Brief Strategic Family Therapy
U.S. Department of Justice
Office of Justice Programs
Office of Juvenile Justice and Delinquency Prevention
John J. Wilson, Acting Administrator
April 2000
Brief Strategic
Strengthening S
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From the Administrator
Just as a child is influenced by his or
Family Therapy
her family, the child’s family, in turn, is
affected by the culture of which it is
an integral part. If we are to succeed
in preventing and combating delin-
quency, we must work to strengthen
the role of the family within the com-
Michael S. Robbins and José Szapocznik
munity in which it resides.
The Office of Juvenile Justice and Delin-
One of the first challenges the Spanish
This Bulletin features a family-
quency Prevention (OJJDP) is dedicated to
Family Guidance Center’s clinical program
strengthening strategy—brief strate-
preventing and reversing trends of increased
encountered involved identifying and de-
gic family therapy—that integrates
delinquency and violence among adoles-
veloping a culturally appropriate and ac-
theory with decades of research and
cents. These trends have alarmed the pub-
ceptable treatment intervention for Cu-
practice at the University of Miami in
lic during the past decade and challenged
ban youth with behavior problems. To
an intensive, short-term, problem-
the juvenile justice system. It is widely ac-
understand Cuban culture and how it re-
focused intervention, generally
cepted that increases in delinquency and
sembled, and differed from, mainstream
lasting 3 months.
violence over the past decade are rooted in
culture, the Center’s staff conducted a
The Bulletin also describes the
a number of interrelated social problems—
comprehensive study on value orienta-
therapy’s implementation by the
child abuse and neglect, alcohol and drug
tions. The study determined that the
Spanish Family Guidance Center.
abuse, youth conflict and aggression, and
Cuban community expected a family-
The Center, which was established
early sexual involvement—that may origi-
oriented approach in which therapists
by the University of Miami’s School
nate within the family structure. The focus
take active, directive, present-oriented
of Medicine, serves the local His-
of OJJDP’s Family Strengthening Series is to
leadership roles (Szapocznik, Scopetta,
panic community, consisting largely
provide assistance to ongoing efforts across
et al., 1978).
of Cuban immigrants. In adapting
the country to strengthen the family unit by
The Center’s second challenge involved
brief strategic family therapy to the
discussing the effectiveness of family inter-
developing interventions to help recent
needs of its clients, the Center took
vention programs and providing resources
immigrant Hispanic families work to-
into account the strengths and weak-
to families and communities.
gether to deal with the stress of accul-
nesses these minority youth and
The 1970’s witnessed a tremendous in-
turation. In these families, it was quite
families bring to therapy, and those
crease in the number of Hispanic adoles-
common for conflicts to emerge or inten-
special risk and protective factors
cents involved with drugs. In response to
sify when the children or adolescents
are also highlighted in these pages.
this problem, the University of Miami (FL)
began to behave in ways that were not
The needs of families are addressed
School of Medicine, Department of Psy-
consistent with the families’ traditional
most effectively within the social and
chiatric and Behavioral Sciences, estab-
cultural values. Typically, these conflicts
cultural milieus of those families.
lished the Spanish Family Guidance Cen-
occurred as children and adolescents as-
Brief strategic family therapy is a
ter in Miami to provide services to the
similated more rapidly than their parents
time-tested approach to that end.
local Hispanic community, which was pre-
to the bicultural environment in which
dominately recent immigrants from Cuba.
they were living, and often involved a clash
John J. Wilson
The Center was initially funded by the
between the American value of individual-
Acting Administrator
U.S. Department of Health, Education, and
ism and the Hispanic value of familism.
Welfare, Office of Economic Opportunity.
Such intergenerational (parent versus
adolescent) and cultural differences often
yielded intense conflict within the family
and resulted in parents and adolescents
feeling alienated from one another.
In 1975, the Spanish Family Guidance Center
adopted structural family therapy (SFT) as
its core approach, and SFT has been at the
heart of the Center’s efforts to develop
interventions for use in culturally diverse
contexts (Szapocznik and Kurtines, 1993).
Over time, the structural approach of SFT
has been refined to meet the needs of the
Hispanic community in Miami. For example,
SFT uses treatment methods that are both
strategic (i.e., problem focused and prag-
matic) and time limited. Thus, the structural
approach has evolved into a time-limited,
family-based approach that combines both
structural and strategic interventions. This
and cultural/contextual factors that influ-
one parent, usually the mother, to come
approach, called brief strategic family
ence youth behavior problems. BSFT is
to the United States alone to establish a
therapy (BSFT), has become the most com-
based on the fundamental assumption
place and economic means for the family,
mon intervention used by the Spanish
that the family is the “bedrock” of child
and then bring the children to this coun-
Family Guidance Center for families that
development; the family is viewed as the
try. For many families, this process is pro-
include youth with behavior problems.
primary context in which children learn
tracted, and they are separated for many
BSFT evolved from more than 25 years of
to think, feel, and behave. Family rela-
years. Moreover, the reunification process
research and practice at the University of
tions are thus believed to play a pivotal
often fails to meet family members’ expec-
Miami. The structural orientation of BSFT
role in the evolution of behavior problems
tations. Children are often disappointed
draws on the work of Minuchin (Minuchin,
and, consequently, they are a primary tar-
when they arrive in the United States and
1974; Minuchin and Fishman, 1981; and
get for intervention.
see that they are living in an impover-
Minuchin, Rosman, and Baker, 1978), and
ished, dangerous, inner-city community.
BSFT recognizes that the family itself is part
the strategic aspects of BSFT are influenced
Likewise, parents are often disappointed
of a larger social system and—as a child is
by Haley (1976) and Madanes (1981). By
when they are confronted with angry and
influenced by her or his family—the family
integrating theory, research findings, and
emotionally detached children. As a re-
is influenced by the larger social system
clinical practice, BSFT has been continu-
sult, treatment often involves attempting
in which it exists. Sensitivity to contextual
ously refined to improve its effectiveness
to reestablish parent-child bonds and cre-
factors begins with an understanding of
with youth with behavior problems.
ate new family structures that include the
the influence of peers, schools, and neigh-
parent who was separated from the family.
Since its modest beginning in a small store-
borhoods on the development of children’s
front location, the Spanish Family Guid-
behavior problems. However, BSFT also
High conflict. Intense and persistent
ance Center has grown in response to the
focuses on parents’ relationships with
conflict is a common characteristic of
needs of the minority community in Mi-
children’s peers, schools, and neighbor-
families of youth with behavior prob-
ami. In particular, work with youth with
hoods and on the unique relationships
lems. High levels of conflict interfere
behavior problems has expanded to in-
that parents have with individuals and
with parents’ ability to resolve problems,
clude minority families from a variety of
systems outside the family (e.g., work or
communicate effectively, nurture, and
backgrounds, including both Hispanic
groups such as Alcoholics Anonymous).
guide their children. BSFT focuses on
(from the Caribbean Islands and Central
assessing the family’s conflict resolution
and South America) and African American
style and developing specific interven-
Program Objectives
youth and families. To accommodate this
tions to help families negotiate and re-
expansion, the Center for Family Studies
BSFT has been revised to respond to the
solve their differences more effectively.
was established as an umbrella organiza-
unique strengths and weaknesses minor-
Inner city. The powerful influence of
tion to serve inner-city minority youth
ity youth and families in Miami bring to
neighborhoods cannot be ignored when
and families in Miami. The mission of the
therapy. Several of these risk and protec-
working with inner-city youth and fami-
Center for Family Studies is to identify the
tive factors are described below.
lies. In fact, accumulating evidence
needs of minority families and develop
shows that the positive changes made in
and refine culturally appropriate interven-
Mitigating Risk Factors
family therapy are often overwhelmed
tions to meet those needs. The Center for
Immigration. Many of the families served
by the harsh and deteriorated conditions
Family Studies uses BSFT to help children
by the Spanish Family Guidance Center
of the inner city. As a result, the focus of
and adolescents with conduct, delin-
have recently immigrated to the United
BSFT has expanded from individual fami-
quency, and other behavior-related prob-
States. The immigration process creates
lies to include the relationship between
lems, including alcohol and substance
specific problems that must be addressed
families and the multiple systems that in-
abuse. To improve youth behavior, BSFT
in treatment. For example, many families
fluence children. Developments in the
attempts to change family interactions
emigrate in stages; it is not uncommon for
clinical model have been heavily influenced
2
by the theoretical work of Urie Bronfen-
BSFT has been implemented as a preven-
system’s structure. This view of structure
brenner (1977, 1979, 1986) and the
tion, early intervention, and intervention
is evident in the following assumptions:
groundbreaking clinical work of Scott
strategy for delinquent and substance-
x Structure refers to the repetitive pat-
Henggeler and his colleagues (Henggeler
abusing adolescents.
terns of interactions that characterize
and Borduin, 1990; Henggeler, Melton,
the family system.
and Smith, 1992). In particular, BSFT has
expanded to include attention to the rela-
Theoretical
x Repetitive interactions (i.e., ways fam-
tionship between families, on one hand,
Underpinnings
ily members behave with one another)
and schools, peers, juvenile justice agen-
are either successful or unsuccessful
The goal of BSFT is to improve youth
cies, and neighborhoods, on the other.
in achieving the goals of the family or
behavior by:
its individual members.
Enhancing Protective
x Improving family relationships that
x BSFT targets repetitive patterns of in-
Factors
are presumed to be directly related
teraction (i.e., the habitual ways in
to youth behavior problems.
Extended families. One of the most effec-
which family members behave with
tive protective factors is the availability of
x Improving relationships between the
one another) that are directly related
strong extended family networks. It is not
family and other important systems that
to the youth’s behavior problems.
uncommon, for example, for treatment to
influence the youth (e.g., school, peers).
include grandparents, aunts, uncles, cous-
To understand the specific way in which
Strategy
ins, or even close friends (“fictive kin”) who
BSFT produces changes in these relation-
BSFT believes in a strategic approach that
grew up with the child’s parents. Although
ships and subsequent changes in behavior
uses pragmatic, problem-focused, and
these networks may also be sources of
problems, it is necessary to understand
planned interventions. This strategic ap-
problems for the family, they are frequently
some of the basic principles on which BSFT
proach emerged from an explicit focus on
sources of strong support. In BSFT, these
is based.
developing an intervention that was quick
networks are often used to bolster or serve
and effective in eliminating symptoms. In
the important functions of the family. For
Systems
BSFT, this strategic approach is evident
example, extended family members are
in the following assumptions:
frequently engaged in treatment to help
BSFT assumes that each family has its
x
monitor the children while parents are at
own unique characteristics and proper-
Interventions are practical. That is,
work. At times, members of the extended
ties that emerge and are apparent only
interventions are tailored to the unique
family or fictive kin assume primary lead-
when family members interact. This fam-
characteristics of families and are
ership roles in the family when parents are
ily “system” influences all members of the
implemented to achieve attainable
unable or unwilling to perform these tasks.
family. Thus, the family must be viewed as
treatment goals.
In most instances, BSFT seeks to strengthen
a whole organism rather than merely as
x Interventions are problem focused. A
social connections by increasing mutual
the composite sum of the individuals or
problem-focused approach targets first
support and decreasing tension and con-
groups that compose it. In BSFT, this view
those patterns of interactions that most
flict between the family and the extended
of the family system is evident in the fol-
directly influence the youth’s psycho-
support network.
lowing assumptions:
social adjustment and antisocial behav-
x
iors and targets one problem at a time.
Family focus. A second protective factor
The family is a system with interde-
that has helped minority families in Miami
pendent/interrelated parts.
x Interventions are well planned, meaning
is their strong sense of family unity. High-
x The behavior of one family member can
that the therapist determines what seem
lighting the needs of the family above the
only be understood by examining the
to be the maladaptive interactions (i.e.,
needs of individual family members moti-
context (i.e., family) in which it occurs.
interactions that are directly related to
vates many adults to participate in inter-
the youth’s behavior problems), deter-
x Interventions must be implemented at
ventions. In fact, the Spanish Family Guid-
mines which of these might be targeted,
the family level and must take into ac-
ance Center initially selected a family
and establishes a plan to help the fam-
count the complex relationships within
approach because of the Cuban (the target
ily develop more effective patterns of
the family system.
population in the 1970’s) emphasis on fam-
interaction.
ily values. As the Center reached out to
Structure
many different Hispanic populations in the
Process Versus Content
1980’s and to African Americans in the
BSFT also focuses on “structure.” While
As noted above, BSFT is primarily con-
1990’s, the emphasis on the importance of
the concept of a system is useful, one
cerned with identifying and ameliorating
families remained consistent. Minority
must understand the system’s basic
patterns of interaction in the family system
groups in the United States generally place
structure to recognize the mechanism
that are presumed to be directly related to
great value on their natural reference group
through which it operates. Thus, as
behavioral symptoms. This focus on pat-
(e.g., family, extended network, or tribe).
noted above, the existence of a system
terns of interactions is also referred to as a
explains how the behaviors of family
“process” focus. Rather than focusing sim-
members are interdependent. These in-
Target Population
ply on what happens in the family (e.g.,
terdependent or linked behavioral inter-
what dad said when he yelled at the chil-
BSFT targets children and adolescents be-
actions among individuals tend to recur
dren), BSFT focuses on how interactions
tween the ages of 8 and 17 who are display-
and create patterns of interactions
occur (e.g., who was involved in the con-
ing or are at risk for developing behavior
among family members. In BSFT, these
flict, when it occurred, who responded to
problems, including substance abuse.
repetitive patterns compose a family
whom, what preceded and followed the
3
incident). This important distinction be-
A number of specific techniques can be
For example, youth interactions at school
tween process (patterns of interaction) and
used to join the family, including mainte-
or with peers and the nature of the neigh-
content (specific and concrete information)
nance (e.g., supporting the family’s struc-
borhood may serve as powerful risk or pro-
is a fundamental concept of BSFT. This pro-
ture and entering the system by accepting
tective factors. In addition, one’s parents,
cess focus is evident in the following
their rules that regulate behavior), track-
extended family, friends, or career may
assumptions:
ing (e.g., using what the family talks about
serve as sources of strength or stress that
(content) and how their interactions un-
may or may not contribute to the problems
x Process refers to what behaviors are
fold (process) to enter the family sys-
experienced by the youth.
involved in an interaction and how
tem), and mimesis (e.g., matching the
they occur. Secondarily, process refers
tempo, mood, and style of family member
to the message that is communicated
Restructuring
interactions).
by the nature of interactions or by the
As therapists identify what a family’s pat-
style of communication, including all
terns of interaction are and how these fit
that is communicated nonverbally,
Diagnosis
with individual and social factors, they
such as emotion, tone, and the under-
In BSFT, diagnosis refers to identifying inter-
make judgments about the relationship be-
lying power relationship.
actional patterns (structure) that allow or
tween the family’s pattern of interactions
x
encourage problematic youth behavior. In
and the youth’s problem behaviors. Based
Content refers to the specific and con-
other words, diagnosis determines how the
on these judgments, therapists develop
crete facts used in the communication.
nature and characteristics of family interac-
specific plans for changing the family inter-
Content includes such things as the
tions (how family members behave with
actions and individual and social factors
reasons that family members offer for
one another) contribute to the family’s
that are directly related to the child’s prob-
a given interaction.
failure to meet its objective of eliminating
lem behavior. The ultimate goal of treat-
x BSFT is process oriented at all times.
youth problems. To derive complex diag-
ment plans in BSFT is to change family
The emphasis is on identifying the na-
noses of the family, therapists carefully ex-
interactions that maintain the problems
ture of the interactions in the family
amine family interactions along five interac-
to more effective and adaptive interac-
and changing those interactions that
tional dimensions (see the table on pages
tions that eliminate the problems. BSFT
are maladaptive.
6 and 7): structure, resonance, develop-
therapists use a range of techniques that
mental stage, identified patient, and con-
fall within three broad categories:
Components of
flict resolution.
x Working in the present.
Intervention
Assessment refers to the systematic review
x Reframing.
of the detailed or molecular aspects of fam-
There are three intervention compo-
ily interaction to identify specific qualities
x Working with boundaries and alliances.
nents in BSFT: joining, diagnosis, and
in the patterns of interaction of each family
restructuring.
Working in the present. While some types
along the five dimensions presented in the
of counseling focus on the past, BSFT fo-
table. In contrast, clinical formulation refers
Joining
cuses primarily on the present interactions
to the process of integrating the informa-
that occur between family members and
Individuals from families that include youth
tion obtained through assessment into
are observable to the therapist. For ex-
with behavior problems are very difficult to
larger patterns or processes that character-
ample, enactments are a critical feature of
engage in treatment. For the past 15 years,
ize the family’s interactions. In family sys-
BSFT. Enactments encourage, help, and/or
the Center’s staff have focused explicitly on
tems therapy, clinical formulation explains
allow family members to behave or interact
family resistance and have developed spe-
the patient’s presenting symptom in rela-
as they would if the therapist were not
cialized procedures for engaging families in
tionship to the family’s characteristic pat-
present. Very frequently, family members
treatment. These procedures, which are
terns of interaction. For example, a child’s
will spontaneously behave in their typical
described in more detail below (see “Engag-
acting out may be seen as resulting from a
way when they fight, interrupt, or criticize
ing Hard-To-Reach Families” on page 8), are
lack of parental supervision and monitoring
one another. Therefore, when families be-
based on two fundamental assumptions:
that, in turn, are influenced by a poor mari-
come rigidly focused on speaking to the
tal relationship and disagreement about
x Engagement or joining begins from the
therapist, the therapist should systemati-
parenting practices.
very first contact with the family.
cally redirect communication to encourage
x
interactions between session participants.
Resistance can be understood in the
In addition to the family interactional factors
same way as any other pattern of
that are central to BSFT, individual and so-
There are two reasons for encouraging en-
family interaction.
cial factors must be considered for a com-
actments. The first is to permit the thera-
plete clinical formulation. At the individual
In BSFT, joining occurs at two levels. First,
pist to observe problematic interactions
level, psychological factors (e.g., beliefs, atti-
at the individual level, joining involves es-
directly rather than relying on stories
tudes, intelligence, and psychopathology)
tablishing a relationship with each partici-
about what happens when the therapist
and biological factors (e.g., family predispo-
pating family member. Second, at the level
is not present. Clinical experience shows
sition toward alcohol abuse or bipolar dis-
of the family, the therapist joins with the
that families’ stories about how they inter-
order) must be considered when evaluating
family system to create a new therapeutic
act are often very different from their ac-
the impact of family interactions on the
system. Joining thus requires both sensi-
tual interactions.
problems experienced by youth. Moreover,
tivity and an ability to respond to the
other social systems that the family comes
The second reason for enactments, and
unique characteristics of individuals and
into contact with may have a profound im-
a central tenet of BSFT, is that the thera-
quickly discern the family’s governing
pact on the family, and consequently, must
pist is responsible for restructuring (or
processes.
be considered in the clinical formulation.
transforming) interactions. Frequently,
4
interactions are transformed when the
changing the patterns of alliance. A common
attempts to include the entire family in
therapist allows family members to inter-
situation of drug-using youth is a strong alli-
treatment. In fact, therapists are very active
act and then intervenes in the midst of
ance with only one parent. The resulting
in trying to engage reluctant family mem-
these interactions to facilitate the occur-
alliance may cross generational lines and
bers, particularly during the early phase of
rence or emergence of a different, more
work against the traditional parental hierar-
therapy. The basic philosophy is that thera-
positive set of interactions. It is important
chy. For example, there may be a strong
pists will be able to understand family prob-
to remember that in BSFT, therapists are
bond between a youth and her or his
lems and treat youth behavior problems
not interested in having the family simply
mother (or mother figure). Whenever the
more effectively if they view the family’s
“talk about” behaving differently. Rather,
youth is punished by the father (or father
patterns of interaction directly.
they are interested in having the family
figure) for inappropriate behavior, the
Although BSFT therapists are active and
behave differently during and following
youth may solicit sympathy and support
directive, they never do what the family
the intervention sessions.
from the “mother” to undermine the
members can do for themselves. The
“father’s” authority and remove the sanc-
Reframing. Perhaps one of the most inter-
therapist’s goal is to move in and out of
tion. In a single-parent family, it may be the
esting, useful, subtle, and powerful tech-
family interactions, creating opportunities
grandmother who overprotects the youth
niques in BSFT is reframing. Reframing
in the session that will propel the family’s
and undermines the parent’s attempts at
creates a different sense of reality; it gives
interactions in a new, more positive direc-
discipline. Shifting of boundaries involves:
family members the opportunity to per-
tion. Even in these circumstances, the
ceive their interactions or situation from
x Creating a more solid bond between
therapist moves briefly into a centralized
a different perspective. Reframing is a re-
the parents so they will make execu-
role and quickly moves out of it. Ideally,
structuring technique that typically does
tive decisions together.
when the therapist leaves the system, the
not cause the therapist to lose his or her
x Removing the inappropriate parent-
family will be able to respond positively to
rapport with the family. For this reason,
child alliance and replacing it with an
internal and external challenges. Excep-
reframing should be used liberally through-
appropriate alliance between both par-
tions are allowed when crises occur or
out the treatment process, especially at the
ents or parent figures and the youth
when situations arise that require expert
beginning of treatment when the therapist
that meets the youth’s needs for sup-
intervention (e.g., suicidal thoughts or be-
needs to bring about changes but is still in
port and nurturance.
haviors, family violence/abuse).
the process of building a working relation-
A fundamental assumption of BSFT is that
ship with the family. Reframing serves two
families enter treatment with their own,
extremely important functions. First, it is a
Implementation
naturally occurring, informal networks,
tool for changing negative and apparently
including friends, extended family members,
“uncaring” emotions into positive and car-
Philosophy
schools, and work. BSFT therapists examine
ing interactions. This is achieved, for ex-
BSFT is based on the assumption that the
these networks to identify potential prob-
ample, by redefining anger and frustration
family—one of the most important and influ-
lems or areas of strength on which to capi-
as the bonds that tie a family together; the
ential systems in the lives of children and
talize in therapy. Thus, rather than attempt-
therapist may help a parent recognize that
adolescents—provides the foundation for
ing to hook family members into formal
his or her anger toward a child is based
child development. As a result, BSFT con-
systems, like social services, that tend to be
on love. The other important function is
ceptualizes and intervenes to change youth
transient in nature, BSFT tries to improve
to shift from a blaming or castigating ap-
behavior problems at the family level. Al-
naturally occurring relationships so the
proach to developing a team spirit that al-
though BSFT also uses unique interventions
family is more likely to maintain positive
lows family members to acknowledge that
to work with individual family members (see
changes when the therapist (or social
they are in therapy because they care about
“One-Person Family Therapy” on page 7), it
one another. One major goal of all restruc-
turing interventions is to create the oppor-
tunity for the family to behave in construc-
tive new ways. That is, when the family is
unable to break out of its maladaptive inter-
actions, the therapist’s job is to help the
family interact in a new, more positive, way.
Working with boundaries and alliances.
The lives of youth who use drugs are likely
to include a complex set of alliances that
require intervention. The alliances between
the drug user and other users and sellers
need to be severed, and alliances with indi-
viduals who can encourage prosocial be-
haviors need to be established.
Boundaries are the social “walls” that exist
around groups of people who are allied with
one another and that stand between indivi-
duals and groups that are not allied with
one another. Shifting boundaries refers to
5
Dimensions of Family Functioning* Addressed in Brief Strategic Family Therapy
Structure
Resonance
Hierarchy/Leadership
Executive Subsystem
Enmeshment
One parent is more active than the
Decisionmaking subsystem is absent.
Emotional, psychological, or physical
other.
boundaries between family members
Sibling Subsystem
Child is more powerful than the parents.
are excessively close.
Relationship between siblings is poor
Behavior Control
(e.g., high conflict or disengagement).
Disengagement
Parents are not engaging in behavior
Emotional, psychological, or physical
Triangulation
control when needed or are engaging
boundaries between family members
Child is stuck in the middle of a
in ineffective behavior control (e.g.,
are excessively distant.
conflict between adults.
inappropriate consequences, lack of
followthrough, unclear expectations,
Communication
inconsistency, or excess emotion).
Family lacks direct verbal communica-
Guidance/Nurturance
tion or uses ineffective communication
(e.g., vagueness, sermonizing, or
Parents do not nurture children.
excess emotion).
Parents are poor role models (e.g.,
One family member serves as a
engaged in illegal activity, substance
switchboard operator or gatekeeper.
abuse, or violence).
Spousal Alliance
Marital relationship is poor (e.g., high
conflict or disengagement).
* Examples of problems in family interaction are listed under each of the five dimensions.
services agency) is no longer involved
resources (e.g., transportation, money) to
specifically designed to ameliorate the
with the family.
make it to the office. BSFT does not believe
acculturation-related stresses confronted
that home- or community-based treatment
by two-generation immigrant families
Length of Treatment
is required for all youth with behavior
(Szapocznik et al., 1984).
problems, but finds that it may be re-
BSFT is a short-term, problem-focused in-
A clinical trial1 investigated the relative effec-
quired for more severe cases. Therapists
tervention. The average treatment includes
tiveness of bicultural effectiveness training
should never allow the location of treat-
approximately 12–15 sessions and lasts
in comparison with BSFT (Szapocznik,
ment (e.g., home, office, schoolyard) to
about 3 months. For more severe cases,
Santisteban, et al., 1986b) in improving be-
become an obstacle to treatment.
such as substance-abusing adolescents, the
havior problems in early adolescence and
average number of sessions and length of
family functioning. (Drug-abusing adoles-
treatment may be doubled. It is important
Development of a
cents were excluded from this study because
to note, however, that BSFT is not a fixed
Culturally Specific
they were considered beyond the reach of
“package.” Treatment continues until the
the intervention.) The results of this study
family achieves changes in key behavioral
Family Approach
indicated that bicultural effectiveness train-
criteria rather than until it completes a
Applying BSFT to Hispanic families revealed
ing was as effective as structural family
predetermined number of sessions.
how profoundly the process of immigration
therapy in improving adolescent and family
and acculturation could affect the family
functioning. These findings suggested that
Location of Treatment
and each member. To meet this challenge,
bicultural effectiveness training could ac-
complish the goals of family therapy while
Most BSFT work with children with behav-
an intervention was specifically designed to
focusing on the cultural content that made
ior problems occurs in the office. How-
address the special stressors and clinical
the therapy attractive to Hispanic families.
ever, some treatment of substance-abusing
problems faced by this population.
adolescents and their families is con-
ducted in the home or community. The
Bicultural Effectiveness
Family Effectiveness Training
movement to “home-based” treatment re-
Training
Subsequently, BSFT and bicultural effec-
sults from many factors; therapists must
The Center for Family Studies developed the
tiveness training were combined into a
deal with families that are highly disorga-
bicultural effectiveness training intervention
nized and/or unmotivated to attend treat-
to enhance bicultural skills in all family mem-
ments and families that lack the necessary
1
bers. Bicultural effectiveness training is
This study was funded by National Institute of Mental
Health (NIMH) grant #MN31226.
6
Developmental Stage
Identified Patient
Conflict Resolution
Parenting
Negativity
Denial/Avoidance
Parent is immature.
Family members are critical about and
Family members deny or avoid
negative toward the identified patient.
conflict.
Children
Child is treated as/acts too young (e.g.,
Centrality
Diffusion
overly restricted, low requirement/
Identified patient is almost always the
Family members jump from conflict to
opportunity for responsible behavior,
central topic of conversation.
conflict without achieving any depth
or no negotiation allowed).
regarding one particular issue.
Family members are organized around
Child is treated as/acts too old (e.g.,
the identified patient and her/his
Emergence Without Resolution
overloaded with adult tasks or exhibits
problem behaviors.
parentlike behavior).
Family engages in an indepth discus-
Support
sion about a particular conflict but is
Extended Family
not able to resolve the problem.
Family members protect or support
Extended family usurps parental power
identified patient.
Negativity/Conflict
or treats the parent like a child.
Family interactions are openly critical
or hostile.
package called family effectiveness training
cultural context that was dominated by
therapy without having the whole family
(Szapocznik, Santisteban, et al., 1986a). A
Cuban immigrants and Caucasian Ameri-
present was an important challenge.
study2 investigated the value of family
cans. However, by the 1990’s, Miami in-
To meet this challenge, it was necessary to
effectiveness training as a prevention/
cluded Cuban Americans, Cuban immi-
question some basic theoretical assump-
intervention strategy for Hispanic families
grants, Caucasian Americans, Latin
tions of conventional family systems prac-
of children ages 6–11 who presented emo-
Americans from nearly all countries in
tice. Family systems theory postulates that
tional and behavioral problems (Szapocznik,
the Western Hemisphere, African Ameri-
the youth’s behavior problems are a symp-
Santisteban, et al., 1989). The results of this
cans, and Haitian immigrants. In response
tom of flawed patterns of family interaction.
study indicated that families in the family
to these changes, the bicultural effec-
As such, interventions must change family
effectiveness training treatment group
tiveness training intervention was rede-
interactions that produce problem behav-
showed significantly greater improvement
signed into the multicultural effective-
iors in the child. Conventional family sys-
than did control families on measures
ness training (Mancilla and Szapocznik,
tems theorists assume that to change these
of family functioning, problem behaviors,
1994) program that helps non-Cuban
interactions, the entire family must be
and child self-concept. Thus, the interven-
Hispanic parents understand the com-
present in therapy. Thus, the challenge in-
tion was able to improve both child
plex cultural context in which they live.
volved developing an approach, One-Person
and family functioning. The improvements
In multicultural effectiveness training, the
Family Therapy, that seeks to change family
were still in effect at 6-month followup.
challenges faced by non-Cuban Hispanic
interactions while working with only one
families who find themselves in a culture
person (Szapocznik, Kurtines, et al.,
Multicultural Effectiveness
that is heavily influenced by Cuban Ameri-
1990; Szapocznik and Kurtines, 1989).
Training
cans are considered for the first time.
One-person family therapy applies the prin-
Recently, the cultural context in Miami has
ciple of complementarity, which suggests
become more complex. When bicultural
One-Person Family
that a change in the behavior of one family
effectiveness training and family effective-
Therapy
member will lead to corresponding changes
ness training were developed in the 1970’s,
in the behavior of other family members.
the targeted Cuban-born families lived in a
Engaging the whole family in treatment is
one of the most challenging aspects of
One-person family therapy uses this prin-
working with youth with behavior problems
ciple deliberately and strategically to direct
2 This study was funded by National Institute on Drug
and their families. Thus, developing a pro-
the identified patient to change his or
Abuse (NIDA) grant #1E0702694.
cedure that can achieve the goals of family
her behavior in ways that will lead to
7
adjustments in the behavior of other family
members toward him or her.
Figure 1: Differential Engagement and Retention Rates for Strategic
Structural Systems Engagement Experimental Group and
A clinical trial3 examined the effectiveness
of one-person family therapy, comparing
Engagement-as-Usual Control Group
the entire family format with the one-person
100
format of BSFT (Szapocznik, Kurtines, et
al., 1983, 1986). Both conditions were de-
signed to use the BSFT framework so that
80
only the number of people would differ.
amilies
Results indicated that one-person family
60
therapy was as effective as the group for-
mat not only in improving behavior and
40
reducing drug abuse in the youth, but
also in improving and maintaining signifi-
cant improvements in family functioning.
20
ercentage of F
The results of this study demonstrated
P
that it is possible to change family inter-
0
actions even when the whole family is not
Engagement
Retention
present at most sessions. It is important
to note, however, that one-person family
Strategic Structural Systems Engagement Experimental Group
therapy was most effective when it was
Engagement-as-Usual Control Group
implemented by expert BSFT therapists.
To implement one-person family therapy,
therapists must be proficient with family
and individual BSFT techniques. One-
(status quo) which, in the case of drug-
To test the effectiveness of strategic struc-
person techniques are very complex and
abusing youth with behavior problems, can
tural systems engagement in engaging and
sophisticated and thus require a therapist
be accomplished by avoiding therapy. Sec-
retaining Hispanic families with drug-
with extensive training and experience in
ond, while the presenting symptom may be
abusing youth in treatment, a major clini-
changing family interactions.
drug abuse, the initial obstacle to change is
cal trial4 was conducted (Szapocznik,
resistance to treatment. The same struc-
Perez-Vidal, et al., 1988). In this study,
tural principles that apply to family
strategic structural systems engagement
Engaging Hard-To-
functioning and treatment also apply to
was compared to an engagement-as-usual
Reach Families
understanding and handling the family’s
control condition. Clients in the control
resistance to treatment (Szapocznik,
condition were approached in a way that
Although it is possible to conduct family
Perez-Vidal, et al., 1990). The solution to
resembled as closely as possible the kind
therapy through one person, getting indi-
overcoming the undesirable “symptom” of
of engagement that usually takes place in
viduals to begin treatment continues to be a
resistance is to restructure the family’s pat-
outpatient centers. There were two basic
problem. For example, in the clinical trial
terns of interaction that permit the symp-
findings from the study (Szapocznik, Perez-
discussed above, only 250 of approximately
tom of resistance to continue to exist. It is
Vidal, et al., 1988). First, as figure 1 shows,
650 families who met intake criteria on the
here that one-person family therapy tech-
the effects of the experimental condition
basis of a telephone screening began the
niques become useful because the person
were dramatic. More than 57 percent of
intake process. Of this number, 145 com-
requesting help becomes the person
the families in the engagement-as-usual
pleted the intake procedure and only 72
through whom therapy can work to im-
condition failed to participate in treat-
completed treatment. Clearly, a very large
prove the family’s pattern of interaction.
ment. In contrast, only 7.15 percent (four
proportion of families who initially seek
Having accomplished the first phase of
families) in the strategic structural sys-
treatment never participate in therapy.
the therapeutic process in which resis-
tems engagement condition failed to par-
tance has been overcome and the family,
ticipate in treatment. The differences in
Strategic Structural Systems
including the drug-abusing youth, have
the retention rates were also dramatic. In
Engagement
agreed to participate in therapy, the
the engagement-as-usual condition, 41
Strategic structural systems engagement
therapist may shift the focus of the inter-
percent of cases did not complete treat-
was developed to more effectively engage
vention toward the removal of behavior
ment; whereas, in the treatment condition,
drug abusers and their families in treatment
problems and drug abuse.
17 percent of cases did not complete
(Szapocznik, Perez-Vidal, et al., 1990;
treatment. Thus, of all cases assigned to
Clinical work suggests that the patterns
Szapocznik and Kurtines, 1989). It is based
therapy, 25 percent in the engagement-
of interaction that permitted the symp-
on the premise that resistance to change
as-usual condition and 77 percent in the
toms to exist may be the same patterns
within the family results from two systems
strategic structural systems engagement
of interaction that keep the families from
properties. First, the family is a self-
condition were successfully completed.
entering treatment. Hence, to have the
regulatory system—that is, the family will
For families that completed treatment in
opportunity to intervene in these hard-to-
attempt to maintain structural equilibrium
both conditions, behavioral improvements
reach families, the therapist using strate-
gic structural systems engagement must
begin the intervention with the first phone
4
3
This study was funded by NIDA grant #DA2059.
This study was funded by NIDA grant #DA0322.
call rather than the first office session.
8
by adolescents were highly significant and
widely used clinical interventions. Two
the two treatment conditions, with more
these improvements were not significantly
such studies are described below.
than two-thirds of dropouts belonging to
different across the engagement conditions.
the control group. Second, the two forms
The critical distinction between the con-
BSFT Versus Individual
of therapy were equally effective in reduc-
ditions was in the rates of participation
Psychodynamic Child
ing behavior and emotional problems.
and completion.
Therapy
A third finding demonstrated the greater
A second major finding of the project
The first study6 compared the effective-
effectiveness of BSFT over child therapy in
(Szapocznik et al., 1988) was the identifi-
ness of a structural family therapy group
protecting family integrity in the long term
cation of a number of resistant family
(Minuchin, 1974; Minuchin and Fishman,
(see figure 2). In this study, psychodynamic
types and the development of interven-
1981) with an individual child therapy
therapy was found to be effective in reduc-
tion strategies for engaging these families
group and a recreational activity control
ing symptoms and improving child psycho-
(Szapocznik and Kurtines, 1989).
group for children with behavior prob-
dynamic functioning, but it was also found
lems. In addition, this study investigated
to result in undesirable deterioration of
Replication Study
the mechanisms for change used by each
family interactions. The findings supported
the BSFT assumption that treating the
An additional study5 was designed to repli-
type of therapy. Both theoretical ap-
whole family is important because it re-
cate these findings and to further explore
proaches assume underlying causes of
duces the symptoms and protects the fam-
the elements of effective interventions
symptoms and try to eliminate or reduce
ily, versus treating just the child, which may
(Santisteban et al., 1996). This study, which
symptoms. However, each form of therapy
cause family interactions to deteriorate.
included a large multicultural sample, dem-
uses a different approach to reducing
onstrated the overall effectiveness of the
symptoms. The individual child approach
specialized engagement interventions dis-
postulates that the child’s internal (i.e.,
Structural Family Therapy
cussed above. Significant differences in
emotional, cognitive) functioning needs to
Versus Group Counseling
rates of engagement were found between
be modified to eliminate the symptoms.
A second clinical trial compared the effec-
the treatment group and the control group.
BSFT, on the other hand, postulates that
tiveness of BSFT with that of a control
In the treatment group, 81 percent of the
family interactions need to be modified
condition delivered in a group format
families were successfully brought into
to eliminate the symptoms. Because of
(Santisteban et al., 1996). This study also
treatment. In contrast, 60 percent of the
these important theoretical differences,
investigated whether changes in family
families assigned to the two control groups
this study explored the impact of each
functioning were responsible for the
were successfully brought into treatment.
form of therapy on child psychodynamic
changes observed in youth behavior.
functioning and family interactions.
In addition to investigating the overall effec-
Youth who received BSFT showed signifi-
tiveness of the specialized engagement
The analysis revealed several important
cantly greater improvement in behavior
intervention, the study also investigated
findings. First, members of the recreational
(p<.05) than youth assigned to group coun-
the influence of culture/ethnicity on the
activity (control) group were significantly
seling. In fact, youth in BSFT showed signi-
multicultural Hispanic sample. The data
more likely to drop out than members of
ficant improvements in conduct disorder
suggested varying rates of engagement
and socialized aggression, while youth in
across Hispanic groups. Among the non-
6
group counseling did not.
This study was funded by NIMH grant #DA34821.
Cuban Hispanics (primarily Nicaraguan, but
also including Colombian, Puerto Rican,
Peruvian, and Mexican) assigned to the
Figure 2: Comparison of Family Functioning at Pretest, Posttest, and
treatment group, the rate of intervention
1-Year Followup for Youth Assigned to Brief Strategic Family
failure was extremely low (3 percent). Fully
Therapy, Individual Child Therapy, and Recreational Control
97 percent of the non-Cuban Hispanic fami-
Group
lies were successfully treated. In contrast,
among the Cuban Hispanic sample assigned
18
Brief Strategic
to the treatment group, the rate of interven-
Family Therapy
tion failure was relatively high at 36 percent,
with 64 percent of the Cuban Hispanic
17
families successfully treated.
16
Control Group
Comparing Structural
amily Functioning*
Family Therapy With
15
Individual Child
Therapy
Other Types of Therapy
el of F
v
Le
Earlier research concentrated on the de-
14
velopment, refinement, and testing of
Timepoint
BSFT theory and strategies. The next
challenge was to compare the relative
Note: The three points on each line designate the following events: pretest, posttest,
effectiveness of BSFT with that of other
and 1-year followup, in that order.
*Numbers on this axis reflect the family’s functioning on five dimensions of family interaction.
Higher numbers represent healthier, more adaptive family functioning.
5 This study was funded by NIDA grant #DAO5334.
9
A Structural Approach
several ongoing ecosystemic prevention
Conclusion
to Changing the Social
and intervention projects are being
implemented in schools and neighbor-
In the evolution of BSFT, the Center for Fam-
Context of Families
hoods to address children’s behavior
ily Studies has sought to integrate theory,
application, and research. The Center’s work
As the needs of families change, the
problems. In place of a review of each of
began in the 1970’s to address an issue of
theoretical and clinical work of the Cen-
these programs, one program that exem-
growing concern: promoting culturally
ter for Family Studies continues to
plifies the ecosystemic philosophy is de-
competent therapists and therapies to ad-
evolve. The Center has expanded and
scribed below.
dress behavior and drug abuse problems
adjusted its interventions in response to
The Family Alliance Project.7 The Fam-
among Miami’s Hispanic youth. Since then,
declining inner-city social conditions, the
ily Alliance Project study is investigat-
the Center has achieved important break-
multiple problems faced by minority
ing the effectiveness of ecosystemic
throughs in assessment, engagement, treat-
families, and the complex contextual fac-
family therapy compared with tradi-
ment, and prevention, which have provided
tors that affect behavior problems. The
tional family therapy and a community
a solid foundation from which to pursue new
Center is developing a structural ap-
control group. The experimental inter-
advances in the field. Refinement of struc-
proach for changing the social context of
vention, structural ecosystems therapy,
tural family theory strategies and goals in
families that works more effectively with
organizes the life context of the drug-
BSFT, in turn, enabled the Center to modify
minority youth with behavior problems
abusing youth using Bronfenbrenner’s
these strategies to achieve the same goals
and their families.
social ecology framework and the theo-
without having the entire family in therapy,
retical principles of BSFT—that is, pat-
thus making one-person family therapy pos-
Theoretical Background
terns of interaction are examined within
sible. Changing family interactions by work-
The Center for Family Studies uses
and outside the family. Structural eco-
ing primarily with one person led to a break-
the theoretical work of Bronfenbrenner
systems therapy includes a full dose of
through in engaging hard-to-reach families
(1977, 1979, 1986) and the multisystemic,
BSFT (e.g., alliance, hierarchy, communi-
in treatment.
service-oriented approach of Henggeler and
cation flow, personal and subsystem
The work of the Center for Family Studies
colleagues (Henggeler and Borduin, 1990;
boundaries, developmental stage, iden-
will help therapists develop new strate-
Henggeler, Melton, and Smith, 1992).
tified patient, conflict resolution style,
gies to support minority families. As the
Bronfenbrenner examined the complexity
and abilities). However, interventions go
needs of families change, work in the field
of contexts, especially the relationships
beyond the family to target other criti-
needs to continue to evolve to address
between various systems that affect an
cal youth interactions. In particular, the
the multiple problems minority families
individual. In doing so, he identified and
youth’s relationships with school au-
will continue to confront. The Center oper-
defined “microsystems” as those systems
thorities and prosocial versus antisocial
ates under the assumption that “it takes a
that have direct contact with the individual.
peers are examined. At the mesosystem
village to raise a child.” It is necessary
For a child, microsystems include the family,
levels, the relationships between par-
both to create a “village,” or community,
school, and peers. He defined “mesosys-
ents and school, parents and their
that can support healthy child develop-
tems” as those systems that occur when
children’s peers, and parents and the
ment and to modify policies and systems
microsystems interact. One example of a
juvenile justice system are considered.
that provide services to the community.
mesosystem occurs when the parents and
At this mesosystem level, the extent to
Bronfenbrenner (1979) wrote, “Seldom is
school collaborate on a child’s education.
which the different systems support one
attention paid to the person’s behavior in
Another example of a mesosystem occurs
another, or are in conflict with one an-
more than one setting or to the way in
when parents and peers interact (e.g., when
other, is critical. For example, in the
which relations between settings can af-
parents organize and supervise peer activi-
parents-peers mesosystem, parents may
fect what happens within them” (p. 18).
ties). “Exosystems” are defined as those
know the peers, organize supervised
He suggested that an individual’s environ-
systems that affect family members and,
peer activities, and know the parents of
ment is composed of a complex set of
through their impact on family members,
their child’s peers. Parents may partici-
nested structures. Scientists involved in
affect the child. Examples of exosystems
pate in community organizations that
intervention must consider the social and
are a mother’s workplace or her natural
provide organized, supervised peer
cultural context in which treated families
support network.
activities.
live. The Center for Family Studies’ devel-
Bronfenbrenner’s theory highlights the
Results of the interventions suggest that
opment of theory, research, and services
pivotal role of context in the life of a
it is possible to affect youth conduct
within the complex community is based
child and her or his family members.
problems at home and school by correct-
on this priority.
Moreover, this theory helps to explain
ing patterns of interaction in the family
how culture influences all other social
and school microsystems and the family-
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Points of view or opinions expressed in this
of the efficacy of specialized engagement
NY: Plenum, pp. 93–114.
document are those of the authors and do not
interventions and factors that contribute
necessarily represent the official position or
policies of OJJDP or the U.S. Department of
Justice.
Acknowledgments
The Office of Juvenile Justice and Delin-
This Bulletin was written by Michael S. Robbins, Ph.D., Research Assistant
quency Prevention is a component of the Of-
Professor, and José Szapocznik, Ph.D., Professor and Director, Center for Family
fice of Justice Programs, which also includes
Studies, Affiliation University of Miami School of Medicine, Department of
the Bureau of Justice Assistance, the Bureau
Psychiatry and Behavioral Sciences.
of Justice Statistics, the National Institute of
Photograph page 2 copyright © 1999 Artville; photograph page 5 copyright © 1999
Justice, and the Office for Victims of Crime.
PhotoDisc, Inc.
11
U.S. Department of Justice
PRESORTED STANDARD
POSTAGE & FEES PAID
Office of Justice Programs
DOJ/OJJDP
Office of Juvenile Justice and Delinquency Prevention
PERMIT NO. G–91
Washington, DC 20531
Official Business
Penalty for Private Use $300
Bulletin
NCJ 179285
