Family Paper

“If I know anything about raising my family, it’s that no one is going to pay attention unless it’s really bad. So I’ve learned to holler real loud until somebody listens.” Those are Sharon’s perceptions as a single parent raising three children, holding down two jobs, and facing the challenges presented by her oldest son. Sharon is 33 years old and is the sole provider for herself and her three children: Brian, who is 15, Cindy, age 14, and Mark, who is 11. The family lives in a transitional neighborhood and would be characterized as “working poor.” Sharon holds down a job as a bus driver and cleans offices and homes in the evening and on weekends. She is determined to avoid welfare but is increasingly frustrated as she tries to make ends meet. The family typically accesses the food bank at least once a month. There is no financial or emotional support from either of the two men who fathered the chil- dren. Brian and Cindy’s father abandoned his common-law relationship with Sharon shortly after Cindy was born and has not contacted the family since. Mark’s father was very physically and emo- tionally abusive to Sharon, and she ran to a women’s shelter when Mark was three. All three children witnessed the abuse of Sharon.

During the last few years, Sharon, who is very committed to her children, has struggled to get help for her oldest son, Brian, and to keep her family together. Brian maintained a 70 average in grade seven. Then he began to be withdrawn and depressed, and he periodically left suicide notes and notes referring to his mother’s violent death. He also was caught exposing himself several times at school activities. His physical aggression towards his mother and his siblings became a weekly if not daily occurrence. During an agonizing two-year period of escalating problems, Sharon frequently called Social Services and discussed the issues with her family physician, and she repeatedly accessed the emer- gency room at the hospital in efforts to get help for her family. While Brian was placed on a waiting list for counseling as a result of a physician referral, other services recommended that the police be called to deal with Brian’s aggression and property destruction. Social Services did not see the issues as related to child welfare mandates, and the hospital had no services to offer. Before Brian could receive counseling, he was caught sexually molesting a younger girl at his school, was expelled from school, and was subsequently arrested, resulting in three months in an open-custody setting.

Transgenerational Model

Transgenerational approaches offer a psychoanalytically influenced historical perspective to current family problems by attending to family relational patterns over decades. Advocates of this view believe current family patterns are embedded in unresolved issues in the families of origin. That is not to say that earlier generations cause the problems of current families but rather that when problems remain unset- tled, they persist and repeat across generations. How today’s family members form attachments, manage intimacy, deal with power, resolve conflict, and so on may mirror earlier family patterns. Unresolved issues in families of origin may show up in symptomatic behavior patterns in later generations. A number of pioneering family therapists—Murray Bowen, Ivan Boszormenyi-Nagy, James Framo, Carl Whitaker—incorporated generational issues in their work with families. As we noted earlier, Framo typically brought each partner’s family members in for family-of-origin sessions in which current differences were discussed, and Whitaker invited extended family members such as grandparents as “consultants” to ongoing family sessions. However, we have chosen to place both Framo and Whitaker elsewhere in the text—Framo with the object relations therapies and Whitaker with the experiential therapies—because their efforts are also strongly influenced by these other outlooks and procedures. The remainder of this chapter focuses on the multigenerational views of Murray Bowen and Ivan Boszormenyi-Nagy. owen’s Family theory

A key figure in the development of family therapy was Murray Bowen, who remained, until his death in 1990, its major theoretician. By turning first to Bowen’s work, we present a theory that represents the intellectual scaffolding upon which much of mainstream family therapy is built. Bowen, the developer of family systems theory, conceptualized the family as an emotional unit, a network of interlocking relationships, best understood when analyzed within a multigenerational or historical framework.

Bowen’s theoretical and therapeutic contributions bridge psychodynamically oriented approaches that emphasize the significance of past family relationships on an individual on the one hand and systems approaches that focus on the family unit as it is presently constituted and currently interacting on the other. His therapeutic stance with couples was disciplined and unruffled but engaged. He was careful not to become triangulated within the couple’s emotional interaction (see his ideas on triangulation later in the chapter). By attending to the processes of their interactions and not the content, Bowen hoped to help the partners hear each other out without deafening passions, accusations, or blame and to learn what each must do to reduce anxiety and build their relationship.

Unlike many of his fellow pioneers in family therapy who struggled at first to stretch classical psychoanalytic theory to fit family life, Bowen recognized early on that most psychoanalytic concepts were too individually derived and not readily translatable into the language of the family. Rather than attempt to adapt such concepts as unconscious motivations to family inter- active patterns, Bowen offered another view. He believed that the driving force underlying all human behavior came from the submerged ebb and flow of family life, the simultaneous push and pull between family members for both distance and togetherness (Wylie, 1990b). This at- tempt to balance two life forces—family togetherness and individual autonomy—was for Bowen the core issue for all humans. Successfully balanced, such persons are able to maintain intimacy with loved ones while differentiating themselves sufficiently as individuals.

Since his early clinical work with schizophrenics and their families at the Menninger Clinic as well as at the National Institute for Mental Health (NIMH), Bowen stressed the importance of theory for research, teaching, and psychotherapy. He was concerned with the field’s lack of a coherent and comprehensive theory of either family development or therapeutic intervention and its all-too-tenuous connections between theory and practice. In particular, Bowen (1978) decried efforts to dismiss theory in favor of an intuitive “seat-of-the-pants” approach, which he considered especially stressful for a novice therapist coping with an intensely emotional, problem-laden family.

Bowen’s professional interest in the family began early in his career when he trained as a psychiatrist and remained on the staff at the Menninger Clinic. Under the leadership of Karl Menninger, innovative psychoanalytic approaches were being tried in treating hospital- ized persons suffering from severe psychiatric illnesses. Intrigued by the family relationships of inpatients, especially schizophrenics, Bowen became particularly interested in researching the possible transgenerational impact of a mother–child symbiosis, or intense enmeshment, in the development and maintenance of schizophrenia. Extrapolating from the psychoana- lytic concept that schizophrenia might result from an unresolved symbiotic attachment to the mother, herself immature and in need of the child to fulfill her own emotional needs, Bowen began studying the emotional fusion between schizophrenic patients and their mothers. In 1951, in order to view their relationship close up, he organized a research project in which mothers and their schizophrenic children resided together in cottages on the Menninger grounds for several months at a time.

In 1954, Bowen was eager to put his new ideas regarding family dynamics into clinical practice. However, stifled by what he saw as the prevailing emphasis on conventional individual psychiatry at the Menninger Clinic, he moved his professional research activities to the NIMH in Bethesda, Maryland. Soon, in what was a radical idea for its time, Bowen had entire families with schizophrenic members living for months at a time in the hospital research wards, where he and his associates were able to observe ongoing family interaction. Here Bowen discovered that the emotional intensity of the mother–child interaction was even more powerful than he had suspected (Kerr, 2003). More important, the emotional intensity seemed to character- ize relationships throughout the family,1 not merely those between mother and child. Fathers and siblings also were found to play key roles in fostering and perpetuating family problems (Hargrove, 2009). Bowen recognized that these additional relations took the form of triangular alliances that were continually formed and dissolved among differing sets of family members.

The reciprocal functioning of all the individual members within the family became so apparent that Bowen expanded his earlier mother–child symbiosis concepts to viewing the entire family as an unbalanced emotional unit made up of members unable to separate or successfully differentiate themselves from one another. Although he did not adopt a cybernetic epistemology per se, nor was he interested especially in directly changing a family’s ongoing interactive pat- terns, Bowen had moved from concentrating on the separate parts of the

family (the patient with the “disease”) to a focus on the whole family. Then he began to direct his attention to what he called the family emotional system—a kind of family guidance system shaped by evolution that governs its behavior. The conceptual shift proved to be a turning point in his thinking, as Bowen increasingly viewed human emotional functioning as part of a natural system that followed the same laws that govern other systems in nature, such as the laws of gravity. Bowen began to study human emotional functioning in a more rigorously scientific way. In so doing, Bowen was beginning to formulate nothing less than a new

theory of human behavior. Family systems theory (sometimes referred to as natural systems theory to differentiate it

Murray Bowen, M.D.

from cybernetically based family systems theories) is derived from the biological view of the human family as one type of living system. As Friedman (1991) points out, the theory is

not fundamentally about families but about life (or what Bowen referred to as the “human phenomenon”), and it attempts to account for humanity’s relationship to other natural sys- tems. As Wylie (1990b, p. 26) explains, Bowen “considered family therapy a by-product of the vast theory of human behavior that he believed it was his real mission to develop.” According to the theory, the human family is seen as appearing due to an evolutionary process in nature. Thus, like all living systems (ant colonies, the tides, the solar system), humans and the human family are guided by processes common in nature. In particular, the theory concerns itself with a special kind of natural system—the family’s emotional system (Kerr, 2003). When the NIMH project ended in 1959, Bowen moved to the Department of Psychiatry at Georgetown University in Washington, DC, because the university was a place more con- ducive to his theoretical bent. He remained there for 31 years, until the end of his career. Working in an outpatient setting, and with families many of whom had less severe prob- lems than schizophrenia, Bowen continued to formulate a comprehensive family systems theory that could be applied to processes occurring in all families, functional as well as dys- functional. At the same time, he proposed a method of therapy based on a solid theoretical foundation. Developing a training program in family therapy while continually refining the concepts he first developed in the 1960s, he published Family Therapy in Clinical Practice in 1978, detailing his theoretical formulations and offering therapeutic techniques consistent with that theory. In 1977, Bowen became the first president of the newly formed American Family Therapy Association, an organization he helped found to pursue interests in research and theory. LO 2 eight interlocking theoretical concepts Bowen’s theory of the family as an emotional relationship system consists of eight interlocking concepts. Six address emotional processes taking place in the nuclear and extended families; two concepts—emotional cutoff and societal regression—speak to the emotional processes across generations in a family and in society. All eight constructs are interlocking, so none is fully understandable apart from the others (Kerr, 2003). The eight concepts are tied together by the underlying premise that chronic anxiety is om- nipresent in life. While it may manifest itself differently, and with different degrees of intensity depending on specific family situations and differing cultural considerations, chronic anxiety is an inevitable part of nature. Bowen viewed chronic anxiety as a biological phenomenon that humans have in common with all forms of life (Friedman, 1991). From this natural systems perspective, past generations transmit chronic anxiety, which impacts family members as they balance togetherness and individual self-differentiation. Anxiety is the sense of arousal in an organism when it perceives a real or imagined threat. In humans, anxiety stimulates the emotional system, overriding the cognitive system and lead- ing to behavior that is automatic or uncontrolled (Kerr, 2003). Anxiety is inevitably aroused as families struggle to balance the pressures toward togetherness as well as toward individ- uation. If greater togetherness prevails, imbalance results and the family moves toward in- creased emotional functioning and less individual autonomy, leading the person to experience increased chronic anxiety.

Consider the case of a high school senior who comes from a working-class family in which a sense of togetherness prevails over an appreciation of the individuality of its members. She has just been accepted to a college in another state and has been offered a scholarship. As the family has only limited financial means, the scholarship represents a major opportunity. In a family such as this, the other members might subtly or explicitly pressure the young woman not to take this chance. Let’s say that part of her wants to go while a part of her understands (because of the submerged ebb and flow of family dynamics) that she shouldn’t go. The chance exists that the family demands for togetherness could keep this young woman feeling anxious, from finding herself as an individual and achieving important life goals. Chronic anxiety, then, represents the underlying basis of all symptomatology; its only antidote is resolution through differentiation (see next section), the process by which an individual learns to chart his or her own direction rather than perpetually following the guidelines of family and others.

LO 3 According to Family Systems Theory, Eight Forces Shape Family Functioning:

1. Differentiation of self 2. Triangles 3. Nuclear family emotional system 4. Family projection process 5. Emotional cutoff 6. Multigenerational transmission process 7. Sibling position 8. Societal regression

LO 4 Differentiation of Self

The cornerstone of the Bowen family systems theory is the notion of forces within the family that lead to individuality and the opposing forces that make for togetherness. Both intrapsy- chic and interpersonal issues are involved here. In the former, the person must, in the face of anxiety, develop the ability to separate feelings from thinking and to choose whether to be guided in a particular instant by intellect or emotion. In the latter, he or she must be able to experience intimacy with others but separate as an autonomous individual from being caught up in any emotional upheaval sweeping the family. The well-differentiated person is able to balance thinking and feeling (adhering to personal convictions while expressing individual emotions) and at the same time retain objectivity and flexibility (remaining independent of the family’s emotional pressures).

Differentiation of self, says Bowen, reflects the extent to which a person is able to distinguish between the intellectual process and the feeling process of what he or she is expe- riencing. Differentiation of self is demonstrated by the degree to which a person can think, plan, and follow his or her own values or convictions, particularly around anxiety-provoking issues, without having behavior automatically driven by the emotional cues from others.

One way people can demonstrate (especially to therapists) their degree of relative differenti- ation is through speaking in I-statements (reflective of I-positions), that is, statements that verbalize the degree of separation an individual feels vis-à-vis others. The degree to which one separates emotionally from parents in growing up is key to differentiation. In extreme cases, the attachment becomes a symbiosis in which parents and child cannot survive without one another. Such unresolved emotional attachment is equiv- alent to a high degree of undifferentiation in a person and in a family (Papero, 1995). (In other cultures, particularly those that focus on family togetherness, individuality and differentiation may be expressed differently.) The ideal here is not to be emotionally detached or fiercely objective or without feelings, but rather to strive for balance, achieving self-definition but not at the expense of losing the capacity for spontaneous emotional expression. Individuals should not be driven by feelings they do not understand. As Hargrove (2009) notes, “The person who balances emotional reactivity and thinking without regard to the family’s emotional process is thought to be func- tioning at a higher level of differentiation of self ” (p. 290). As Papero (1990, p. 48) summarizes, “To the degree that one can thoughtfully guide personal behavior in accordance with well-defined principles in spite of intense anxiety in the family, he or she displays a level or degree of differentiation.” For example, suppose our high school student mentioned previously chooses to go to college. After living away, she goes home at midyear to attend her sister’s wedding. Amid the tensions that typically occur around such an event, to what degree is she drawn into family feuds, conflicts, coalitions, or emo- tional turmoil? Her differentiation can be gauged by the degree to which she is able to remain sufficiently involved to enjoy the pleasures of this family event while sufficiently separated so as not to be drawn into the family emotional system. Individuals with the greatest fusion between their thoughts and feelings (e.g., schizophrenics dealing with their families) function most poorly; they are likely to be at the mercy of automatic or involuntary emotional reactions and tend to become dysfunctional even under low levels of anxiety. Unable to differentiate thought from feeling, such persons have trouble differentiating themselves from others and merge easily with whatever emotions dominate or sweep through the family. Highly fused persons, with few firmly held positions

of their own, are apt to remain emotionally “stuck” throughout their lives in the position they occupied in their families of origin (Bowen, 1978). Bowen (1966) early on introduced the concept of undifferentiated family ego mass, a term derived from psychoanalysis. The term conveys the idea of a family emotionally “stuck together,” one in which “a conglomerate emotional oneness . . . exists in all levels of intensity” (p. 171). The classic example of the symbiotic relationship between mother and child may represent the most intense version of this concept (in such families, a father’s detachment may be the least intense). The degree to which any one member is involved in the family from moment to moment depends on that person’s basic level of involvement in the fam- ily ego mass. Sometimes the emotional closeness can be so intense that family members feel they know each other’s feelings, thoughts, fantasies, and dreams. This intimacy may lead to uncomfortable “overcloseness” and ultimately to a phase of mutual rejection between mem- bers. So emotional tensions in a family system shift over time (sometimes slowly, sometimes rapidly) in a series of alliances and splits. Bowen later recast the term undifferentiated family ego mass into systems language as fusion-differentiation. Both terms underscore the transgenerational view that maturity and self-actualization demand that an individual become free of unresolved emotional attach- ments to his or her family of origin. To illustrate his point, Bowen (1966) proposed a theoret- ical scale (not an actual psychometric instrument) for evaluating an individual’s differentiation level. As noted in Figure 8.1, the greater the degree of undifferentiation (no sense of self or a weak or unstable personal identity), the greater the emotional fusion into a common self with others (the undifferentiated family ego mass).

A person with a strong sense of self (“These are my opinions . . . This is who I am . . . This is what I will do, but not this”) expresses convic- tions and clearly defined beliefs. Such a person is said to be expressing a solid self. He or she does not compromise that self for the sake of marital bliss, to please parents, or to achieve family harmony. People at the low end of the scale are those whose emotions and intellect are so fused that their lives are dominated by the feelings of those around them. As a consequence, they feel anxious and are easily stressed into dysfunction. Fearful and emotionally needy, they sacrifice their individuality in order to ensure acceptance from others. They are expressing an undif- ferentiated pseudo self, which they may deceive themselves into thinking is real but which is composed of the opinions and values of others. Those far fewer individuals at the high end are emotionally mature. They can think, feel, and take actions on their own despite exter- nal pressures to fall in line. Because their intellectual or rational functioning remains rela- tively (although not completely) dominant during stressful periods, they are more certain of who they are and what they believe, freer to make judgments independent of any emotional turmoil around them. In the midrange are persons with relative degrees of fusion or differ- entiation. Note that the scale eliminates the need for the concept of normality. It is possible for people at the low end of the scale to keep their lives in emotional equilibrium and stay free of symptoms, thus appearing “normal.” However, they are more vulnerable to stress and, under stress, may develop symptoms from which they recover far more slowly than those at the high end of the scale.

bowen’s theoretical differentiation-of-self scale distinguishes people according to the degree of fusion or differentiation between their emotional and intellectual functioning

• those at the lower level (0–25) are emotionally fused to the family and others, and lead lives in which their thinking is submerged and their feelings dominate.

• those in the 25–50 range are still guided by their emotional system and the reactions of others; goal-directed behavior is present but carried out in order to seek the approval of others.

• in the 50–75 range, thinking is sufficiently developed so as not to be dominated by feeling when stress occurs, and there is a reasonably developed sense of self.

• those rare people functioning between 75 and 100 routinely separate their thinking from their feelings; they base decisions on the former but are free to lose themselves in the intimacy of a close relationship. bowen (1978) considers someone at 75 to have a very high level of differentiation.

• those over 60 constitute a small percentage of society. To summarize:

• Below 50 (low differentiation): tries to please others; supports others and seeks support; dependent; lacks capacity for autonomy; primary need for security; avoids conflict; little ability to independently reach decisions or solve problems.

• 51–75 (midrange differentiation): definite beliefs and values but tends to be overcon- cerned with the opinions of others; may make decisions based on emotional reactivity, especially whether significant others will disapprove.

• 76–100 (high differentiation): clear values and beliefs; goal directed; flexible; secure; autonomous; can tolerate conflict and stress; well-defined sense of solid self and less pseudo self (Roberto, 1992).

A person’s level of differentiation also relates to the person’s relative independence from others outside the family group. A moderate to high level of differentiation permits interac- tion with others without fear of fusion (losing one’s sense of self in the relationship). While all relationships ranging from poorly to well-differentiated ones are in a state of dynamic equilib- rium, the flexibility in that balance decreases as differentiation decreases. Figure 8.2 illustrates the varying degrees to which a person’s functioning can be influenced by the relationship process. Bowen family systems theory assumes that an instinctively rooted life force in every human propels the developing child to grow up to be an emotionally separate person, able to think, feel, and act as an individual. At the same time, a corresponding life force propels the child and family to remain emotionally connected. Because of these counterbalancing forces, no one ever achieves complete emotional separation from the family of origin. There are considerable differences in the amount of separation each of us accomplishes, including differences between siblings in the degree to which they emotionally separate from the family.

relationship a is one where the functioning of each person is almost completely determined by the relationship process. The degree to which individual functioning is either enhanced or undermined by the relationship is indicated by the shaded area. The clear area indicates the capacity for self-determined functioning while in a relationship. relationships b and c are progressively better differentiated. Individual functioning, therefore, is less likely to be enhanced or undermined by the relationship process. relationship d is theoretical for the human. It represents two people who can be actively involved in a relationship yet remain self-determined Source: Kerr and Bowen (1988), p. 71.

The latter is due to characteristics of the different parental relationships established with each child, which we elaborate on later in this section. LO 5 Triangles Bowen family systems theory also emphasizes the emotional tension within an individual or in that person’s relationships. For example, the greater the fusion in a couple, the more difficult it is to find a stable balance satisfying to both. One way to defuse such an anxious two-person relationship, according to Bowen (1978), is to triangulate—draw in a significant family member to form a three-person interaction. Triangulation is a common way that two-person systems under stress attempt to achieve stability (Hargrove, 2009). Think of a couple in therapy that are considering divorce. After weeks of hostility and mutual blaming, the therapist invited the couple to bring in their 16-year-old son and asks the young man, “What do you think of your parents getting a divorce?” The young man, looking very sad, says, “Finally, someone has asked me for my opinion.” Each parent looks at each other and realizes that in their fused state of rage and anxiety, they have both neglected their son.

They both take deep breaths and for the first time start talking more honestly about all their thoughts and feelings. As this example suggests, the basic building block in a family’s emotional or relational system is the triangle. During periods when anxiety is low and external conditions are calm, the dyad or two-person system may engage in a comfortable back-and-forth exchange of feelings. However, the stability of this situation is threatened if one or both participants get upset or anxious, either because of internal stress or from stress external to the pair. When a certain moderate anxiety level is reached, one or both partners often will involve a vulnerable third person. Let’s continue the example of the divorcing couple and their son by suggesting that throughout their lives together, the son has often played the role of his parents’ referee. A few weeks of family therapy go by, and the son tells his parents and the therapist that he feels that his father’s frequent absences from home due to his sales job are the cause of his parents problems. The father becomes defensive and angry, and the mother becomes anxious. She now turns to the therapist and says, “That is one of the most important problems between us. He’s never home. Certainly you see how painful this has been for me.” Now the mother, perhaps with the son’s collusion, wants to create a new triangle, this time with the therapist. The ther- apeutic goal is for the clients to view themselves as individual, differentiated selves as well as family members. However, if the therapist (as the third person in the triangle) loses emotional contact with the other two, the twosome will proceed to triangulate with someone else. Bowen (1976) refers to the triangle as the smallest stable relationship system.

By defini- tion, a two-person system is unstable and forms a three-person system under stress as each partner creates a triangle in order to reduce the tension in their relationship. When anxiety is so great that the three-person triangle can no longer contain the tension, the distress may spread to others (as when the family in our example tried to triangulate with the therapist). As more people become involved, the system may become a series of interlocking triangles, in some cases heightening the very problem the triangulations sought to resolve. For example, a distraught mother’s request for help from her husband in dealing with their daughter is met with withdrawal by the father. As the mother–daughter conflict escalates, she commu- nicates her distress to a son, who proceeds to get into conflict with his sister for upsetting their mother. What began as a mother–daughter conflict has now erupted into interlock- ing conflicts—between mother and daughter, brother and sister, and mother and father. Thus, triangles extend and interlock into ever-larger groups as tension increases (Kerr, 2003). Sometimes such triangulation can reach beyond the family, ultimately encompassing social agencies or the courts. Generally speaking, the higher the degree of family fusion, the more intense and insistent the triangulating efforts will be. The least-well-differentiated person in the family is particularly vulnerable to being drawn in to reduce tension. Often this person winds up being the identified patient. The higher a family member’s degree of differentiation, the better that person will manage anxiety without creating triangles (Papero, 1995).

Beyond seeking relief of discomfort, the family relies on triangles to help maintain an optimum level of closeness and distance between members while permitting them the greatest freedom from anxiety. Perhaps in our example, the father and mother might discuss the prospect of divorce with their son. Kerr and Bowen (1988; Kerr, 2003) point out that triangulation has at least four pos- sible outcomes: (a) a stable twosome can be destabilized by the addition of a third person (e.g., the birth of a child brings conflict to a harmonious marriage); (b) a stable twosome can be destabilized by the removal of a third person (a child leaves home and thus is no longer available to be triangulated into parental conflict); (c) an unstable twosome can be stabilized by the addition of a third person (a conflictual marriage becomes more harmonious after the birth of a child); and (d) an unstable twosome can be stabilized by the removal of a third per- son (conflict is reduced by getting a third person, say a mother-in-law who has consistently taken sides, out of the picture). In another familiar example, conflict between siblings quickly attracts a parent’s attention. Let us assume that the parent has positive feelings toward both children. If the parent can control his or her emotional responsiveness and manage not to take sides while staying in contact with both children, the emotional intensity between the siblings will diminish. As McGoldrick and Carter (2001) observe, involvement in triangles and interlocking triangles represents a key mechanism whereby patterns of relating to one another are transmitted over generations in a family.

The Structural Outlook Model

The uniqueness of structural family therapy is its use of spatial and organizational metaphors, both in describing problems and identifying solutions and in its insistence on active therapist direction (Colapinto, 1991). The model’s major thesis divides into three parts: • Individual symptoms are rooted in the context of family transaction patterns. • Family organization or structure must change before symptoms are relieved. • The therapist must provide a directive leadership role in changing the structure or context in which the symptom is embedded. Salvador Minuchin and his supervisees (Minuchin, Lee, & Simon, 2006) describe the major determinants of structural theory: • The wholeness of the family system • The influence of the family’s hierarchical organization • The interdependent functioning of its subsystems The family’s underlying organizational structure and its flexibility in responding to changing conditions throughout the family life cycle help govern the appearance of functional or dysfunctional patterns. Minuchin (1984) views families as going through their life cycles seeking to maintain a delicate balance between stability and change. The more functional the family, Minuchin suggests, the more open to change and structure modification during periods of family transition, as new conditions demand. The primary role of structural therapists is the facilitation of organizational changes in the dysfunctional family, assuming that individual behavioral changes and symptom reduction will follow as the context for the family’s transactions changes. When the family’s structure is transformed, the positions of its members are altered, and each person experiences change. As an instrument of change, the therapist actively engages the whole family to introduce challenges1 that force adaptive changes, supporting and coaching family members as they attempt to cope with the consequences (Colapinto, 1991). Leading Figure: Salvador Minuchin Raised in Argentina of European immigrant parents, Salvador Minuchin practiced pediat- rics following his medical training. When Israel declared itself a state in 1948, Minuchin, guided by his sense of social purpose, volunteered his services to Israel as an army doctor for 18 months. After subsequent training as a child psychiatrist in the United States, partly under the tutelage of Nathan Ackerman, Minuchin returned to Israel in 1952 to work with children displaced from the Holocaust and with Jewish immigrants to Israel.

In 1954 Minuchin returned to the United States to begin psychoanalytic training at the William Alanson White Institute (where Sullivan’s interpersonal psychiatry ideas held sway), eventually becoming the intake psychiatrist at the Wiltwyck School, a residential school for delinquent adolescents outside New York City. Inspired by an article by Don Jackson in 1959, Minuchin began to look beyond the individual children to examine and analyze their family predicaments. He worked primarily with low-income African-American and Puerto Rican adolescents from New York’s inner city. Minuchin and his therapeutic team began developing a theory and a special set of intervention techniques in response to the multiple problems arising from the disconnected and underorganized structures of the families they encountered. Increasingly, he turned to a sociological analysis of social context—how the experience of living in poverty affected family func- tioning. Minuchin and his coworkers developed therapeutic ways to change family context rather than focusing on personality or behavioral problems.

Finding that long-term, interpretive psychoanalytic techniques were ineffective with this population, Minuchin and associates devised many brief, direct, concrete, action-oriented, and problem-solving interventions to effect context change by restruc- turing the family. (Nathan Ackerman’s influences regarding interlocking pathology and his provocative, charismatic presence with families are clear here.) Minuchin’s 8 years at Wiltwyck, during which he developed many highly original and action-oriented techniques for working with disadvantaged families, were described in Families of the Slums (Minuchin, Montalvo, Guerney, Rosman, & Schumer, 1967) and earned Minuchin widespread recog- nition (Simon, 1984). The Wiltwyck focus on family reorganization and effective hierarchy among family members laid the cornerstone for structural family therapy. In 1965, wanting to test his techniques with a wider cross-section of families, including both working-class and middle-class populations, Minuchin took on the directorship of the Philadelphia Child Guidance Center. To assist with training, he brought along social worker Braulio Montalvo from Wiltwyck and recruited Jay Haley from Palo Alto. Originally a small clinic with a staff of 10 serving the African-American population, the Philadelphia Child Guidance Clinic blossomed under Minuchin’s boldly imaginative leadership as it grew into the largest facility of its kind ever established, with an elaborate modern complex, close to 300 people on its staff, and affiliation with Children’s Hospital on the campus of the University of Pennsyl- vania. It was the first clinic in the United States where poor urban families represented a majority of the clients served. In 1974, Minuchin published the widely read Families and Family Therapy, an elaboration of ideas concerning change in families through structural family therapy. After stepping down as director of the Philadelphia Child Guidance Center in 1975 and as director of training there in 1981, Minuchin spent most of his professional time teaching, consulting, supervising, writing, and demonstrating his dramatic techniques in front of pro- fessional audiences around the world. In 1981, he founded and, until 1996, led a small insti- tute called Family Studies (now renamed the Minuchin Center for the Family) in New York City, offering consultative services to community organizations, particularly those dealing with poor families (Minuchin, Colapinto, & Minuchin, 2007). Minuchin has now retired to Florida but continues to lecture around the world.

Other Leading Figures in Structural Theory

Over the years, Minuchin surrounded himself with clinicians from various disciplines who themselves have contributed significantly to shaping structural family theory and therapy. Psychiatrist Charles Fishman (1993), social worker Harry Aponte (2009), and psychologist Marion Lindblad-Goldberg (Lindblad-Goldberg, Dore, & Stern, 1998), all of Philadelphia, have contributed to advancing the structural viewpoint through offering family therapy train- ing, typically with economically needy families.

Marianne Walters, a social worker in Washington, DC, is best known for the groundbreaking work she and her associates (Walters, Carter, Papp, & Silverstein, 1988) produced as part of the long-running Women’s Project, employing the lens of gender to examine family relationships. Psychiatrist Jorge Colapinto (2000) is Coordinator of Training and Consultation at the Minuchin Center. The original Philadelphia Child Guidance Center, having trained thousands of family therapists, closed a decade ago and has been replaced by a more modest Philadelphia Child and Family Guidance Training Center, still structurally oriented, under Lindblad-Goldberg’s direction.

Psychosomatic Families

At the Philadelphia Child Guidance Clinic, Minuchin turned his attention to the role of family context in psychosomatic conditions, especially such urgent medical problems as diabetes and anorexia. More specifically, no medical explanations could be found for the unusually large number of diabetic children who required emergency hospitalization for acidosis (a depletion of alkali in the body), nor would they respond to individual psychotherapy directed at helping them deal with stress. As Minuchin and his coworkers began to accu- mulate research and clinical data and to redefine the problem in family terms, successful interventions involving the entire family became possible. Later research expanded to include asthmatic children with severe, recurrent attacks as well as anorectic children; the additional data confirmed for Minuchin that the locus of pathology was in the context of the family and not simply in the afflicted individual. As noted in Psychosomatic Families (Minuchin, Rosman, & Baker, 1978), families of children who manifest severe psychosomatic symptoms are characterized by transactional problems that encourage somatization. Enmeshment is common, subsystems function poorly, and boundaries between family members are too diffuse to allow individual autonomy. A psychosomatic family was found to be overprotective, inhibiting the child from develop- ing a sense of independence, competence, or interest in activities outside the safety of the family.

The physiologically vulnerable child, in turn, feels great responsibility for protecting the family. The manifestation of symptoms typically occurs when stress overloads the fam- ily’s already dysfunctional coping mechanisms. Thus, the symptoms are regarded as having a regulating effect on the family system, the sick child acting as a family conflict defuser by diverting family attention from more basic but less easily resolved family conflicts. Unlike the underorganized, often single-parent, family population at Wiltwyck, at the Philadelphia Child Guidance Center, there were primarily middle-class, intact families that often appeared to be too tightly organized. Interventions had to be modified to first destructure the family’s rigid patterns and then restructure them to permit greater flexibility. Therapeutic efforts were directed at changing the structure of relationships within the fam- ily, helping the family develop clearer boundaries, learning to negotiate for desired changes, and dealing more directly with hidden, underlying conflicts. According to Colapinto (1991), the Minuchin team’s family-focused success in treating anorexia nervosa—which, unlike diabetes or asthma, has no physiological basis—drew many family therapists to the structural model. LO 1

Structural Family Theory Minuchin (1974) describes his viewpoint as follows: In essence, the structural approach to families is based on the concept that a family is more than the individual biopsychodynamics of its members. Family members relate according to certain arrangements, which govern their transactions. These arrangements, though usually not explicitly stated or even recognized, form a whole—the structure of the family. The reality of the structure is of a different order from the reality of the individual members. (p. 89) Like most systems theorists, structuralists are interested in how the components of a system interact, how balance or homeostasis is achieved, how family feedback mechanisms operate, how dysfunctional communication patterns develop, and so forth. Consistent with Minuchin’s background in child psychiatry, he influenced his associates to observe too how families cope with developmental tasks and make adaptive changes during periods of transi- tion. Structuralists pay attention to family transactional patterns because these offer clues to the family’s structure, the permeability of the family’s subsystem boundaries, and the existence of alignments or coalitions—all of which ultimately affect the family’s ability to achieve a deli- cate balance between stability and change. Before an individual’s symptoms can be reduced or extinguished, according to this model, structural changes must first occur within the family. Family Structure Families need some form of internal organization that dictates how, when, and to whom to relate. The subsequent transactional patterns make up the structure of the family (Colapinto, 1991). Put another way, a family’s structure is the covert set of functional demands or codes that organizes the way family members interact with one another (Minuchin, 1974).

The structure represents the sum of the operational rules the family has evolved for carrying out its important functions. It provides a framework for understanding those consistent, repetitive, and enduring patterns that reveal how a particular family organizes itself in order to main- tain its stability or, under new conditions, to seek adaptive alternatives. Once established, such patterns are self-perpetuating and resistant to change until changing circumstances cause tensions and imbalance within the system. For example, an interactive routine may evolve in a family whereby the young son refuses to comply with his mother’s pleading to clean up his room but will submit to his father’s request without hesitation. Repeated over time and in a variety of situations, a basic family structure may emerge in which the father is seen in the family as the ultimate authority and the mother as possessing insufficient power or clout to be obeyed. Subsequent transactional patterns are likely to reflect this now-established blueprint, combining into more or less constant relationships (Umbarger, 1983) and regulating the fam- ily’s day-to-day functioning. However, structure is not static or fixed. On the contrary, certain temporary structures (a mother–son coalition in which the father is kept in the dark, say, about erratic school attendance or a bad grade) may occur but not persist beyond a brief arrangement and thus must be considered to be dynamic. The structural therapist watches for repeatable family processes in action during therapy sessions in order to detect problematic or ineffective patterns that need restructuring. A family’s transactional patterns regulate the behavior of its members and are main- tained by two sets of constraints: generic or universal rules and idiosyncratic or individualized rules (Minuchin, 1974). For example, structuralists contend that it is a universal rule that well-functioning families should be hierarchically organized, with the parents exercising more authority and power than the children and the older children having more responsibilities as well as more privileges than their younger siblings. In addition, complementarity of functions is universal—the husband and wife, for ex- ample, operate as a team and accept their interdependency. The degree to which the needs and abilities of both spouses dovetail and reciprocal role relations provide satisfaction are key factors in harmonious family functioning. In some cases, family balance is achieved by family members being assigned complementary roles or functions (good child–bad child; tender mother–tough father). Complementarity takes the form of teamwork in well- functioning families. Idiosyncratic constraints apply to specific families and involve mutual presumptions regarding family member behavior toward one another. While the origin of certain expectations may no longer be clear, buried in years of implicit and explicit negoti- ations, their pattern of mutual accommodation and functional effectiveness is maintained (Minuchin, 1974). Some feminists take exception to Minuchin’s insistence on family hierarchies, claiming that they run the risk of reinforcing sex-role stereotypes. Luepnitz (1988) argues that Minuchin bases many of his ideas regarding family organization on the work of the influential functional sociologist Talcott Parsons (Parsons & Bales, 1955), who saw normal family life neatly orga- nized according to gender roles, family functions, and hierarchical power. Parsons maintained that adaptation to society requires that husbands perform an “instrumental” role (e.g., making managerial decisions) in the family and that wives perform “expressive” roles (caring for the family’s emotional needs). Hare-Mustin, as quoted by Simon (1984), believes Minuchin him- self models the male executive functions while working with families, in effect demanding that the father resume control of the family and exert leadership much as Minuchin leads and directs the therapeutic session. Colapinto (1991) contends that Minuchin does not hold the stereotypic division of instrumental versus expressive as an ideal but rather believes all families need some kind of structure, some form of hierarchy, and some differentiation between subsystems. A family will try to maintain preferred patterns—its present structure—as long as possible. While alternate patterns may be considered, any deviation from established rules that goes too far too fast will be met with resistance as the family seeks to reestablish equilibrium. On the other hand, the family must be able to adapt to changing circumstances (a child grows into a young adult; mother goes to work outside the home; grandmother comes to live with them). It must have a sufficient range of patterns (including alternatives to call upon whenever necessary) and must be flexible enough to mobilize these new patterns in the face of impending change if members are to continue as a family. Family Subsystems As we pointed out in Chapter 4, families organize themselves into coexisting subsystems, often arranged in hierarchical order. Typically, subsystem divisions are made according to gender (male/female), generation (parents/children), common interests (intellectual/social), or function (who is responsible for what chores). Other possibilities (older children vs. younger; parents vs. teenagers) spring up in most families. All families contain a number of coexisting but separate subsystems. Subsystems are components of a family’s structure. They exist to carry out various family tasks necessary for the functioning of the overall family system. Each member may belong to several subgroups at the same time, and families are capable of organizing themselves into a limitless number of such units. Each person may have a differing level of power within different subgroups, may play different roles, may exercise different skills, and may engage in different interactions with members of other subsystems within the family. Complementarity of roles (Ackerman’s influence again) is a key here—as Minuchin (1974) points out, a child has to act like a son so his father can act like a father, but he may take on executive powers when he is alone with his younger brother.

Subsystems are defined by interpersonal boundaries and rules for membership; in ef- fect, they regulate the amount of contact with other subsystems. Such boundaries determine who participates and what roles those participants will have in dealing with one another and with outsiders who are not included in the subsystem. They may be temporary alliances (mother and daughter go shopping together on Saturday afternoon) and may have rules concerning exclusion (fathers and brothers are unwelcome). Or they may be more enduring (based on generational differences in roles and interests between parents and children), with clearly defined boundaries separating the two generations (one watches public television documentaries, the other spends hours on Facebook and Twitter). Subsystem organization within a family provides valuable training in developing a sense of self in the process of honing interpersonal skills at different levels.

The spousal, parental, and sibling subsystems are the most prominent and important subsystems in the family. The strength and durability of the spousal subsystem in particular offers a key regarding family stability. How spouses learn to negotiate differences and accom- modate to one another’s needs and develop complementary roles impacts the likelihood of family stability and flexibility to adapt to changing circumstances.

While the arrival of children forces the couple to transform their system to become a parental subsystem grappling with new responsibilities, complementarity of roles remains essential as the couple negotiates differences in parenting attitudes and styles. Accommodations to one another’s perspectives are apt to be renegotiated as children grow and require different parental responses at different stages of their lives. It is crucial that, whatever the demands of child rearing and the evolution of an effective parental subsystem, the parents work to main- tain and strengthen their spousal subsystem, which is fundamental to family well-being.

The sibling subsystem offers the first experience of being part of a peer group and learn- ing to support, cooperate, and protect (as well as compete, fight, and negotiate differences). The sibling subsystem deals with the parental subsystem to work out relationship changes commensurate with the developmental changes they are going through. In a well-functioning family, all three subsystems operate in an integrated way to protect the differentiation and integrity of the family system. When the integrated family structure is flexible enough to meet ongoing family developmental challenges, we may consider the family functional. When the family cannot adjust to changing circumstances, we consider it dysfunctional. From the struc- tural perspective, family dysfunction generally involves boundary issues such as enmeshment, disengagement, alignments, power, and coalitions.

Family Dysfunction

Rosenberg (1983) summarizes the structural position: “when a family runs into difficulty, one can assume that it is operating within a dysfunctional structure” (p. 160). This may happen when the family hits a snag entering a life cycle stage, such as the birth of a child, children leaving for college, or retirement. Perhaps the family members have become enmeshed, or, at the other end of the continuum, perhaps they are disengaged. Dysfunction suggests that the covert rules that govern family transactions have become, if only temporarily, ineffective and require renegotiation.

n the Wiltwyck families (Minuchin et al., 1967), typically burdened by severe external stressors brought about by poverty, five dysfunctional family structures were differentiated: (a) enmeshed families, (b) disengaged families, (c) families with a peripheral male, (d) fam- ilies with noninvolved parents, and (e) families with juvenile parents. A sense of feeling overwhelmed and helpless was common to these families, often led by single mothers, who struggled to control or guide their delinquent children.

Just as the social context as stressor was apparent in the Wiltwyck population, so the in- adequate internal responses to stress—the other component of the dysfunctional equation— played a key role for the Philadelphia working-class and middle-class families suffering from psychosomatic disorders (Colapinto, 1991). Here the problem stemmed from inflexibility, particularly the family’s inability to modify those transactional patterns that had ceased to satisfy the needs of family members. For example, a couple that negotiated a complementary relationship before the arrival of children that did not allow for much open conflict failed to adapt readily to becoming parents because there was conflict regarding the new roles of mother and father. Or parents accustomed to dealing with young children were unable to adapt to growing teenagers who now demanded more autonomy. Fear of departing from established patterns led to rigid repetition of failed patterns.

Disengagement or enmeshment—avoiding contact with one another or continuous bickering—are both directed at circumventing change, thus failing to achieve conflict resolu- tion. Overprotection of the sick child by the entire family helped cover up underlying family conflicts and tended to discourage the development of a sense of competence, maturity, or self-reliance on the part of the symptomatic child.

Minuchin (1974) reserves the label of pathological for those families who, when faced with a stressful situation, increase the rigidity of their transactional patterns and boundaries, thus preventing any further exploration of alternatives. Normal families, in contrast, preserve family continuity and permit family restructuring.

Boundary Permeability

The specific composition of a subsystem is not as important as the clarity of its boundaries. Boundaries in a family vary in their permeability, and that degree of accessibility helps deter- mine the nature and frequency of contact between family members. Clearly defined boundaries between subsystems help maintain separateness and at the same time emphasize belongingness to the overall family system. In an ideal arrangement, the clarity enhances the family’s overall well-being by providing support and easy access for communication and negotiation between subsystems while simultaneously encouraging independence and the freedom to experiment by the members of the separate subsystems.