiltwyck, Minuchin and his colleagues—Dick Auerswald, Charlie King, Braulio Montalvo,and Clara Rabinowitz—taught themselves to dofamily therapy, inventing it as they went along.To do so, they built a one-way mirror and tookturns observing each other work. In 1962 Min-uchin made a hajj to what was then the meccaof family therapy, Palo Alto. There he met JayHaley and began a friendship that was to bearfruit in an extraordinarily fertile collaboration.The success of Minuchin’s work with fam-ilies at Wiltwyck led to a groundbreakingbook, Families of the Slums, written with Mon-talvo, Guerney, Rosman, and Schumer. Min-uchin’s reputation as a practitioner of familytherapy grew, and he became the Director ofthe Philadelphia Child Guidance Clinic in1965. The clinic then consisted of less than adozen staff members. From this modest begin-ning Minuchin created one of the largest andmost prestigious child guidance clinics in theworld.Among Minuchin’s colleagues in Philadel-phia were Braulio Montalvo, Jay Haley, BerniceRosman, Harry Aponte, Carter Umbarger, Mar-ianne Walters, Charles Fishman, Cloe Madanes,and Stephen Greenstein, all of whom had a rolein shaping structural family therapy. By the1970s structural family therapy had becomethe most influential and widely practiced of allsystems of family therapy.In 1976 Minuchin stepped down as Direc-tor of the Philadelphia Child Guidance Clinic,but stayed on as head of training until 1981.After leaving Philadelphia, Minuchin startedhis own center in New York, where he contin-ued to practice and teach family therapy until1996, when he retired and moved to Boston.Long committed to addressing problems ofpoverty and social justice, Minuchin is nowconsulting with the Massachusetts Depart-ment of Mental Health on home-based ther-apy programs. In 1996 he completed his ninthbook, Mastering Family Therapy: Journeys ofGrowth and Transformation, coauthored with

CHAPTER 7 l Structural Family Therapy 177

Salvador Minuchin’sstructural model is themost influential ap-proach to familytherapy throughoutthe world.

nine of his supervisees, which explains hisviews on the state of the art in family therapyand training.Like good players on the same team with asuperstar, some of Minuchin’s colleagues arenot as well known as they might be. Foremostamong these is Braulio Montalvo, one of theunderrated geniuses of family therapy. Bornand raised in Puerto Rico, Montalvo, like Min-uchin, has always been committed to treatingminority families. Like Minuchin, he is also abrilliant therapist, though he favors a gentler,more supportive approach. Montalvo was in-strumental in building the Philadelphia ChildGuidance Clinic, but his contributions are lesswell known because he is a quiet man whoprefers to work behind the scenes.Following Minuchin’s retirement the centerin New York was renamed the Minuchin Centerfor the Family in his honor, and the torch hasbeen passed to a new generation. The staff ofleading teachers at the Minuchin Center nowincludes Ema Genijovich, David Greenan,Richard Holm, and Wai-Yung Lee. Their task isto keep the leading center of structural familytherapy in the forefront of the field without thecharismatic leadership of its progenitor.Among Minuchin’s other prominent stu-dents are Jorge Colapinto, now at the Acker-man Institute in New York; Michael Nichols,who teaches at the College of William andMary; Jay Lappin who works with child welfarefor the state of Delaware; and Charles Fishman,in private practice in Philadelphia.Theoretical FormulationsBeginners tend to get bogged down in the con-tent of family problems because they don’thave a theory to help them see the patterns offamily dynamics. Structural family therapy of-fers a blueprint for analyzing the process offamily interactions. As such, it provides a basisfor consistent strategies of treatment, which

obviates the need to have a specific technique—usually someone else’s—for every occasion.Three constructs are the essential componentsof structural family theory: structure, subsys-tems, and boundaries.Family structure, the organized pattern inwhich family members interact, is a determin-istic concept, but it doesn’t prescribe or legislatebehavior; it describes sequences that are pre-dictable. As family transactions are repeatedthey foster expectations that establish enduringpatterns. Once patterns are established, familymembers use only a small fraction of the fullrange of behavior available to them. The firsttime the baby cries, or a teenager misses theschool bus, it’s not clear who will do what. Willthe load be shared? Will there be a quarrel? Willone person get stuck with most of the work?Soon, however, patterns are set, roles assigned,and things take on a sameness and predictabil-ity. “Who’s going to . . . ?” becomes “She’llprobably . . . ” and then “She always.”Family structure is reinforced by the expec-tations that establish rules in the family. For ex-ample, a rule such as “family members shouldalways protect one another” will be manifest invarious ways depending on the context andwho is involved. If a boy gets into a fight withanother boy in the neighborhood, his motherwill go to the neighbors to complain. If ateenager has to wake up early for school,mother wakes her. If a husband is too hungover to get to work in the morning, his wife callsin to say he has the flu. If the parents have anargument, their kids interrupt. The parents areso preoccupied with the doings of their childrenthat it keeps them from spending time alone to-gether. These sequences are isomorphic: They’restructured. Changing any of them may not af-fect the basic structure, but altering the under-lying structure will have ripple effects on allfamily transactions.Family structure is shaped partly by univer-sal and partly by idiosyncratic constraints. Forexample, all families have some kind of hierar-

178 PART TWO l The Classic Schools of Family Therapy

chical structure, with adults and children hav-ing different amounts of authority. Familymembers also tend to have reciprocal and com-plementary functions. Often these become soingrained that their origin is forgotten and theyare presumed necessary rather than optional. Ifa young mother, burdened by the demands ofher infant, gets upset and complains to her hus-band, he may respond in various ways. Perhapshe’ll move closer and share the demands ofchildrearing. This creates a united parentalteam. On the other hand, if he decides that hiswife is “depressed,” she may end up in psy-chotherapy to get the emotional support sheneeds. This creates a structure where themother remains distant from her husband, andlearns to turn outside the family for sympathy.Whatever the chosen pattern, it tends to be self-perpetuating. Although alternatives are avail-able, families are unlikely to consider themuntil changing circumstances produce stress inthe system.Families don’t walk in and hand you theirstructural patterns as if they were bringing anapple to the teacher. What they bring is chaosand confusion. You have to discover thesubtext—and you have to be careful that it’saccurate—not imposed but discovered. Twothings are necessary: a theoretical system thatexplains structure, and seeing the family inaction. Knowing that a family is a single-parent family with three children, or that twoparents are having trouble with a middle childdoesn’t tell you what their structure is.Structure becomes evident only when you ob-serve the actual interactions among familymembers.Consider the following. A mother calls tocomplain of misbehavior in her seventeen-year-old son. She is asked to bring her husband,son, and their three other children to the firstsession. When they arrive, the mother begins todescribe a series of minor ways in which theson is disobedient. He interrupts to say thatshe’s always on his case, he never gets a break

from his mother. This spontaneous bickeringbetween mother and son reveals an intenseinvolvement between them—a mutual preoc-cupation no less intense simply because it’sconflictual. This sequence doesn’t tell thewhole story, however, because it doesn’t in-clude the father or the other children. Theymust be engaged to observe their role in thefamily structure. If the father sides with his wifebut seems unconcerned, then it may be that themother’s preoccupation with her son is relatedto her husband’s lack of involvement. If theyounger children tend to agree with theirmother and describe their brother as bad, thenit becomes clear that all the children are closeto the mother—close and obedient up to apoint, then close and disobedient.Families are differentiated into subsystemsbased on generation, gender, and common in-terests. Obvious groupings such as the parentsor the teenagers are sometimes less significantthan covert coalitions. A mother and heryoungest child may form such a tightly bondedsubsystem that others are excluded. Anotherfamily may be split into two camps, with momand the boys on one side, and dad and the girlson the other. Though certain patterns arecommon, the possibilities for subgrouping areendless.Every family member plays many roles inseveral subgroups. Mary may be a wife, amother, a daughter, and a niece. In each ofthese roles she will be required to behave differ-ently and exercise a variety of interpersonal op-tions. If she’s mature and flexible, she will beable to vary her behavior to fit different sub-groups. Scolding may be okay from a mother,but it can cause problems from a wife or adaughter.Individuals, subsystems, and whole familiesare demarcated by interpersonal boundaries, in-visible barriers that regulate contact with oth-ers. A rule forbidding phone calls at dinnerestablishes a boundary that protects the familyfrom outside intrusion. When small children


are permitted to freely interrupt their parents’conversations, the boundary separating thegenerations is eroded. Subsystems that aren’tadequately protected by boundaries limit thedevelopment of interpersonal skills achievablein these subsystems. If parents always step in tosettle arguments between their children, thechildren won’t learn to fight their own battles.Interpersonal boundaries vary from rigid todiffuse (see Figure 7.1). Rigid boundaries areoverly restrictive and permit little contact withoutside subsystems, resulting in disengagement.Disengaged individuals or subsystems are inde-pendent but isolated. On the positive side, thisfosters autonomy. On the other hand, disen-gagement limits affection and assistance. Dis-engaged families must come under extremestress before they mobilize mutual support.Enmeshed subsystems offer a heightenedsense of mutual support, but at the expense ofindependence and autonomy. Enmeshed par-ents are loving and considerate; they spend alot of time with their kids and do a lot for them.However, children enmeshed with their parentsbecome dependent. They’re less comfortable bythemselves and may have trouble relating topeople outside the family.Minuchin described some of the features offamily subsystems in his most accessible work,Families and Family Therapy (Minuchin, 1974).Families begin when two people join together toform a spouse subsystem. Two people in loveagree to share their lives and futures and ex-pectations; but a period of often difficult adjust-ment is required before they can complete thetransition from courtship to a functionalspouse subsystem. They must learn to accom-modate each other’s needs and preferred stylesof interaction. In a healthy couple, each gives

and gets. He learns to accommodate her wishto be kissed hello and goodbye. She learns toleave him alone with his paper and morningcoffee. These little arrangements, multiplied athousand times, may be accomplished easily oronly after intense struggle. Whatever the case,this process of accommodation cements thecouple into a unit.The couple must also develop complementarypatterns of mutual support. Some patterns aretransitory and may later be reversed—perhaps,for instance, one works while the other com-pletes school. Other patterns are more stable andlasting. Exaggerated complementary roles candetract from individual growth; moderate com-plementarity enables spouses to divide functions,to support and enrich each other. When one hasthe flu and feels lousy, the other takes over. One’spermissiveness with children may be balancedby the other’s strictness. One’s fiery dispositionmay help to melt the other’s reserve. Comple-mentary patterns exist in most couples. They be-come problematic when they are so exaggeratedthat they create a dysfunctional subsystem.Therapists must learn to accept those structuralpatterns that work and challenge only those thatdo not.The spouse subsystem must also develop aboundary that separates it from parents, chil-dren, and other outsiders. All too often, husbandand wife give up the space they need for support-ing each other when children are born. Too rigida boundary around the couple can deprive thechildren of the care they need; but in our child-centered culture, the boundary between parentsand children is often ambiguous at best.The birth of a child instantly transforms thefamily structure; the pattern of interaction be-tween the parental and child subsystems must


Diffuse Boundary

Enmeshment

Clear Boundary

Normal Range

Rigid Boundary

DisengagementFIGURE 7.1 Boundaries

be worked out and then modified to fit chang-ing circumstances. A clear boundary enableschildren to interact with their parents but ex-cludes them from the spouse subsystem. Par-ents and children eat together, play together,and share much of each others’ lives. But thereare some spouse functions that need not beshared. Husband and wife are sustained as aloving couple, and enhanced as parents, if theyhave time to be alone together—to talk, to goout to dinner occasionally, to fight, and to makelove. Unhappily, the clamorous demands ofsmall children often make parents lose sight oftheir need to maintain a boundary aroundtheir relationship.In addition to maintaining privacy for thecouple, a clear boundary establishes a hierar-chical structure in which parents exercise a po-sition of leadership. All too often this hierarchyis disrupted by a child-centered ethos, which in-fluences helping professionals as well as par-ents. Parents enmeshed with their childrentend to argue with them about who’s in charge,and misguidedly share—or shirk—the respon-sibility for making parental decisions.In Institutionalizing Madness (Elizur & Min-uchin, 1989), Minuchin makes a compellingcase for a systems view of family problems thatextends beyond the family to encompass the en-tire community. As Minuchin points out, unlesstherapists learn to look beyond the limited sliceof ecology where they work to the larger socialstructures within which their work is embed-ded, their efforts may amount to little morethan spinning wheels.Normal Family DevelopmentWhat distinguishes a normal family isn’t theabsence of problems, but a functional structurefor dealing with them. All couples must learn toadjust to each other, rear their children, if theychoose to have any, deal with their parents,cope with their jobs, and fit into their commu-nities. The nature of these struggles changes

with developmental stages and situationalcrises.When two people join to form a couple, thestructural requirements for the new union areaccommodation and boundary making. The firstpriority is mutual accommodation to managethe myriad details of everyday living. Eachpartner tries to organize the relationship alongfamiliar lines and pressures the other to comply.Each must adjust to the other’s expectationsand wants. They must agree on major issues,such as where to live and if and when to havechildren; less obvious, but equally important,they must coordinate daily rituals, like what towatch on television, what to eat for supper,when to go to bed, and what to do there.In accommodating to each other, a couplemust also negotiate the nature of the bound-ary between them, as well as the boundaryseparating them from the outside. A diffuseboundary exists between the couple if they calleach other at work frequently, if neither hastheir own friends or independent activities,and if they come to view themselves only as apair rather than as two separate personalities.On the other hand, they’ve established a rigidboundary if they spend little time together,have separate bedrooms, take separate vaca-tions, have different checking accounts, andeach is considerably more invested in careersor outside relationships than in the marriage.Each partner tends to be more comfortablewith the sort of proximity that existed in theirown family. Since these expectations differ, astruggle ensues that may be the most difficultaspect of a new union. He wants to play golfwith the boys; she feels deserted. She wants totalk; he wants to watch ESPN. His focus is onhis career; her focus is on the relationship. Eachthinks the other is unreasonable.Couples must also define a boundary sepa-rating them from their original families. Rathersuddenly the families that each grew up inmust take second place to the new marriage.This, too, is a difficult adjustment, both fornewlyweds and for their parents. Families vary


in the ease with which they accept and supportthese new unions.The addition of children transforms thestructure of the new family into a parental sub-system and a child subsystem. It’s typical forspouses to have different patterns of commit-ment to the babies. A woman’s commitment toa unit of three is likely to begin with pregnancy,since the child inside her womb is an unavoid-able reality. Her husband, on the other hand,may only begin to feel like a father when thechild is born. Many men don’t accept the role offather until their infants are old enough to re-spond to them. Thus, even in normal families,children bring with them great potential forstress and conflict. A mother’s life is usuallymore radically transformed than a father’s. Shesacrifices a great deal and typically needs moresupport from her husband. The husband,meanwhile, continues his job, and the newbaby is far less of a disruption. Though he maytry to support his wife, he’s likely to resent someof her demands as inordinate.Children require different styles of parentingat different ages. Infants primarily need nurtureand support. Children need guidance and con-trol; and adolescents need independence and re-sponsibility. Good parenting for a two-year-oldmay be totally inadequate for a five-year-old ora fourteen-year-old. Normal parents adjust tothese developmental challenges. The familymodifies its structure to adapt to new additions,to the children’s growth and development, andto changes in the external environment.Minuchin (1974) warns family therapistsnot to mistake growing pains for pathology. Thenormal family experiences anxiety and disrup-tion as its members adapt to growth andchange. Many families seek help at transitionalstages, and therapists should keep in mind thatthey may simply be in the process of modifyingtheir structure to accommodate to new cir-cumstances.All families face situations that stress the sys-tem. Although no clear dividing line exists be-

tween healthy and unhealthy families, we cansay that healthy families modify their structureto accommodate to changed circumstances;dysfunctional families increase the rigidity ofstructures that are no longer effective.Development ofBehavior DisordersFamily systems must be stable enough to en-sure continuity, but flexible enough to accom-modate to changing circumstances. Problemsarise when inflexible family structures cannotadjust adequately to maturational or situa-tional challenges. Adaptive changes in struc-ture are required when the family or one of itsmembers faces external stress and when tran-sitional points of growth are reached.Family dysfunction results from a combina-tion of stress and failure to realign themselvesto cope with it (Colapinto, 1991). Stressors maybe environmental (a parent is laid off, the fam-ily moves) or developmental (a child reachesadolescence, parents retire). The family’s fail-ure to handle adversity may be due to flaws intheir structure or merely to their inability to ad-just to changed circumstances.In disengaged families, boundaries are rigidand the family fails to mobilize support whenit’s needed. Disengaged parents may be un-aware that a child is depressed or experiencingdifficulties at school until the problem is far ad-vanced. In enmeshed families, on the otherhand, boundaries are diffuse and family mem-bers overreact and become intrusively involvedwith one another. Enmeshed parents create dif-ficulties by hindering the development of moremature forms of behavior in their children andby interfering with their ability to solve theirown problems.In their book of case studies, Family Healing,Minuchin and Nichols (1993) describe a com-mon example of enmeshment as a father jumpsin to settle minor arguments between his two


boys—“as though the siblings were Cain andAbel, and fraternal jealousy might lead to mur-der” (p. 149). The problem, of course, is that ifparents always interrupt their children’s quar-rels, the children won’t learn to fight their ownbattles.Although we may speak of enmeshed anddisengaged families, it is more accurate to speakof particular subsystems as being enmeshed ordisengaged. In fact, enmeshment and disen-gagement tend to be reciprocal, so that, for ex-ample, a father who’s overly involved with hiswork is likely to be less involved with his family.A frequently encountered pattern is the en-meshed mother/disengaged father syndrome—“the signature arrangement of the troubledmiddle-class family: a mother’s closeness to herchildren substituting for closeness in the mar-riage” (Minuchin & Nichols, 1993, p. 121).Feminists have criticized the notion of anenmeshed mother/disengaged father syn-drome because they reject the stereotypical di-vision of labor (instrumental role for thefather, expressive role for the mother) thatthey think Minuchin’s belief in hierarchy im-plies, and because they worry about blamingmothers for an arrangement that is culturallysanctioned. Both concerns are valid. But prej-udice and blaming are due to insensitive ap-plication of these ideas, not inherent in theideas themselves. Skewed relationships, what-ever the reason for them, can be problematic,though no single family member should beblamed or expected to unilaterally redress im-balances. Likewise, the need for hierarchydoesn’t imply any particular division of roles;it only implies that families need some kind ofstructure, some parental teamwork, and somedegree of differentiation between subsystems.Hierarchies can be weak and ineffective, orrigid and arbitrary. In the first case, youngermembers of the family may find themselves un-protected because of a lack of guidance; in thesecond, their growth as autonomous individu-als may be impaired, or power struggles may

ensue. Just as a functional hierarchy is neces-sary for a healthy family’s stability, flexibility isnecessary for them to adapt to change.The most common expression of fear ofchange is conflict avoidance, when family mem-bers shy away from addressing their disagree-ments to protect themselves from the pain offacing each other with hard truths. Disengagedfamilies avert conflict by avoiding contact; en-meshed families avoid conflict by denying dif-ferences or by constant bickering, which allowsthem to vent feelings without pressing forchange or resolving conflict.Structural family therapists use a few sim-ple symbols to diagram structural problemsand these diagrams usually make it clearwhat changes are required. Figure 7.2 showssome of the symbols used to diagram familystructure.One problem often seen by family therapistsarises when parents who are unable to resolveconflicts between them divert the focus of con-cern onto a child. Instead of worrying about


Rigid Boundary

Clear Boundary

Diffuse Boundary

Coalition

Conflict

Detouring

Involvement

OverinvolvementFIGURE 7.2 Symbols of Family Structure

each other, they worry about the child (see Fig-ure 7.3). Although this reduces the strain onfather (F) and mother (M), it victimizes thechild (C) and is therefore dysfunctional.An alternate but equally common pattern isfor the parents to continue to argue through thechildren. Father says mother is too permissive;she says he’s too strict. He may withdraw, caus-ing her to criticize his lack of concern, which inturn causes further withdrawal. The enmeshedmother responds to the child’s needs with exces-sive concern. The disengaged father tends not torespond even when a response is necessary.Both may be critical of the other’s way, but bothperpetuate the other’s behavior with their own.The result is a cross-generational coalitionbetween mother and child, which excludes thefather (Figure 7.4).Some families function well when the chil-dren are small but are unable to adjust to a grow-ing child’s need for discipline and control. Youngchildren in enmeshed families (Figure 7.5) re-ceive wonderful care: Their parents hug them,love them, and give them lots of attention. Al-though such parents may be too tired from car-ing for the children to have much time for eachother, the system may be moderately success-ful. However, if these doting parents don’tteach their children to obey rules and respectauthority, the children may be unprepared tonegotiate their entrance into school. Used togetting their own way, they may be unruly anddisruptive. Several possible consequences ofthis situation may bring the family into treat-ment. The children may be reluctant to go toschool, and their fears may be covertly rein-

forced by “understanding” parents who permitthem to remain at home (Figure 7.6). Such acase may be labeled as school phobia, and maybecome entrenched if the parents permit thechildren to remain at home for more than a fewdays.Alternatively, the children of such a familymay go to school, but since they haven’tlearned to accommodate to others, they may berejected by their schoolmates. Such childrenoften become depressed and withdrawn. Inother cases, children enmeshed with their par-ents become discipline problems at school, andthe school authorities may initiate counseling.A major change in family composition thatrequires structural adjustment occurs when di-vorced or widowed spouses remarry. Such“blended families” either readjust their bound-aries or soon experience transitional conflicts.When a woman divorces, she and the children


F M

CFIGURE 7.3 Scapegoating as a Means of Detouring Conflict

M F

Becomes

F

M C

FIGURE 7.4 Mother–Child Coalition

F M

ChildrenFIGURE 7.5 Parents Enmeshed with ChildrenM F

C

SchoolFIGURE 7.6 School Phobia

must first learn to readjust to a structure thatestablishes a clear boundary separating thedivorced spouses but still permits contactbetween father and children; then if she remar-ries, the family must readjust to functioning witha new husband and stepfather (Figure 7.7).Sometimes it’s hard for a mother and childrento allow a stepfather to participate as an equalpartner in the new parental subsystem.Mother and children have long since estab-lished transactional rules and learned to ac-commodate to each other. The new parentmay be treated as an outsider who’s supposedto learn the “right” (accustomed) way of doingthings, rather than as a new partner who willgive as well as receive ideas about childrearing(Figure 7.8). The more mother and childreninsist on maintaining their familiar patternswithout modifications required to absorb thestepfather, the more frustrated and angry he’llbecome. The result may lead to child abuse orchronic arguing between the parents. Thesooner such families enter treatment, the eas-ier it is to help them adjust to the transition.The longer they wait, the more entrenchedstructural problems become.

An important aspect of structural familyproblems is that symptoms in one member re-flect not only that person’s relationships withothers, but also the fact that those relationshipsare a function of still other relationships in thefamily. If Johnny, aged sixteen, is depressed, it’shelpful to know that he’s enmeshed with hismother. Discovering that she demands absoluteobedience from him and refuses to let him de-velop his own thinking or outside relationshipshelps to explain his depression (Figure 7.9). Butthat’s only a partial view of the family system.Why is the mother enmeshed with her son?Perhaps she’s disengaged from her husband.Perhaps she’s a widow who hasn’t found newfriends, a job, or other interests. Helping Johnnyresolve his depression may best be accomplishedby helping his mother satisfy her need for close-ness with her husband or friends.Because problems are a function of the en-tire family structure, it’s important to includethe whole group for assessment. For example, ifa father complains of a child’s misbehavior, see-ing the child alone won’t help the father to state


M F

Children

M F

Children

Becomes

M Step F

ChildrenF

Becomes

FIGURE 7.7 Divorce and Remarriage

M

Children

Step F

FIGURE 7.8 Failure to Accept a Stepparent

FM

Johnny

or

M

Johnny

Outside

Interests

FIGURE 7.9 Johnny’s Enmeshment with HisMother and Disengagement with Outside Interests

rules clearly or enforce them effectively. Norwill seeing the father and child together do any-thing to stop the mother from undercutting thefather’s authority. Only by seeing the wholefamily interacting is it possible to get a completepicture of their structure.Sometimes even seeing the whole familyisn’t enough. Structural family therapy is basedon recognition of the importance of the con-text of the social system. The family may not al-ways be the complete or most relevant context.If one of the parents is having an affair, that re-lationship is a crucial part of the family’s con-text. It may not be advisable to invite the loverto family sessions, but it is crucial to recognizethe structural implications of the extramaritalrelationship.In some cases, the family may not be thecontext most relevant to the presenting prob-lem. A mother’s depression might be due moreto her relationships at work than at home. Ason’s problems at school might be due more tothe structural context at school than to the onein the family. In such instances, structural fam-ily therapists work with the most relevant con-text to alleviate the presenting problems.Finally, some problems may be treated asproblems of the individual. As Minuchin(1974) has written, “Pathology may be insidethe patient, in his social context, or in the feed-back between them” (p. 9). Elsewhere Min-uchin (Minuchin, Rosman, & Baker, 1978)referred to the danger of “denying the individ-ual while enthroning the system” (p. 91). Fam-ily therapists shouldn’t overlook the possibilitythat some problems may be most appropriatelydealt with on an individual basis. The therapistmust not neglect the experience of individuals,although this is easy to do, especially withyoung children. While interviewing a family tosee how the parents deal with their children, acareful clinician may notice that one child hasa neurological problem or a learning disability.These problems need to be identified and ap-propriate referrals made. Usually when a child

has trouble in school, there’s a problem in thefamily or school context. Usually, but notalways.Goals of TherapyStructural family therapists believe that prob-lems are maintained by dysfunctional familyorganization. Therefore therapy is directed ataltering family structure so that the family cansolve its problems. The goal of therapy is struc-tural change; problem-solving is a by-productof this systemic goal.The idea that family problems are embed-ded in dysfunctional family structures has ledto the criticism of structural family therapy aspathologizing. Critics see structural maps ofdysfunctional organization as portraying apathological core in client families. This isn’ttrue. Structural problems are generally viewedas a simple failure to adjust to changing cir-cumstances. Far from seeing families as inher-ently flawed, structural therapists see theirwork as activating latent adaptive structuresthat are already in client families’ repertoires(Simon, 1995).The structural family therapist joins thefamily system to help its members change theirstructure. By altering boundaries and realign-ing subsystems, the therapist changes the be-havior and experience of each family member.The therapist doesn’t solve problems; that’sthe family’s job. The therapist helps modifythe family’s functioning so that family mem-bers can solve their own problems. In thisway, structural family therapy is like dynamicpsychotherapy—symptom resolution is soughtnot as an end in itself, but as a result of lastingstructural change. The analyst modifies thestructure of the patient’s mind; the structuralfamily therapist modifies the structure of thepatient’s family.The most effective way to change symptomsis to change the family patterns that maintain


them. The goal of structural family therapy is tofacilitate the growth of the system to resolvesymptoms and encourage growth in individu-als, while also preserving the mutual support ofthe family.Short-range goals may be to alleviate acuteproblems, especially life-threatening symptomssuch as anorexia nervosa (Minuchin, Rosman,& Baker, 1978). At times, behavioral tech-niques, suggestion, or manipulation may beused to achieve an immediate effect. However,unless structural change in the family system isachieved, short-term symptom resolution maycollapse.The goals for each family are dictated by theproblems they present and by the nature oftheir structural dysfunction. Although everyfamily is unique, there are common problemsand typical structural goals. Most important ofthe general goals for families is the creation ofan effective hierarchical structure. Parents areexpected to be in charge, not to relate as equalsto their children. Another common goal is tohelp parents function together as a cohesive ex-ecutive subsystem. When there is only one par-ent, or when there are several children, one ormore of the oldest children may be encouraged

to become a parental assistant. But this child’sneeds must not be neglected, either.With enmeshed families the goal is to differ-entiate individuals and subsystems by strength-ening the boundaries around them. With dis-engaged families the goal is to increase interac-tion by making boundaries more permeable.Conditions for Behavior ChangeStructural therapy changes behavior by open-ing alternative patterns of interaction that canmodify family structure. It’s not a matter of cre-ating new structures, but of activating dor-mant ones. When new transactional patternsbecome regularly repeated and predictably ef-fective, they will stabilize the new and morefunctional structure.The therapist produces change by joiningthe family, probing for areas of flexibility, andthen activating dormant structural alterna-tives. Joining gets the therapist into the family;accommodating to their style gives him or herleverage; and restructuring maneuvers trans-form the family structure. If the therapist


Structural therapists useenactments to observeand modify problematicfamily patterns.

remains an outsider or uses interventionsthat are too dystonic, the family will rejecthim or her. If the therapist becomes too mucha part of the family or uses interventions thatare too syntonic, the family will assimilate theinterventions into previous transactional pat-terns. In either case there will be no struc-tural change.Joining and accommodating are consideredprerequisite to restructuring. To join the familythe therapist must convey acceptance of familymembers and respect for their way of doingthings. Minuchin (1974) likened the familytherapist to an anthropologist who must firstjoin a culture before being able to study it.To join a family’s culture the therapist makesaccommodating overtures—the sort of thingwe usually do unthinkingly, although not al-ways successfully. If parents come for help witha child’s problems, the therapist doesn’t beginby asking for the child’s views. This conveys alack of respect for the parents and may leadthem to reject the therapist. Only after the ther-apist has successfully joined with a family is itfruitful to attempt restructuring—the oftendramatic confrontations that challenge fami-lies and force them to change.The first task is to understand the family’sview of their problems. The therapist does thisby tracking their formulation in the contentthey use to explain it and in the sequences withwhich they demonstrate it. Then the familytherapist reframes their formulation into onebased on an understanding of family structure.In fact, all psychotherapies use reframing.Patients, whether individuals or families, comewith their own views as to the cause of theirproblems—views that usually haven’t helpedthem solve the problems—and the therapist of-fers them a new and potentially more con-structive view of these same problems. Whatmakes structural family therapy unique is thatit uses enactments within therapy sessions tomake the reframing happen. This is the sinequa non of structural family therapy: observ-

ing and modifying the structure of familytransactions in the immediate context of thesession. Structural therapists work with whatthey see going on in the session, not what fam-ily members describe. Action in the session,family dynamics in process, is what structuralfamily therapists deal with.There are two types of live, in-session mater-ial on which structural family therapy focuses—enactments and spontaneous behavior sequences.An enactment occurs when the therapist stim-ulates the family to demonstrate how they han-dle a particular type of problem. Enactmentscommonly begin when the therapist suggeststhat specific subgroups begin to discuss a par-ticular problem. As they do so, the therapistobserves the family process. Working with en-actments requires three operations. First, thetherapist defines or recognizes a sequence. Forexample, the therapist observes that whenmother talks to her daughter they talk as peers,and little brother gets left out. Second, the ther-apist directs an enactment. For example, thetherapist might say to the mother, “Talk thisover with your kids.” Third, and most impor-tant, the therapist must guide the family tomodify the enactment. If mother talks to herchildren in such a way that she doesn’t take re-sponsibility for major decisions, the therapistmust guide her to do so as the family continuesthe enactment. All the therapist’s moves shouldcreate new options for the family, options formore productive interactions.Once an enactment breaks down, the thera-pist intervenes in one of two ways: comment-ing on what went wrong, or simply pushingthem to keep going. For example, if a father re-sponds to the suggestion to talk with his twelve-year-old daughter about how she’s feeling byberating her, the therapist could say to the fa-ther: “Congratulations.” Father: “What do youmean?” Therapist: “Congratulations; you win,she loses.” Or the therapist could simply nudgethe transaction by saying to the father: “Good,keep talking, but help her express her feelings


more. She’s still a little girl; she needs yourhelp.”In addition to working with enacted se-quences, structural therapists are alert to spon-taneous sequences that illustrate familystructure. Creating enactments is like directingplays; working with spontaneous sequences islike focusing a spotlight on action that occurswithout direction. By observing and modifyingsuch sequences early in therapy the therapistavoids getting bogged down in a family’s usualnonproductive ways of doing business. Dealingwith problematic behavior as soon as it occursenables the therapist to organize the session, tounderscore the process, and to modify it.An experienced therapist develops hunchesabout family structure even before the first in-terview. For example, if a family is coming tothe clinic because of a “hyperactive” child, it’spossible to guess something about the familystructure and something about sequences thatmay occur as the session begins, since “hyper-active” behavior is often a function of a child’senmeshment with the mother. Mother’s rela-tionship with the child may be a product of alack of hierarchical differentiation within thefamily; that is, parents and children relate toeach other as peers, not as members of differentgenerations. Furthermore, mother’s overin-volvement with the “hyperactive” child is likelyto be both a result and a cause of emotional dis-tance from her husband. Knowing that this is acommon pattern, the therapist can anticipatethat early in the first session the “hyperactive”child will begin to misbehave, and that themother will be ineffective in dealing with thismisbehavior. Armed with this informed guessthe therapist can spotlight (rather than enact)such a sequence as soon as it occurs. If the “hy-peractive” child begins to run around the room,and the mother protests but does nothing effec-tive, the therapist might say, “I see that yourchild feels free to ignore you.” This challengemay push the mother to behave in a more com-petent manner.

TherapyAssessmentDiagnosis implies knowledge: You describesomething and give it a name. Assessmentdeals with assumptions. A structural assess-ment is based on the assumption that a family’sdifficulties often reflect problems in the way thefamily is organized. It is assumed that if the or-ganization shifts, the problem will shift. Per-haps it’s important to add, that difficulties oftenreflect problems in the way the whole family isorganized. Thus, it is assumed that if changeoccurs between mother and daughter, thingswill also change between husband and wife.Structural therapists make assessments firstby joining with the family to build an alliance,and then by setting the family system in motionthrough the use of enactments, in-session dia-logues that permit the therapist to observe howfamily members actually interact.Suppose, for example, a young woman com-plains of obsessional indecisiveness. In re-sponding to the therapist’s questions during aninitial meeting with the family, a young womanbecomes indecisive and glances at her father.He speaks up to clarify what she was havingtrouble explaining. Now the daughter’s indeci-siveness could be linked to the father’s helpful-ness, suggesting a pattern of enmeshment.When the therapist asks the parents to discusstheir opinions about their daughter’s problems,they have trouble talking without becoming re-active and the discussion doesn’t last long. Thissuggests disengagement between the parents,which may be related (as cause and effect) toenmeshment between parent a child.Notice how the structural assessment ex-tends beyond the presenting problem to includethe whole family, and—let’s be frank—to theassumption that families with problems oftenhave some kind of underlying structural prob-lem. However, it is important to note that


structural therapists make no assumptionsabout how families should be organized. Single-parent families can be perfectly functional, ascan families with two mommies (or daddies), orindeed any other family variation. It is the factthat a family seeks therapy for a problem theyhave been unable to solve that gives a therapistlicense to assume that something about theway this particular family is organized may notbe working for them.Although structural assessments are fairlyglobal—that is, they involve the basic organiza-tion of the whole family—making an assess-ment is best done by focusing on the presentingproblem and then exploring the family’s re-sponse to it. Consider the case of a thirteen-year-old girl whose parents complain that shelies. The first question might be, “Who is shelying to?” Let’s say the answer is both parents.(Families rarely walk in and hand you theirstructure the way a student brings an apple tothe teacher.) The next question would be, “Howgood are the parents at detecting when thedaughter is lying?” And then, less innocently,“Which parent is better at detecting the daugh-ter’s lies?” Perhaps it turns out to be the mother.In fact, let’s say the mother is obsessed with de-tecting the daughter’s lies—most of whichhave to do with seeking independence in waysthat raise the mother’s anxiety. Thus a worriedmother and a disobedient daughter are lockedin struggle over growing up that excludes thefather.To carry this assessment further, a struc-tural therapist would explore the relationshipbetween the parents. The assumption wouldnot, however, be that the child’s problems arethe result of marital problems, but simply thatthe mother–daughter relationship might be re-lated to the relationship between the parents.Perhaps the parents got along famously untiltheir first child approached adolescence, andthen the mother began to worry much morethan the father. Whatever the case, the assess-ment would also involve talking with the par-

ents about growing up in their own families inorder to explore how their pasts helped makethem the way that they are.Therapeutic TechniquesIn Families and Family Therapy, Minuchin(1974) taught family therapists to see whatthey were looking at. Through the lens of struc-tural family theory, previously puzzling familyinteractions suddenly swam into focus. Whereothers saw only chaos and cruelty, Minuchinsaw structure: families organized into subsys-tems with boundaries. This enormously suc-cessful book (over 200,000 copies in print) notonly taught us to see enmeshment and disen-gagement, but also let us hope that changingthem was just a matter of joining, enactment,and unbalancing. Minuchin made changingfamilies look simple. It isn’t.Anyone who watched Minuchin at work tenor twenty years after the publication of Familiesand Family Therapy would see a creative thera-pist still evolving, not someone frozen in timeback in 1974. There would still be the patentedconfrontations (“Who’s the sheriff in this fam-ily?”) but there would be fewer enactments, lessstage-directed dialogue. We would also hearbits and pieces borrowed from Carl Whitaker(“When did you divorce your wife and marryyour job?”), Maurizio Andolfi (“Why don’t youpiss on the rug, too?”), and others. Minuchincombines many things in his work. To those fa-miliar with his earlier work, all of this raises thequestion: Is Minuchin still a structural familytherapist? The question is, of course, absurd; weraise it to make one point: Structural familytherapy isn’t a set of techniques; it’s a way oflooking at families.In the remainder of this section, we will pre-sent the classic outlines of structural family tech-nique, with the caveat that once therapistsmaster the basics of structural theory, they mustlearn to translate the approach in a way that


suits their own personal style. Implementing in-terventions is an art; therapists must discoverand create techniques that fit each family’stransactional style and the therapist’s personal-ity. Because every therapeutic session has idio-syncratic features, there can be no immediacy ifthe context is ignored. Imitating someone else’stechnique is stifling and ineffective—stifling be-cause it doesn’t fit the therapist, ineffective be-cause it doesn’t fit the family.In Families and Family Therapy, Minuchin(1974) listed three overlapping phases in theprocess of structural family therapy. The thera-pist (1) joins the family in a position of leader-ship; (2) maps their underlying structure; and(3) intervenes to transform this structure. Thisprogram is simple, in the sense that it follows aclear plan, but immensely complicated becausethere are an endless variety of family patterns.Observed in practice, structural family ther-apy is an organic whole, created out of thevery real human interaction of therapist andfamily. To be genuine and effective, a therapist’smoves cannot be preplanned or rehearsed.Good therapists are more than technicians.The strategy of therapy, on the other hand,must be thoughtfully planned. In general, thestrategy of structural family therapy followsthese seven steps:1. Joining and accommodating2. Working with interaction3. Structural mapping4. Highlighting and modifying interactions5. Boundary making6. Unbalancing7. Challenging unproductive assumptions

Joining and Accommodating. Becausefamilies have firmly established homeostaticpatterns, effective family therapy requires chal-lenge and confrontation. But assaults on a fam-ily’s habitual style will be dismissed unlessthey’re made from a position of acceptance andunderstanding. Families, like you and me, resist

efforts to change them by people they feel don’tunderstand and accept them.Individual patients generally enter treatmentalready predisposed to accept the therapist’s au-thority. By seeking therapy, an individual tacitlyacknowledges a need for help and a willingnessto trust the therapist. Not so with families.The family therapist is an unwelcome out-sider. After all, why did she insist on seeing thewhole family rather than just the official pa-tient? Family members expect to be told thatthey’re doing something wrong, and they’reprepared to defend themselves. The family isthus a group of nonpatients who feel anxiousand exposed; they’re set is to resist, not tocooperate.First the therapist must disarm defenses andease anxiety. This is done by building an al-liance of understanding with every singlemember of the family. The therapist greets eachperson by name and makes some kind offriendly contact.These initial greetings convey respect, notonly for the individuals in the family, but alsofor their hierarchical structure and organiza-tion. The therapist shows respect for parents bytaking their authority for granted. They, nottheir children, are asked first to describe theproblems. If a family elects one person to speakfor the others, the therapist notes this but doesnot initially challenge it.Children also have special concerns and ca-pacities. They should be greeted gently andasked simple, concrete questions, “Hi, I’m so-and-so; what’s your name? Oh, Shelly, that’s anice name. Where do you go to school, Shelly?”With older children, try to avoid the usual sanc-timonious grown-up questions (“And what doyou want to be when you grow up?”). Try some-thing a little fresher (like “What do you hatemost about school?”). Those who wish to re-main silent should be “allowed” to do so. Theywill anyway, but the therapist who accepts theirreticence will have made a valuable step towardkeeping them involved. “And what’s your view


of the problem?” (Grim silence.) “I see, youdon’t feel like saying anything right now?That’s fine; perhaps you’ll have something tosay later.”Failure to join and accommodate producesresistance, which is often blamed on the family.It may be comforting to blame others whenthings don’t go well, but it doesn’t improve mat-ters. Family members can be called “negative,”“rebellious,” “resistant,” or “defiant,” and seenas “unmotivated”; but it’s more useful to makean extra effort to connect with them.It’s particularly important to join powerfulfamily members, as well as angry ones. Specialpains must be taken to accept the point of viewof the father who thinks therapy is hooey or theangry teenager who feels like an accused crim-inal. It’s also important to reconnect with suchpeople at frequent intervals, particularly asthings begin to heat up.A useful beginning is to greet the family andthen ask for each person’s view of the prob-lems. Listen carefully and acknowledge eachperson’s position by reflecting what you hear.“I see, Mrs. Jones, you think Sally must be de-pressed about something that happened atschool.” “So Mr. Jones, you see some of thesame things your wife sees, but you’re not con-vinced it’s that serious a problem. Is thatright?”Working with Interaction. Family struc-ture is manifest in the way family members in-teract. It can’t always be inferred from theirdescriptions. Therefore, asking questions suchas “Who’s in charge?” or “Do you two agree?”tends to be unproductive. Families generally de-scribe themselves more as they think theyshould be than as they are.Getting family members to talk amongthemselves runs counter to their expectations.They expect to present their case to an expertand then be told what to do. If asked to discusssomething in the session, they’ll say: “We’vetalked about this many times”; or “It won’t do

any good, he (or she) doesn’t listen”; or “Butyou’re supposed to be the expert.”If the therapist begins by giving each persona chance to speak, usually one will say some-thing about another that can be a springboardfor an enactment. When, for example, one par-ent says that the other is too strict, the therapistcan develop an enactment by saying: “She saysyou’re too strict; can you answer her?” Pickinga specific point for response is more effectivethan a vague request, such as “Why don’t youtwo talk this over?”Once an enactment is begun, the therapistcan discover many things about a family’sstructure. How long can two people talk with-out being interrupted—that is, how clear is theboundary? Does one attack, the other defend?Who is central, who peripheral? Do parentsbring children into their discussions—that is,are they enmeshed?Families demonstrate enmeshment by fre-quently interrupting each other, speaking forother family members, doing things for chil-dren that they can do for themselves, or by con-stantly arguing. In disengaged families onemay see a husband sitting impassively while hiswife cries; a total absence of conflict; a surpris-ing ignorance of important information aboutthe children; a lack of concern for each other’sinterests.If, as soon as the first session starts, the kidsbegin running around the room while the par-ents protest ineffectually, the therapist doesn’tneed to hear descriptions of what goes on athome to see the executive incompetence. If amother and daughter rant and rave at eachother while the father sits silently in the corner,it isn’t necessary to ask how involved he is athome. In fact, asking may yield a less accuratepicture than the one revealed spontaneously.Structural Mapping. Families usually con-ceive of problems as located in the identifiedpatient and as determined by events from thepast. They hope the therapist will change the


identified patient—with as little disruption tothe family as possible. Family therapists regardthe identified patient’s symptoms as an expres-sion of dysfunctional patterns affecting thewhole family. A structural assessment broad-ens the problem beyond individuals to the fam-ily system, and moves the focus from discreteevents in the past to ongoing transactions inthe present.Even family therapists often categorize fam-ilies with constructs that apply more to individ-uals than to systems. “The problem in thisfamily is that the mother is smothering thekids,” or “These kids are defiant,” or “He’s un-involved.” Structural family therapists diag-nose so as to describe the interrelationship ofall family members. Using the concepts ofboundaries and subsystems, the structureof the whole system is described in a way thatpoints to desired changes.Preliminary assessments are based on ob-served interactions in the first session. In latersessions these formulations are refined and re-vised. Although there is some danger of bend-ing families to fit categories when they’reapplied early, the greater danger is waiting toolong. We see people with the greatest clarityand freshness during the initial contact. Later,as we come to know them better, we get used totheir idiosyncrasies and soon no longer noticethem.Families quickly induct therapists into theirculture. A family that initially appears to bechaotic and enmeshed soon comes to be justthe familiar Jones family. For this reason, it’scritical to develop structural hypotheses asquickly as possible.In fact, it’s helpful to make some guessesabout family structure even before the first ses-sion. This starts a process of active thinkingand sets the stage for observing the family. Forexample, suppose you’re about to see a familyconsisting of a mother, a sixteen-year-olddaughter, and a stepfather. The mother calledto complain of her daughter’s misbehavior.

What do you imagine the structure might be,and how would you test your hypothesis? Agood guess might be that mother and daughterare enmeshed, excluding the stepfather. Thiscan be tested by seeing if mother and daughtertend to talk mostly about each other in thesession—whether positively or negatively. Thestepfather’s disengagement would be con-firmed if he and his wife were unable to con-verse without the daughter’s intrusion.Structural assessments take into accountboth the problem the family presents and thestructural dynamics they display. And they in-clude all family members. In this instance,knowing that the mother and daughter are en-meshed isn’t enough; you also have to knowwhat role the stepfather plays. If he’s reason-ably close with his wife but distant from thedaughter, finding mutually enjoyable activitiesfor stepfather and stepdaughter will help in-crease the girl’s independence from her mother.On the other hand, if the mother’s proximity toher daughter appears to be a function of herdistance from her husband, then the maritalpair may be the most productive focus.Without a structural formulation and aplan, a therapist is defensive and passive. In-stead of knowing where to go and moving de-liberately, the therapist lays back and tries tocope with the family, to put out brush fires, andto help them through a succession of incidents.Consistent awareness of the family’s structureand focus on one or two structural changeshelps the therapist see behind the various con-tent issues that family members bring up.Highlighting and Modifying Interactions.Once families begin to interact, problematictransactions emerge. Recognizing their struc-tural implications demands focus on process,not content. Nothing about structure is re-vealed by hearing who is in favor of punish-ment or who says nice things about whom.Family structure is revealed by who says whatto whom, and in what way.


Perhaps a wife complains, “We have a com-munication problem. My husband won’t talk tome; he never expresses his feelings.” The thera-pist then stimulates an interaction to see whatactually does happen. “Your wife says you havea communication problem; can you respond tothat? Talk with her.” If, when they talk, the wifebecomes domineering and critical while thehusband grows increasingly silent, then thetherapist sees what’s wrong: The problem isn’tthat he doesn’t talk, which is a linear explana-tion. Nor is the problem that she nags, also alinear explanation. The problem is that themore she nags, the more he withdraws, and themore he withdraws, the more she nags.The trick is to modify this pattern. This mayrequire forceful intervening, or what structuraltherapists call intensity.Minuchin speaks to families with dramaticand forceful impact. He regulates the intensityof his messages to exceed the threshold familymembers have for not hearing challenges to theway they perceive reality. When Minuchinspeaks, families listen.Minuchin is forceful, but his intensity isn’tmerely a function of personality; it reflects clar-ity of purpose. Knowledge of family structureand a commitment to help families changemakes powerful interventions possible.Structural therapists achieve intensity by se-lective regulation of affect, repetition, and du-ration. Tone, volume, pacing, and choice ofwords can be used to raise the affective inten-sity of statements. It helps if you know whatyou want to say. Here’s an example of a limpstatement: “People are always concerned withthemselves, kind of seeing themselves as thecenter of attention and just looking for what-ever they can get. Wouldn’t it be nice, for achange, if everybody started thinking aboutwhat they could do for others?” Compare thatwith, “Ask not what your country can do foryou—ask what you can do for your country.”John Kennedy’s words had impact because theywere carefully chosen and clearly put. Family

therapists don’t need to make speeches, butthey do occasionally have to speak forcefully toget the point across.Affective intensity isn’t simply a matter ofcrisp phrasing. You have to know how andwhen to be provocative. For example, MikeNichols worked with a family in which atwenty-nine-year-old woman with anorexianervosa was the identified patient. Althoughthe family maintained a facade of togetherness,it was rigidly structured; the mother and heranorexic daughter were enmeshed, while thefather was excluded. In this family, the fatherwas the only one to express anger openly, andthis was part of the official rationale for why hewas excluded. His daughter was afraid of hisanger, which she freely admitted. What was lessclear, however, was that the mother hadcovertly taught the daughter to avoid him, be-cause she, the mother, couldn’t deal with hisanger. Consequently, the daughter grew upafraid of her father, and of men in general.At one point the father described how iso-lated he felt from his daughter; he said hethought it was because she feared his anger.The daughter agreed, “It’s his fault, all right.”The therapist asked the mother what shethought, and she replied, “It isn’t his fault.” Thetherapist said, “You’re right.” She went on,denying her real feelings to avoid conflict, “It’sno one’s fault.” The therapist answered in away that got her attention, “That’s not true.”Startled, she asked what he meant. “It’s yourfault,” he said.This level of intensity was necessary to in-terrupt a rigid pattern of conflict avoidancethat sustained a destructive alliance betweenmother and daughter. The content—who reallyis afraid of anger—is less important than thestructural goal: freeing the daughter from herposition of overinvolvement with her mother.Therapists too often dilute their interven-tions by overqualifying, apologizing, or ram-bling. This is less of a problem in individualtherapy, where it’s often best to elicit interpreta-


tions from the patient. Families are more like thefarmer’s proverbial mule—you sometimes haveto hit them over the head to get their attention.Intensity can also be achieved by extendingthe duration of a sequence beyond the pointwhere the dysfunctional homeostasis is rein-stated. A common example is the managementof temper tantrums. Temper tantrums aremaintained by parents who give in. Most par-ents try not to give in; they just don’t try longenough. Recently a four-year-old girl began toscream bloody murder when her sister left theroom. She wanted to go with her sister. Herscreaming was almost unbearable, and the par-ents were soon ready to back down. However,the therapist urged that they not allow them-selves to be defeated, and suggested that theyhold her “to show her who’s in charge” untilshe calmed down. She screamed for thirty min-utes! Everyone in the room was frazzled. But thelittle girl finally realized that this time she wasnot going to get her way, and so she calmeddown. Subsequently, the parents were able touse the same intensity of duration to break herof this highly destructive habit.Sometimes intensity requires repetition ofone theme in a variety of contexts. Infantilizingparents may have to be told not to hang uptheir child’s coat, not to speak for her, not totake her to the bathroom, and not to do manyother things that she’s able to do for herself.Shaping competence is another method ofmodifying interactions, and it’s a hallmark ofstructural family therapy. Intensity is generallyused to block the stream of interactions. Shap-ing competence is like nudging the direction ofthe flow. By highlighting and shaping the pos-itive, structural therapists help family membersuse functional alternatives that are already intheir repertoire.A common mistake made by beginning ther-apists is to attempt to foster competent perfor-mance by pointing out mistakes. This focuseson content without regard for process. Tellingparents that they’re doing something wrong or

suggesting they do something different has theeffect of criticizing their competence. Howeverwell-intentioned, it’s still a put-down. Whilethis kind of intervention cannot be completelyavoided, a more effective approach is to pointout what they’re doing right.Even when people do most things ineffec-tively, it’s usually possible to pick out somethingthat they’re doing successfully. A sense of timinghelps. For example, in a large chaotic family theparents were extremely ineffective at controllingthe children. At one point the therapist turned tothe mother and said, “It’s too noisy in here;would you quiet the kids?” Knowing how muchdifficulty the woman had controlling her chil-dren, the therapist was poised to comment im-mediately on any step in the direction of effectivemanagement. The mother had to yell “Quiet!” acouple of times before the children momentarilystopped what they were doing. Quickly—beforethe children resumed their misbehavior—thetherapist complimented the mother for “lovingher kids enough to be firm with them.” Thus themessage delivered was “You’re a competent per-son, you know how to be firm.” If the therapisthad waited until the chaos resumed before tell-ing the mother she should be firm, the messagewould be “You’re incompetent.”Wherever possible, structural therapists avoiddoing things for family members that they’re ca-pable of doing themselves. Here, too, the mes-sage is “You are competent, you can do it.” Sometherapists justify taking over family functions bycalling it “modeling.” Whatever it’s called it hasthe impact of telling family members that they’reinadequate. Recently a young mother confessedshe hadn’t known how to tell her children thatthey were coming to see a family therapist and sohad simply said she was taking them for a ride.Thinking to be helpful, the therapist then ex-plained to the children that “Mommy told methere were some problems in the family, so we’reall here to talk things over to see if we can im-prove things.” This lovely explanation tells thekids why they came, but confirms the mother as


incompetent to do so. If instead the therapisthad suggested to the mother, “Would you like totell them now?” Then the mother, not the ther-apist, would have had to perform as an effectiveparent.Boundary Making. Dysfunctional family dy-namics are a product of overly rigid or diffuseboundaries. Structural therapists intervene torealign boundaries, increasing either proximityor distance between family subsystems.In enmeshed families the therapist’s inter-ventions are designed to strengthen boundariesbetween subsystems and increase the indepen-dence of individuals. Family members areurged to speak for themselves, interruptions areblocked, and dyads are helped to finish conver-sations without intrusion from others. A ther-apist who wishes to support the sibling systemand protect it from unnecessary parental intru-sion may say, “Susie and Sean, talk this over,and everyone else will listen carefully.” If chil-dren frequently interrupt their parents, a ther-apist might challenge the parents to strengthenthe hierarchical boundary by saying, “Whydon’t you get them to butt out so that you twogrown-ups can settle this.”Although structural family therapy is begunwith the total family group, subsequent sessionsmay be held with individuals or subgroups tostrengthen the boundaries surrounding them.A teenager who is overprotected by her motheris supported as a separate person by participat-ing in some individual sessions. Parents so en-meshed with their children that they never haveprivate conversations may begin to learn how ifthey meet separately with the therapist.When a forty-year-old woman called theclinic for help with depression, she was asked tocome in with the rest of the family. It soon be-came apparent that this woman was overbur-dened by her four children and received littlesupport from her husband. The therapist’s strat-egy was to strengthen the boundary betweenthe mother and children and help the parents

move closer toward each other. This was done instages. First the therapist joined the oldest child,a sixteen-year-old girl, and supported her com-petence as a potential helper for her mother.Once this was done, the girl was able to assumea good deal of responsibility for her younger sib-lings, both in sessions and at home.Freed from preoccupation with the chil-dren, the parents now had the opportunity totalk more with each other. They had little tosay, however. This wasn’t the result of hiddenconflict but instead reflected the marriage oftwo relatively nonverbal people. After severalsessions of trying to get the pair talking, thetherapist realized that while talking may befun for some people, it might not be for others.So to support the bond between the couple thetherapist asked them to plan a special trip to-gether. They chose a boat ride on a nearby lake.When they returned for the next session, theywere beaming. They had a wonderful time,being apart from the kids and enjoying eachother’s company. Subsequently they decided tospend a little time out together each week.Disengaged families tend to avoid conflict,and thus minimize interaction. The structuraltherapist intervenes to challenge conflict avoid-ance, and to block detouring in order to helpdisengaged members increase contact witheach other. Without acting as judge or referee,the structural therapist encourages familymembers to face each other squarely and strug-gle with the difficulties between them. Whenbeginners see disengagement, they tend tothink of ways to increase positive interaction.In fact, disengagement is usually a way ofavoiding arguments. Therefore, spouses iso-lated from each other typically need to fight be-fore they can become more loving.Most people underestimate the degree towhich their own behavior influences the behav-ior of those around them. This is particularlytrue in disengaged families. Problems are usu-ally seen as the result of what someone else isdoing, and solutions are thought to require that


the others change. The following complaints aretypical: “We have a communication problem; hewon’t tell me what he’s feeling.” “He just doesn’tcare about us. All he cares about is that damn jobof his.” “Our sex life is lousy—my wife’s frigid.”“Who can talk to her? All she does is complainabout the kids.” Each of these statements sug-gests that the power to change rests solely withthe other person. This is the almost universallyperceived view of linear causality.Whereas most people see things this way,family therapists see the inherent circularity insystems interaction. He doesn’t tell his wifewhat he’s feeling, because she nags and criti-cizes; and she nags and criticizes because hedoesn’t tell her what he’s feeling.Structural therapists move family discus-sions from linear to circular perspectives bystressing complementarity. The mother whocomplains that her son is naughty is taught toconsider what she’s doing to trigger or main-tain his behavior. The one who asks for changemust learn to change his or her way of tryingto get it. The wife who nags her husband tospend more time with her must learn to makeincreased involvement more attractive. Thehusband who complains that his wife never lis-tens to him may have to listen to her more, be-fore she’s willing to reciprocate.Minuchin emphasizes complementarity byasking family members to help each otherchange. When positive changes are reported,he’s liable to congratulate others, underscoringfamily interrelatedness.Unbalancing. In boundary making the ther-apist aims to realign relationships between sub-systems. In unbalancing, the goal is to changethe relationship of members within a subsys-tem. What often keeps families stuck in stale-mate is that members in conflict check andbalance each other and, as a result, remainfrozen in inaction. In unbalancing, the thera-pist joins and supports one individual or sub-system at the expense of others.

Taking sides—let’s call it what it is—seemslike a violation of therapy’s sacred canon ofneutrality. However, the therapist takes sides tounbalance and realign the system, not becauseshe is the judge of who’s right and wrong. Ulti-mately, balance and fairness are achieved be-cause the therapist sides in turn with variousmembers of the family.

For example, when the MacLean family sought help foran “unmanageable” child, a terror who’d been expelledfrom two schools, Dr. Minuchin uncovered a covert split be-tween the parents, held in balance by not being talkedabout. The ten-year-old boy’s misbehavior was dramaticallyvisible; his father had to drag him kicking and screaminginto the consulting room. Meanwhile, his seven-year-oldbrother sat quietly, smiling engagingly. The good boy.To broaden the focus from an “impossible child” to is-sues of parental control and cooperation, Minuchin askedabout seven-year-old Kevin, who misbehaved invisibly. Hepeed on the floor in the bathroom. According to his father,Kevin’s peeing on the floor was due to “inattentiveness.”The mother laughed when Minuchin said “nobody couldhave such poor aim.”Minuchin talked with the boy about how wolves marktheir territory, and suggested that he expand his territoryby peeing in all four corners of the family room.Minuchin: “Do you have a dog?”Kevin: “No.”Minuchin: “Oh, so you are the family dog.”In the process of discussing the boy who peed—andhis parents’ response—Minuchin dramatized how the par-ents polarized each other.Minuchin: “Why would he do such a thing?”Father: “I don’t know if he did it on purpose.”Minuchin: “Maybe he was in a trance?”Father: “No, I think it was carelessness.”Minuchin: “His aim must be terrible.”The father described the boy’s behavior as accidental;the mother considered it defiance. One of the reasons par-ents fall under the control of their young children is that


CaseStudy

they avoid confronting their differences. Differences arenormal, but they become toxic when one parent under-cuts the other’s handling of the children. (It’s cowardly re-venge for unaddressed grievances.)Minuchin’s gentle but insistent pressure on the coupleto talk about how they respond, without switching to focuson how the children behave, led to their bringing up long-held but seldom-voiced resentments.Mother: “Bob makes excuses for the children’s behaviorbecause he doesn’t want to get in there and help me finda solution for the problem.”Father: “Yes, but when I did try to help, you’d always criti-cize me. So after a while I gave up.”Like a photographic print in a developing tray, thespouses’ conflict had become visible. Minuchin protectedthe parents from embarrassment (and the children frombeing burdened) by asking the children to leave the room.Without the preoccupation of parenting, the spouses couldface each other, man and woman—and talk about theirhurts and grievances. It turned out to be a sad story oflonely disengagement.Minuchin: “Do you two have areas of agreement?”He said yes; she said no. He was a minimizer; she wasa critic.Minuchin: “When did you divorce Bob and marry thechildren?”She turned quiet; he looked off into space. She said,softly: “Probably ten years ago.”What followed was a painful but familiar story of how amarriage can drown in parenting and its conflicts. The con-flict was never resolved because it never surfaced. And sothe rift never healed; it just expanded.With Minuchin’s help, the couple took turns talkingabout their pain—and learning to listen. By unbalancing,Minuchin brought enormous pressure to bear to help thiscouple break through their differences, open up to eachother, fight for what they want, and, finally, begin to cometogether—as husband and wife, and as parents.

Unbalancing is part of a struggle for changethat sometimes takes on the appearance of

combat. When a therapist says to a father thathe’s not doing enough or to a mother that she’sunwittingly excluding her husband, it mayseem that the combat is between the therapistand the family, that he or she is attacking them.But the real combat is between them and fear—fear of change.Challenging Unproductive Assumptions.Although structural family therapy is not pri-marily a cognitive treatment, its practitionerssometimes challenge the way family memberssee things. Changing the way family membersrelate to each other offers alternative views oftheir situation. The converse is also true:Changing the way family members view theirsituation enables them to change the way theyrelate to each other.When six-year-old Cassie’s parents com-plain about her behavior, they say she’s“hyper,” “sensitive,” a “nervous child.” Such la-bels convey how parents respond to their chil-dren and have a tremendous controlling power.Is a child’s behavior “misbehavior,” or is it asymptom of “nervousness?” Is it “naughty,” oris it a “cry for help?” Is the child mad or bad,and who is in charge? What’s in a name?Plenty.Sometimes the structural family therapistacts as teacher, offering information and ad-vice, often about structural matters. Doing so islikely to be a restructuring maneuver and mustbe done in a way that minimizes resistance. Atherapist does this by delivering first a “stroke,”then a “kick.” If the therapist were dealing witha family in which the mother speaks for herchildren, he might say to her, “You are veryhelpful” (stroke). But to the child, “Mommytakes away your voice. You can speak for your-self ” (kick). Thus mother is defined as helpfulbut intrusive (a stroke and a kick).Structural therapists also use pragmatic fic-tions to provide family members with a differ-ent frame for experiencing. The aim isn’t toeducate or deceive, but to offer a pronounce-


ment that will help the family change. For in-stance, telling children that they’re behavingyounger than they are is a very effective meansof getting them to change. “How old are you?”“Seven.” “Oh, I thought you were younger;most seven-year-olds don’t need Mommy totake them to school anymore.”Paradoxes are cognitive constructions thatfrustrate or confuse family members into asearch for alternatives. Minuchin makes littleuse of paradox, but sometimes it’s helpful to ex-press skepticism about people changing. Al-though this can have the paradoxical effect ofchallenging them to prove you wrong, it isn’t somuch a clever stratagem as it is a benign state-ment of the truth. Most people don’t change—they wait for others to do so.Evaluating Therapy Theory and ResultsWhile he was Director of the Philadelphia ChildGuidance Clinic, Minuchin developed a highlypragmatic commitment to research. As an ad-ministrator he learned that research demon-strating effective outcomes is the best argumentfor the legitimacy of family therapy. Both hisstudies of psychosomatic children and Stan-ton’s studies of drug addicts show very clearlyhow effective structural family therapy can be.In Families of the Slums, Minuchin and hiscolleagues (1967) described the structuralcharacteristics of low socioeconomic familiesand demonstrated the effectiveness of familytherapy with this population. Prior to treat-ment, mothers in patient families were found tobe either over- or undercontrolling; either waytheir children were more disruptive than thosein control families. After treatment mothersused less coercive control, yet were clearer andmore firm. In this study, seven of eleven fami-lies were judged to be improved after six monthsto a year of family therapy. Although no con-trol group was used, the authors compared

their results favorably to the usual 50 percentrate of successful treatment at Wiltwyck. Theauthors also noted that none of the familiesrated as disengaged improved.By far the strongest empirical support forstructural family therapy comes from a series ofstudies with psychosomatic children and adultdrug addicts. Studies demonstrating the effec-tiveness of therapy with severely ill psychoso-matic children are convincing because of thephysiological measures employed, and dra-matic because of the life-threatening nature ofthe problems. Minuchin, Rosman, and Baker(1978) reported one study that clearly demon-strated how family conflict can precipitate ke-toacidosis crises in psychosomatic-type diabeticchildren. In baseline interviews parents dis-cussed family problems with their children ab-sent. Normal spouses showed the highest levelsof confrontation, while psychosomatic spousesexhibited a wide range of conflict-avoidancemaneuvers. Next, a therapist pressed the par-ents to increase the level of their conflict, whiletheir children observed behind a one-way mir-ror. As the parents argued, only the psychoso-matic children seemed really upset. Moreover,these children’s manifest distress was accom-panied by dramatic increases in free fatty acidlevels of the blood, a measure related to ke-toacidosis. In the third stage of these inter-views, the patients joined their parents. Normaland behavior-disorder parents continued as be-fore, but the psychosomatic parents detouredtheir conflict, either by drawing their childreninto their discussions or by switching the sub-ject from themselves to the children. When thishappened, the free fatty acid levels of the par-ents fell, while the children’s levels continued torise. This study provided strong confirmation ofthe clinical observations that psychosomaticchildren are used (and let themselves be used)to regulate the stress between their parents.Minuchin, Rosman, and Baker (1978) sum-marized the results of treating fifty-three casesof anorexia nervosa with structural family


therapy. After a course of treatment that in-cluded hospitalization followed by family ther-apy on an outpatient basis, forty-three anorexicchildren were “greatly improved,” two were“improved,” three showed “no change,” twowere “worse,” and three had dropped out. Al-though ethical considerations precluded a con-trol treatment with these seriously ill children,the 90 percent improvement rate is impressive,especially compared with the 30 percent mor-tality rate for this disorder. Moreover, the posi-tive results at termination were maintained atfollow-up intervals of several years. Structuralfamily therapy has also been shown to be effec-tive in treating psychosomatic asthmatics andpsychosomatically complicated cases of dia-betes (Minuchin, Baker, Rosman, Liebman, Mil-man, & Todd, 1975).While no body of empirical evidence has es-tablished that any one psychotherapeutic ap-proach is consistently better than the others,structural family therapy has proven to be ef-fective in a variety of studies, including manythat involved what are usually considered verydifficult cases. Duke Stanton showed that struc-tural family therapy can be effective for drugaddicts and their families. In a well-controlledstudy, Stanton and Todd (1979) compared fam-

ily therapy with a family placebo condition andindividual therapy. Symptom reduction wassignificant with structural family therapy; thelevel of positive change was more than doublethat achieved in the other conditions, and thesepositive effects persisted at follow-up of six andtwelve months.More recently, structural family therapy hasbeen successfully applied to establish moreadaptive parenting roles in heroin addicts (Grief& Dreschler, 1993) and as a means to reducethe likelihood that African American andLatino youths would initiate drug use (Santise-ban, Coatsworth, Perez-Vidal, Mitrani, Jean-Gilles, & Szapocznik, 1997). Other studiesindicate that structural family therapy is equalin effectiveness to communication training andbehavioral management training in reducingnegative communication, conflicts, and ex-pressed anger between adolescents diagnosedwith attention deficit hyperactivity disorder(ADHD) and their parents (Barkley, Guevre-mont, Anastopoulos, & Fletcher, 1992). Struc-tural family therapy has also been effective fortreating adolescent disorders, such as conductdisorders (Szapocznik et al., 1989; Chamber-lain & Rosicky, 1995), and anorexia nervosa(Campbell & Patterson, 1995).


ummarySMinuchin may be best known for the artistryof his clinical technique, yet his structuralfamily theory has become one of the mostwidely used conceptual models in the field.The reason structural theory is so popularis that it’s simple, inclusive, and practical.The basic concepts—boundaries, subsystems,alignments, and complementarity—are easilygrasped and applied. They take into accountthe individual, family, and social context, and

they provide a clear organizing framework forunderstanding and treating families.The single most important tenet of this ap-proach is that every family has a structure, andthat this structure is revealed only when thefamily is in action. According to this view, ther-apists who fail to consider the entire family’sstructure, and intervene in only one subsys-tem, are unlikely to effect lasting change. If amother’s overinvolvement with her son is part

of a structure that includes distance from herhusband, no amount of therapy for the motherand son is likely to bring about basic change inthe family.Subsystems are units of the family based onfunction. If the leadership of a family is takenover by a father and daughter, then they, not thehusband and wife, are the executive subsystem.Subsystems are circumscribed and regulated byinterpersonal boundaries. In healthy familiesboundaries are clear enough to protect indepen-dence and autonomy, and permeable enough toallow mutual support and affection. Enmeshedfamilies are characterized by diffuse boundaries;disengaged families by rigid boundaries.Structural family therapy is designed to re-solve presenting problems by reorganizingfamily structure. Assessment, therefore, re-quires the presence of the whole family, so thatthe therapist can observe the structure under-lying the family’s interactions. In the process,therapists should distinguish between dys-functional and functional structures. Familieswith growing pains shouldn’t be treated aspathological. Where structural problems doexist, the goal is to create an effective hierar-chical structure. This means activating dor-mant structures, not creating new ones.Structural family therapists work quickly toavoid being inducted as members of the familiesthey work with. They begin by making con-certed efforts to accommodate to the family’saccustomed ways of behaving, in order to cir-cumvent resistance. Once they’ve gained a fam-ily’s trust, therapists promote family interaction,while they assume a decentralized role. Fromthis position they can watch what goes on in thefamily and make a structural assessment, whichincludes the problem and the organization thatsupports it. These assessments are framed interms of boundaries and subsystems, easily con-ceptualized as two-dimensional maps used tosuggest avenues for change.Once they have successfully joined and as-sessed a family, structural therapists proceed to

activate dormant structures using techniquesthat alter alignments and shift power withinand between subsystems. These restructuringtechniques are concrete, forceful, and some-times dramatic. However, their success dependsas much on the joining and assessment as onthe power of the techniques themselves.Structural family therapy’s popularity isbased on its theory and techniques of treat-ment; its central position in the field has beenaugmented by its research and training pro-grams. There is now a substantial body of re-search that lends considerable empiricalsupport to this school’s approach. Moreover,the training programs at the Philadelphia ChildGuidance Clinic and Minuchin Center in NewYork have influenced an enormous number offamily therapy practitioners throughout theworld.Although structural family therapy is soclosely identified with Salvador Minuchin thatthey once were synonymous, it may be a goodidea to differentiate the man from the method.When we think of structural family therapy, wetend to remember the approach as described inFamilies and Family Therapy, published in 1974.That book adequately represents structuraltheory, but emphasizes only the techniquesMinuchin favored at the time. Minuchin, thethinker, has always thought of families in orga-nizational terms. He read Talcott Parsons andRobert Bales and George Herbert Mead; and inIsrael he saw how children from unstructuredMoroccan families often became delinquents,while those from organized Yemenite familiesdid not. Minuchin the therapist has alwaysbeen an opportunist, using whatever works. Inthe 1990s, you can see Carl Whitaker andconstructivism in Minuchin’s work. FromWhitaker, he took the idea of challenging fam-ilies’ myths and engaging with them from a po-sition of passionate involvement. The youngMinuchin followed families and watched themin action; that’s why he made such use of en-actments. The older Minuchin, who has seen


thousands of families, now sees things faster;he uses enactment less and is likely to confrontone family on the basis of what he has seen inhundreds of similar cases. Should we followhim in this? Yes, as soon as we have the sameexperience.Minuchin has always been a constructivist,though he comes by it intuitively, not fromreading books. He challenges families, tellingthem, essentially, that they are wrong; theirstories are too narrow. And he helps themrewrite stories that work. Minuchin has alwaysbeen interested in literature and storytelling;

perhaps he likes the doctrine of constructivismsimply because it legitimizes his storytelling.But, he cautions, when constructivism isn’tgrounded in structural understanding or whenit neglects the emotional side of human beings,it can become arid intellectualism. Minuchinhas moved toward eclecticism in technique, butnot in theory. Although Minuchin the therapisthas changed since 1974, his basic perspectiveon families, described in structural family the-ory, still stands, and continues to be the mostwidely used way of understanding what goeson in the nuclear family.


ecommendedR eadingsRColapinto J. 1991. Structural family therapy. In Hand-book of family therapy, vol. II, A. S. Gurman andD. P. Kniskern, eds. New York: Brunner/Mazel.Minuchin, S. 1974. Families and family therapy. Cam-bridge, MA: Harvard University Press.Minuchin, S., and Fishman, H. C. 1981. Family ther-apy techniques. Cambridge, MA: Harvard Univer-sity Press.Minuchin, S., Lee, W-Y., and Simon, G. M. 1996.Mastering family therapy: Journeys of growth andtransformation. New York: Wiley.Minuchin, S., Montalvo, B., Guerney, B., Rosman, B.,and Schumer, F. 1967. Families of the slums. NewYork: Basic Books.

Minuchin, S., and Nichols, M. P. 1993. Family healing:Tales of hope and renewal from family therapy. NewYork: Free Press.Minuchin, S., Rosman, B. L., and Baker, L. 1978. Psy-chosomatic families: Anorexia nervosa in context.Cambridge, MA: Harvard University Press.Nichols, M. P. 1999. Inside family therapy. Boston:Allyn & Bacon.Nichols, M. P. and Minuchin, S. 1999. Short-termstructural family therapy with couples. In Short-term couple therapy, J. M. Donovad, ed. New York:Guilford Press.

eferencesRBarkley, R., Guevremont, D., Anastopoulos, A., andFletcher, K. 1992. A comparison of three familytherapy programs for treating family conflicts inadolescents with attention-deficit hyperactivitydisorder. Journal of Consulting and Clinical Psychol-ogy. 60:450–463.Campbell, T., and Patterson, J. 1995. The effective-ness of family interventions in the treatment ofphysical illness. Journal of Marital and Family Ther-apy. 21:545–584.

Chamberlain, P., and Rosicky, J. 1995. The effective-ness of family therapy in the treatment of adoles-cents with conduct disorders and delinquency.Journal of Marital and Family Therapy. 21:441–459.Colapinto, J. 1991. Structural family therapy. In Hand-book of family therapy, vol. II. A. S. Gurman andD. P. Kniskern, eds. New York: Brunner/Mazel.Elizur, J., and Minuchin, S. 1989. Institutionalizingmadness: Families, therapy, and society. New York:Basic Books.

Grief, G., and Dreschler, L. 1993. Common issues forparents in a methadone maintenance group. Jour-nal of Substance Abuse Treatment. 10: 335–339.Minuchin, S. 1974. Families and family therapy. Cam-bridge, MA: Harvard University Press.Minuchin, S., Baker, L., Rosman, B., Liebman, R., Mil-man, L., and Todd, T. C. 1975. A conceptualmodel of psychosomatic illness in children.Archives of General Psychiatry. 32:1031–1038.Minuchin, S., and Fishman, H. C. 1981. Family ther-apy techniques. Cambridge, MA: Harvard Univer-sity Press.Minuchin, S., Lee, W-Y., and Simon, G. M. 1996.Mastering family therapy: Journeys of growth andtransformation. New York: Wiley.Minuchin, S., Montalvo, B., Guerney, B., Rosman, B.,and Schumer, F. 1967. Families of the slums. NewYork: Basic Books.Minuchin, S., and Nichols, M. P. 1993. Family healing:Tales of hope and renewal from family therapy. NewYork: Free Press.

Minuchin, S., Rosman, B., and Baker, L. 1978. Psy-chosomatic families: Anorexia nervosa in context.Cambridge, MA: Harvard University Press.Santiseban, D., Coatsworth, J., Perez-Vidal, A., Mi-trani, V., Jean-Gilles, M., and Szapocznik, J. 1997.Brief structural/strategic family therapy withAfrican American and Hispanic high-risk youth.Journal of Community Psychology. 25:453–471.Simon, G. M. 1995. A revisionist rendering of struc-tural family therapy. Journal of Marital and FamilyTherapy. 21:17–26.Stanton, M. D., and Todd, T. C. 1979. Structural fam-ily therapy with drug addicts. In The family therapyof drug and alcohol abuse, E. Kaufman and P. Kauf-mann, eds. New York: Gardner Press.Szapocznik, J., Rio, A., Murray, E., Cohen, R., Scopetta,M., Rivas-Vazquez, A., Hervis, O., Posada, V., andKurtines, W. 1989. Structural family versus psy-chodynamic child therapy for problematic His-panic boys. Journal of Consulting and ClinicalPsychology. 57:571–578.


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