What Is Structural Family Therapy?
Structural family therapy (SFT) is a type of family therapy that looks at the structure of a family unit and improves the interactions between family members. This approach to therapy was originally developed by Salvador Minuchin and has become one of the dominant forms of family intervention.
It suggests that dysfunctional family relationships can create stress and mental health problems for members of that family.
By addressing how members of the family relate to one another, the goal is to improve communication and relationships to create positive changes for both individual family members and the family unit as a whole.
Techniques
Structural family therapy relies on a technique known as family mapping to uncover and understand patterns of behavior and family interactions. During this process, the therapist creates a visual representation that identifies the family’s problems and how those issues are maintained through family dynamics.
This map diagrams the basic structure of the family, including the members of the family unit, their ages, genders, and relationships to one another. Aspects of the family observed during this process include:
- Family rules
- Patterns of behavior
- Family structure/hierarchies
This process frequently involves having family members themselves make their own maps describing their family. This not only boosts engagement in the therapeutic process but also gives a therapist a better understanding of how individual family members view their place within the family.
“Inviting family members to place the people and write their names inside a circle promotes a recognition of their mutual belongingness, an awareness that ‘these are us,'” explained Salvador Minuchin and his colleagues in Working With Families of the Poor.
After this initial process, the therapist observes the family during therapy sessions and in the home environment to track interactions and develop a hypothesis about the nature of the family’s relationships and interaction patterns.
Other techniques that may be used during SFT include:
- Joining: This technique involves the therapist developing a sharing and empathetic relationship to “join” the family.
- Boundary-making: The therapist will help the family identify, explore, and adopt clear boundaries and hierarchies within the family.
- Role-play: This involves acting out scenarios with the therapist’s guidance to look at certain patterns of behavior, identify dysfunction, and practice enacting alternatives.
- Reframing: In cognitive reframing, the therapist helps family members think about situations in different ways or see things from a different perspective. This can help people see experiences more positively.
What Structural Family Therapy Can Help With
Structural family therapy can be helpful for many families, but it is often recommended in situations or life events that involve:
- Families affected by trauma
- Divorce, separation, or remarriage
- Blended families
- Intergenerational families
- Single-parent families
- When one family member is affected by a mental health condition such as depression, anxiety, substance use, or post-traumatic stress disorder (PTSD)
- Families affected by chronic illness or disability
- Significant life changes such as changing careers, coming out, or moving
Any family that is coping with tension or conflict can potentially benefit from structural family therapy.
Vulnerable families faced with readjustments caused by shifting roles, changed norms, and new demands may benefit from this type of therapy, which has been shown to help empower and strengthen the entire family system.
Benefits of Structural Family Therapy
Families struggling with conflict can benefit from this type of therapy for many reasons. Some of the ways it may help include:
- Corrects imbalances within a family
- Establishes healthy boundaries
- Helps individuals improve their reactions to changing demands
- Improves communication
- Improves hierarchies within the family system
- Increases parental competence and satisfaction
- Improves relationship dynamics
- Reduces anger and resentment
SFT recognizes that many aspects of a family’s structure—including behavior patterns, routines, habits, and communication—can contribute to dysfunction. However, this approach to therapy can help families become more stable and improve support to individual family members who may need extra help by working to address these issues.
It can be beneficial for families that have dealt with some significant change in their lives. For example, this might involve the death of a family member, a change in the family structure through a divorce, or some trauma such as interpersonal violence or an accident.
Effectiveness
Structural family therapy has been shown to be effective at helping to address problems within families. Studies have also demonstrated the efficacy of this type of therapy.
- A 2019 study looking at the impact of family therapy on adolescents with mental health problems and their families found that therapy incorporating SFT offered several benefits. For example, the results indicated that after treatment, teens exhibited fewer externalizing and internalizing symptoms. In terms of other improvements, parents also reported increased family cohesion, better parental practices, and greater perceived efficacy as a parent.
- A small 2020 case study found that structural family therapy was an effective approach for improving marital mediation and reducing marital distress. However, the study authors noted that follow-up was needed to evaluate the long-term effects of treatment better.
Since its initial development in the 1960s, SFT has become one of the predominant family counseling theories.
Things to Consider
The amount of time needed for treatment to be successful often depends on the dynamics of the family and the situation they are facing. Some families may require relatively short-term treatment lasting a few weeks, while others may need more sessions lasting several months.
Participation and cooperation play an important role in the success of this type of treatment. However, some family members may be less cooperative or may refuse to participate altogether.
How to Get Started
If you think that structural family therapy may be helpful, ask your doctor if they can refer you to a professional who practices this type of treatment. You may also search an online directory to locate professionals in your area who specialize in SFT.
Some questions you might ask before you begin treatment include:
- How much experience does the therapist have with SFT?
- How long treatment is expected to take?
- How will progress be measured?
- What happens if some family members miss therapy sessions?
During your first appointment, your therapist will ask you questions to learn more about the problems you are facing and how your family currently functions. They may ask you to create a family diagram to describe relationships between members of the family and work to get a better view of the dynamic between individuals in the family.
After your initial session, your therapist will then be able to provide a fuller view of your family’s treatment plan and what else you can expect during treatment.
1. Introduction
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Mental health problems during adolescence constitute a major public health concern today for both families and stakeholders [ 1 2 ]. Epidemiological studies show that mental health issues are the first nonfatal cause of illness [ 3 ], are in the top five causes of death among adolescents [ 4 ], and represent 16% of the global health-related burden in young people [ 4 5 ]. In addition, mental health problems during adolescence are an important predictor of socialization difficulties and absenteeism at this developmental stage, as well as one of the most significant predictors of adjustment problems and mental disorders in adulthood [ 6 8 ]. In order to address these pressing issues, it is essential to have effective intervention and prevention strategies that meet the specific needs of adolescents with mental health problems.
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Adolescence is a challenging transitional period for both children and families. It is a developmental stage characterized by normative physical, social, and psychological changes [ 9 ], some of which may be identified as potentially stressful among this population [ 10 ]. Psychosocial stress in adolescents can be accentuated by the presence of stressful or adverse life events (as maltreatment and violence, loss events, intrafamilial problems, school and interpersonal problems) that are associated with severe negative outcomes [ 11 ]. Although there are important inter-individual differences, the current homogenization of adolescents’ daily experiences has contributed to the observation of fewer cross-cultural and gender differences during this stage [ 12 ]. Some of the normative developmental tasks that adolescents need to undertake for a healthy development are the search for autonomy, identity, and independence [ 9 ]. For families, this is a period characterized by the readjustment of family roles and norms, along with an increase in family conflicts [ 9 14 ]. Families face the challenge of adjusting to these new demands and needs while trying to conserve family unity [ 9 14 ]. The inability to adjust to these new demands, together with inflexibility within the family over the negotiation of new norms and different solutions, are often related to mental health problems. Families with an adolescent with mental health problems have additional needs, demands, and difficulties stemming from the mental disorder [ 15 ]. Parents often face challenging behaviors and conflictive situations, having to manage symptoms and coordinate and engage with different service systems [ 16 17 ]. As they struggle to deal with these additional demands, parents often find their skills coming into question, and this can be accompanied by feelings of low competence, frustration, and powerlessness, together with increased isolation and contraction in their social network [ 15 18 ].
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There has been a proliferation of family-oriented and family-based interventions with adolescents with mental health difficulties; some of these are considered as evidence-based practices in the treatment of children and adolescents with certain disorders [ 19 20 ]. Previous research indicates that the incorporation of family members or family elements in therapy is either directly or indirectly an effective component of interventions that target adolescents with mental health problems [ 21 23 ]. On one hand, direct approaches (e.g., family-centered behavioral management or family therapy) involve a more immediate engagement with the family and usually include specific objectives that target families or family members. On the other hand, indirect approaches (e.g., psychodynamic therapy or cognitive–behavioral therapy) incorporate the family context through reviews or reports, using them as informants at some point and by keeping the family elements in mind while intervening [ 22 ]. In sum, under the “family-based interventions” umbrella term, there are a wide range of qualitatively different interventions and approaches. The most widely used family-based interventions include psychoeducational approaches [ 24 ], behavioral interventions, and systemic family therapy [ 25 ]. The goal of the present study was to evaluate the efficacy of specific systemic family therapy approaches in families with an adolescent presenting a mental health problem.
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From a systemic perspective, family is defined as a transactional system, where difficulties in any member have an influence on every other member and on the whole family as a unit. In turn, family processes have an impact on every individual member, as well as on the different relationships embedded within the family context [ 26 ]. This perspective shifts away from a linear consideration of family processes by recognizing the multiple recursive influences that shape family relationships and family functioning, perceiving it as an ongoing process throughout the life cycle [ 27 ]. Systemic family therapy has been shown to be an efficacious intervention for families and adolescents with a wide range of mental health problems, such as drug use [ 19 32 ]), eating disorders [ 29 30 ] and both internalizing and externalizing disorders [ 19 36 ]. Despite these advances, most of the literature has focused on either systemic family therapy as a whole, without taking into account the different approaches embedded within this framework, or on the effectiveness of more manualized approaches, such as multisystemic family therapy (e.g., [ 37 ]) or functional family therapy (e.g., [ 34 38 ]). Few studies have examined the effectiveness of more classical and widely used approaches, such as structural and strategic family therapy [ 39 ]. Hence, more research is needed to be able to draw more definite conclusions regarding the use of these types of family therapy approaches.
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Structural family therapy is one of the dominant approaches in systemic family intervention, originally created by Minuchin [ 40 ]. The focus of this approach is on achieving a healthy hierarchical family organization, where there are different subsystems with their limits and boundaries [ 27 41 ]. According to this approach, the difficulties expressed by the adolescent are a reflection of: (1) A family structural imbalance; (2) a dysfunctional hierarchy within the family system, often characterized by difficulties in establishing boundaries between the parental and the child subsystem; and (3) a maladaptive reaction to changing demands [ 27 ]. Therefore, the intervention focuses on reinforcing the parental subsystem, highlighting the need to present a “united front”, and clearly differentiating it from the parent–child subsystem [ 25 42 ]. It also emphasizes the need to adjust the rigidity of the limits and the relationship between subsystems according to the moment of the life cycle [ 42 ]. During adolescence, while authority still relies on the parental subsystem, the way it is exerted cannot be the same as in previous developmental stages, and the limits between the subsystems, while remaining clear, have to be more flexible [ 25 42 ]. Although the core elements of this approach are well established and widely used among the clinical community [ 30 43 ], few studies have addressed the effectiveness of this approach for adolescents with mental health problems [ 39 44 ].
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Strategic family therapy is purely embedded within the systemic model and has a more directive impression [ 25 45 ]. From this approach, the symptom is considered as serving a function to the family, as well as reflecting a difficulty of the family to solve a problem [ 25 45 ]. According to the strategic approach, when faced with a problem, families adopt solutions that have been useful to them in the past. However, symptoms such as behavioral or emotional difficulties or an increase in conflicts emerge for which those solutions are no longer valid, and the family is unable to find and effectively use alternative ones; thus, they become stuck in a symptom-maintaining sequence [ 27 ]. The objective of this therapy is for the family to initiate actions and solutions that are different to the ones previously attempted [ 27 45 ]. There is extensive evidence about the effectiveness of the brief–strategic family therapy approach, which is a manualized and specific variant of the strategic approach, with different populations [ 46 ], including adolescents with mental health problems (e.g., [ 32 48 ]). Though structural and strategic family therapy are conceptually two different approaches within the systemic framework, they share certain core elements, and it is not rare to use them conjointly. Some illustrative examples are brief–strategic family therapy and multisystemic therapy, both of which incorporate representative elements from both approaches.
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In general, literature has shown that systemic family therapy has a significant impact by reducing internalizing and externalizing symptoms of adolescents, as well as improving overall family functioning [ 35 36 ]. However, in spite of the evidence indicating gender differences in adjustment problems, especially in internalizing symptoms, most available studies have not taken into account the adolescent’s gender when examining the impact of these interventions [ 49 ]. In addition, most studies have focused on individual outcomes or on family functioning as a whole, rather than incorporating parent–child dyadic measures or parental dyadic measures. Research has shown that some of these dyadic dimensions play an important role in families with adolescents with mental health problems; they should therefore be incorporated in effectiveness evaluations. More specifically, coercive and permissive parenting practices [ 50 52 ] have generally been considered as two of the most important predictors of internalizing and externalizing problems. Other parenting dimensions linked to child psychopathology include: Low sense of parental competence, defined as the perception parents have of their own performance as parents [ 52 54 ], and high levels of interparental conflict [ 55 ]. As a result, parental practices, sense of parental competence, and parenting alliance constitute intervention targets and should be included in effectiveness evaluations.
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For some of these dimensions, the studies available highlight the need to control gender differences. Specifically, there is evidence of important differences in parenting practices between mothers and fathers, with mothers scoring higher in communication and control dimensions [ 56 58 ]. In addition, there is evidence of gender differences in the perception of parenting alliance and co-parenting; more specifically, in parental support and involvement dimensions. Thus, mothers are more likely to be involved in parental decision-making processes than fathers but also feel less supported in their parental role [ 59 ].
In this framework, the goal of this study was to evaluate the effectiveness of structural–strategic family therapy on different individual, dyadic, and family dimensions in families with an adolescent with a mental health problem; to do so, we conducted a comprehensive analysis and incorporated a gender perspective. According to previous evidence on systemic family therapy, we expected a reduction of internalizing and externalizing symptoms of adolescents, as well as an improvement in family functioning. Due to their role in child psychopathology, a reduction of coercive and permissive parenting practices as well as an increase in sense of parental competence and parenting alliance were hypothesized. Because of an absence of previous studies, we did not have expectations regarding the adolescent’s gender, although higher improvements in mothers were expected in comparison to fathers.
