Therapy Manuals 

for Drug Addiction

Brief Strategic 

Family Therapy for 

Adolescent Drug Abuse

José Szapocznik, Ph.D.

Olga Hervis, M.S.W., L.C.S.W.

Seth Schwartz, Ph.D.

Center for Family Studies

Department of Psychiatry and Behavioral Sciences

University of Miami School of Medicine

U.S. Department of Health and Human Services

National Institutes of Health

National Institute on Drug Abuse

6001 Executive Boulevard

Bethesda, Maryland 20892
ACKNOWLEDGMENTS

This treatment manual was written by Jose Szapocznik, Ph.D., Olga Hervis, M.S.W.,

and Seth Schwartz, Ph.D., of the Center for Family Studies, Department of Psychiatry

and Behavioral Sciences, at the University of Miami, under contract to the National

Institute on Drug Abuse (NIDA). The treatment described in this manual was developed

over the course of several decades by a team of researchers and clinicians. Among

those who were integral to the development of this manual are: Mercedes Scopetta,

who founded the University of Miami Center for Family Studies; Daniel Santisteban,

who continues to pioneer culturally sensitive family therapy interventions for Hispanic

families; Michael Robbins, who directs the Center’s research on in-session processes

and their relationship to treatment outcomes; Angel Perez-Vidal, who was the lead

therapist in many BSFT studies; and Victoria Mitrani, who has worked intensively on

a BSFT-relevant measure of family functioning.

NIDA wishes to thank all who contributed to the development of this manual, including

the families who participated in this research, without whom this research would not

have been possible.

DISCLAIMER

The opinions expressed herein are the views of the authors and do not necessarily

reflect the official policy or position of the National Institute on Drug Abuse or any

other part of the U.S. Department of Health and Human Services. The U.S. Government

does not endorse or favor any specific commercial product.

PUBLIC DOMAIN NOTICE

All material appearing in this report is in the public domain and may be reproduced

without permission from the National Institute on Drug Abuse or the authors. Citation

of the source is appreciated.

NIH Pub. No. 03-4751

Printed August 2003
Foreword

More than 20 years of research has shown that addiction is clearly

treatable. Addiction treatment has been effective in reducing drug use

and HIV infection, diminishing the health and social costs that result

from addiction, and decreasing criminal behavior. The National

Institute on Drug Abuse (NIDA), which supports more than 85 percent of the world’s research on drug abuse and addiction, has found

that behavioral approaches can be very effective in treating cocaine

addiction.

To ensure that treatment providers apply the most current scientifically supported approaches to their patients, NIDA has supported

the development of the “Therapy Manuals for Drug Addiction” series.

This series reflects NIDA’s commitment to rapidly applying basic findings in real life settings. The manuals are derived from those used

efficaciously in NIDA-supported drug abuse treatment studies. They

are intended for use by drug abuse treatment practitioners, mental

health professionals, and all others concerned with the treatment of

drug addiction.

The manuals present clear, helpful information to aid drug treatment

practitioners in providing the best possible care that science has to

offer. They describe scientifically supported therapies for addiction and

provide guidance on session content and how to implement specific

techniques. Of course, there is no substitute for training and supervision, and these manuals may not be applicable to all types of

patients nor compatible with all clinical programs or treatment

approaches. These manuals should be viewed as a supplement to,

but not a replacement for, careful assessment of each patient, appropriate case formulation, ongoing monitoring of clinical status, and

clinical judgment.

The therapies presented in this series exemplify the best of what we

currently know about treating drug addiction. As our knowledge

evolves, new and improved therapies are certain to emerge. We look

forward to continuously bringing you the latest scientific findings

through manuals and other science-based publications. We welcome

your feedback about the usefulness of this manual series and any

ideas you have about how it might be improved.

Nora D. Volkow, M.D.

Director

National Institute on Drug Abuse

iii

Contents

Page

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Chapter 1 Brief Strategic Family Therapy: An Overview . . . . . . . . 1

Why Brief Strategic Family Therapy? . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

What Are the Goals of Brief Strategic Family Therapy? . . . . . . . . . . . . . 3

What Are the Most Common Problems Facing the Family of a 

Drug-Abusing Adolescent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

What Is Not the Focus of Brief Strategic Family Therapy? . . . . . . . . . . . 5

This Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 2 Basic Concepts of Brief Strategic Family Therapy . . . . 7

Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Structure: Patterns of Family Interaction . . . . . . . . . . . . . . . . . . . . . . . 10 

Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Content Versus Process: A Critical Distinction . . . . . . . . . . . . . . . . . . . 13 

Chapter 3 Diagnosing Family System Problems . . . . . . . . . . . . . 15

Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Resonance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Developmental Stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Life Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Identified Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Conflict Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Chapter 4 Orchestrating Change . . . . . . . . . . . . . . . . . . . . . . . . . 25

Establishing a Therapeutic Relationship . . . . . . . . . . . . . . . . . . . . . . . 25 

Producing Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

v
Contents

Page

Chapter 5 Engaging the Family Into Treatment . . . . . . . . . . . . . 43

The Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

The Task of Coming to Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Diagnosing the Interactions That Keep the Family From Coming 

Into Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Complementarity: Understanding How the Family “Pieces” 

Fit Together to Create Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Restructuring the Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Chapter 6 Clinical Research Supporting Brief Strategic 

Family Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Outpatient Brief Strategic Family Therapy Versus Outpatient 

Group Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

One Person Brief Strategic Family Therapy . . . . . . . . . . . . . . . . . . . . . 58

Brief Strategic Family Therapy Engagement . . . . . . . . . . . . . . . . . . . . 59

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

APPENDIX A: Training Counselors in Brief Strategic Family Therapy . . 71

Selecting Counselors . . . . . . . . . . . . . . . . . . . . . . . . . 71

Required Brief Strategic Family Therapy Training: 

Four Phases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Required Supervision . . . . . . . . . . . . . . . . . . . . . . . . 75

APPENDIX B: Case Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Case Example I: The Guerrero Family . . . . . . . . . . . . . 77

Case Example II: The Hernandez Family . . . . . . . . . . . 82

vi
1

Chapter 1 Brief Strategic Family Therapy: 

An Overview

Brief Strategic Family Therapy (BSFT) is a brief intervention used to

treat adolescent drug use that occurs with other problem behaviors.

These co-occurring problem behaviors include conduct problems at

home and at school, oppositional behavior, delinquency, associating

with antisocial peers, aggressive and violent behavior, and risky sexual

behavior (Jessor and Jessor 1977; Newcomb and Bentler 1989;

Perrino et al. 2000). 

BSFT is based on three basic principles. The first is that BSFT is a

family systems approach. Family systems means that family members

are interdependent: What affects one family member affects other

family members. According to family systems theory, the drug-using

adolescent is a family member who displays symptoms, including

drug use and related co-occurring problem behaviors. These symptoms are indicative, at least in part, of what else is going on in the

family system (Szapocznik and Kurtines 1989). Just as important,

research shows that families are the strongest and most enduring

force in the development of children and adolescents (Szapocznik

and Coatsworth 1999). For this reason, family-based interventions

have been studied as treatments for drug-abusing adolescents and

have been found to be efficacious in treating both the drug abuse and

related co-occurring problem behaviors (for reviews, see Liddle and

Dakof 1995; Robbins et al. 1998; Ozechowski and Liddle 2000).

The second BSFT principle is that the patterns of interaction in the

family influence the behavior of each family member. Patterns of

interaction are defined as the sequential behaviors among family

members that become habitual and repeat over time (Minuchin et al.

1967). An example of this is an adolescent who attracts attention to

herself when her two caregivers (e.g., her mother and grandmother) are

fighting as a way to disrupt the fight. In extreme cases, the adolescent

may suffer a drug overdose or get arrested to attract attention to herself when her mother and grandmother are having a very serious fight.

The role of the BSFT counselor is to identify the patterns of family

interaction that are associated with the adolescent’s behavior problems. For example, a mother and grandmother who are arguing

1
Chapter 1 Brief Strategic Family Therapy: An Overview

about establishing rules and consequences for a problem adolescent

never reach an agreement because the adolescent disrupts their 

arguments with self-destructive attempts to get attention.

Therefore, the third principle of BSFT is to plan interventions that

carefully target and provide practical ways to change those patterns

of interaction (e.g., the way in which mother and grandmother

attempt but fail to establish rules and consequences) that are directly

linked to the adolescent’s drug use and other problem behaviors.

Why Brief Strategic Family Therapy?

The scientific literature describes various treatment approaches for

adolescents with drug addictions, including behavioral therapy, 

multisystemic therapy, and several family therapy approaches. Each

of these approaches has strengths. 

BSFT’s strengths include the following:

■ BSFT is an intervention that targets self-sustaining changes in the

family environment of the adolescent. That means that the treatment environment is built into the adolescent’s daily family life.

■ BSFT can be implemented in approximately 8 to 24 sessions.

The number of sessions needed depends on the severity of the

problem.

■ BSFT has been extensively evaluated for more than 25 years and

has been found to be efficacious in treating adolescent drug

abuse, conduct problems, associations with antisocial peers, and

impaired family functioning. 

■ BSFT is “manualized,” and training programs are available to 

certify BSFT counselors.

■ BSFT is a flexible approach that can be adapted to a broad range

of family situations in a variety of service settings (e.g., mental

health clinics, drug abuse treatment programs, and other social

service settings) and in a variety of treatment modalities (e.g., as a

primary outpatient intervention, in combination with residential

or day treatment, and as an aftercare/continuing-care service to

residential treatment).

■ BSFT appeals to cultural groups that emphasize family and 

interpersonal relationships.

2
Chapter 1 Brief Strategic Family Therapy: An Overview

What Are the Goals of Brief Strategic Family Therapy?

In BSFT, whenever possible, preserving the family is desirable. While

family preservation is important, two goals must be set: to eliminate

or reduce the adolescent’s use of drugs and associated problem

behaviors, known as “symptom focus,” and to change the family

interactions that are associated with the adolescent’s drug abuse,

known as “system focus.” An example of the latter occurs when families direct their negative feelings toward the drug-abusing youth. The

parents’ negativity toward the adolescent directly affects his or her

drug abuse, and the adolescent’s drug abuse increases the parents’

negativity. At the family systems level, the counselor intervenes to

change the way family members act toward each other (i.e., patterns

of interaction). This will prompt family members to speak and act in

ways that promote more positive family interaction, which, in turn,

will make it possible for the adolescent to reduce his or her drug

abuse and other problematic behaviors.

What Are the Most Common Problems 

Facing the Family of a Drug-Abusing Adolescent?

The makeup and dynamics of the family are discussed in terms of the

adolescent’s symptoms and the family’s problems.

The Family Profile Research shows that many adolescent behavior problems have comof a Drug-Abusing mon causes and that families, in particular, play a large role in those

Adolescent problems in many cases (Szapocznik and Coatsworth 1999). Some of

the family problems that have been identified as linked to adolescent

problem behaviors include:

■ Parental drug use or other antisocial behavior

■ Parental under- or over-involvement with the adolescent

■ Parental over- or under-control of the adolescent

■ Poor quality of parent-adolescent communication

■ Lack of clear rules and consequences for adolescent behavior

■ Inconsistent application of rules and consequences for adolescent

behavior

■ Inadequate monitoring and management of the adolescent’s

activities with peers

■ Lack of adult supervision of the adolescent’s activities with peers

■ Poor adolescent bonding to family

■ Poor family cohesiveness

3
Chapter 1 Brief Strategic Family Therapy: An Overview

Some adolescents may have families who had these problems before

they began using drugs (Szapocznik and Coatsworth 1999). Other

families may have developed problems in response to the adolescent’s problem behaviors (Santisteban et al. in press).

Because family problems are an integral part of the profile of drugabusing adolescents and have been linked to the initiation and maintenance of adolescent drug use, it is necessary to improve conditions

in the youth’s most lasting and influential environment: the family.

BSFT targets all of the family problems listed on page 3.

The Behavioral Profile Adolescents who need drug abuse treatment usually exhibit a variety

of a Drug-Abusing of externalizing behavior problems. These may include:

Adolescent

■ School truancy

■ Delinquency

■ Associating with antisocial peers

■ Conduct problems at home and/or school

■ Violent or aggressive behavior

■ Oppositional behavior

■ Risky sexual behavior

Negativity in the Family Families of drug-abusing adolescents exhibit high degrees of negativity (Robbins et al. 1998). Very often, this negativity takes the form

of family members blaming each other for both the adolescent’s and

the family’s problems. Examples might include a parent who refers to

her drug-abusing son as “no good” or “a lost cause.” Parents or parent

figures may blame each other for what they perceive as a failure in

raising the child. For example, one parent may accuse the other of

having been a “bad example,” or for not “being there” when the

youngster needed him or her. The adolescent, in turn, may speak

about the parent accused of setting a bad example with disrespect

and resentment. The communication among family members is 

contaminated with anger, bitterness, and animosity. To the BSFT

counselor, these signs of emotional or affective distress indicate that

the work of changing dysfunctional behaviors must start with changing

the negative tone of the family members’ emotions and the negative

content of their interactions. Research shows that when family negativity is reduced early in treatment, families are more likely to remain

in therapy (Robbins et al. 1998).

4
Chapter 1 Brief Strategic Family Therapy: An Overview

What Is Not the Focus of Brief Strategic Family Therapy?

BSFT has not been tested with adult addicts. For this reason, BSFT is

not considered a treatment for adult addiction. Instead, when a parent

is found to be using drugs, a counselor needs to decide the severity of

the parent’s drug problem. A parent who is moderately involved with

drugs can be helped as part of his or her adolescent’s BSFT treatment.

However, if a parent is drug dependent, the BSFT counselor should

work to engage the parent in drug abuse treatment. If the parent is

unwilling to get drug abuse treatment, the BSFT counselor should

work to protect and disengage the adolescent from the drug dependent parent. This is done by creating an interpersonal wall or boundary

that separates the adolescent and non-drug-using family members from

the drug dependent parent(s). This process is discussed in Chapter 4

in the section on “Working With Boundaries and Alliances,” beginning

on page 36.

This Manual

This manual introduces counselors to concepts that are needed to

understand the family as a vital context within which adolescent drug

abuse occurs. It also describes strategies for creating a therapeutic

relationship with families, assessing and diagnosing maladaptive 

patterns of family interaction, and changing patterns of family interaction from maladaptive to adaptive. This manual assumes that therapists

who adopt these BSFT techniques will be able to engage and retain

families in drug abuse treatment and ultimately cause them to behave

more effectively. Chapter 2 will discuss the basic theoretical concepts

of BSFT. Chapter 3 will present the BSFT diagnostic approach, and

Chapter 4 will explain how change is achieved. Chapter 5 is a

detailed discussion of how to engage resistant families of drug-abusing

adolescents in treatment. Chapter 6 summarizes some of the research

that supports the use of BSFT with adolescents. The manual also has

two appendices, one on training counselors to implement BSFT and

another presenting case examples from the authors’ work. Concepts

and techniques discussed by Minuchin and Fishman (1981) have been

adapted in this BSFT manual for application to drug-abusing adolescents. Additional discussion of BSFT can be found in Szapocznik and

Kurtines (1989).

5

Chapter 2 Basic Concepts 

of Brief Strategic Family Therapy

The previous chapter introduced the underlying philosophy of BSFT:

to help families help themselves and to preserve the family unit,

whenever possible. The remainder of this manual focuses more

directly on BSFT as a strategy to treat adolescent drug abuse and its

associated behavior problems. This chapter presents the most basic

concepts of the BSFT approach. It begins with a discussion of five

theoretical concepts that comprise the basic foundation of BSFT.

Some of these concepts may be new for drug abuse counselors. The

five concepts discussed in this chapter are:

■ Context

■ Systems

■ Structure 

■ Strategy

■ Content versus process

Context

The social influences an individual encounters have an important

impact on his or her behavior. Such influences are particularly powerful during the critical years of childhood and adolescence. The BSFT

approach asserts that the counselor will not be able to understand the

adolescent’s drug-abusing behavior without understanding what is

going on in the various contexts in which he or she lives. Drug-abusing

behavior does not happen in a vacuum; it exists within an environment that includes family, peers, neighborhood, and the cultures that

define the rules, values, and behaviors of the adolescent.

Family as Context Context, as defined by Urie Bronfenbrenner (1977, 1979, 1986, 1988),

includes a number of social contexts. The most immediate are those

that include the youth, such as family, peers, and neighborhoods.

Bronfenbrenner recognized the enormous influence the family has,

and he suggested that the family is the primary context in which the

7
Chapter 2 Basic Concepts of Brief Strategic Family Therapy

child learns and develops. More recent research has supported

Bronfenbrenner’s contention that the family is the primary context for

socializing children and adolescents (for reviews, see Perrino et al.

2000; Szapocznik and Coatsworth 1999).

Peers as Context Considerable research has demonstrated the influences that friends’ 

attitudes, norms, and behaviors have on adolescent drug abuse

(Brook et al. 1999; Newcomb and Bentler 1989; Scheier and

Newcomb 1991). Moreover, drug-using adolescents often introduce

their peers to and supply them with drugs (Bush et al. 1994). In the

face of such powerful peer influences, it may seem that parents can

do little to help their adolescents.

However, recent research suggests that, even in the presence of drugusing (Steinberg et al. 1994) or delinquent (Mason et al. 1994) peers,

parents can wield considerable influence over their adolescents. Most

of the critical family issues (e.g., involvement, control, communication,

rules and consequences, monitoring and supervision, bonding, family

cohesion, and family negativity) have an impact on how much influence

parents can have in countering the negative impact peers have on

their adolescents’ drug use.

Neighborhood as Context The interactions between the family and the context in which the 

family lives may also be important to consider. A family functions

within a neighborhood context, family members live in a particular

neighborhood, and the children in the family are students at a 

particular school. For instance, to effectively manage a troubled 15-

year-old’s behavioral problems in a particular neighborhood, families

may have to work against high drug availability, crime, and social 

isolation. In contrast, a small town in a semi-rural community may

have a community network that includes parents, teachers, grandparents, and civic leaders, all of whom collaborate in raising the

town’s children. Neighborhood context, then, can introduce additional challenges to parenting or resources that should be considered

when working with families.

Culture as Context Bronfenbrenner also suggested that families, peers, and neighborhoods exist within a wider cultural context that influences the family

and its individual members. Extensive research on culture and the

family has demonstrated that the family and the child are influenced

by their cultural contexts (Santisteban et al. 2003; Szapocznik and

Kurtines 1993). Much of the researchers’ work has examined the

ways in which minority families’ values and behaviors have an impact

on the relationship between parents and children and affect adolescents’ involvement with drug abuse and its associated problems

(Santisteban et al. 2003; Szapocznik and Kurtines 1980, 1993;

Szapocznik et al. 1978). 

8
Chapter 2 Basic Concepts of Brief Strategic Family Therapy

Counseling as Context The counseling situation itself is a context that is associated with a set 

of rules, expectations, and experiences. The cultures of the client

(i.e., the family), the counselor, the agency, and the funding source

can all affect the nature of counseling as can the client’s feelings

about how responsive the “system” is to his or her needs.

Systems

Systems are a special case of context. A system is made up of parts

that are interdependent and interrelated. Families are systems that are

made up of individuals (parts) who are responsive (interrelated) to

each other’s behaviors.

A Whole Organism “Systems” implies that the family must be viewed as a whole organism.

In other words, it is much more than merely the sum of the individuals or groups that it comprises. During the many years that a family

is together, family members develop habitual patterns of behavior

after having repeated them thousands of times. In this way, each individual member has become accustomed to act, react, and respond in

a specific manner within the family. Each member’s actions elicit a

certain reaction from another family member over and over again

over time. These repetitive sequences give the family its own form

and style.

The patterns that develop in a family actually shape the behaviors

and styles of each of its members. Each family member has become

accustomed to behaving in certain ways in the family. Basically, as

one family member develops certain behaviors, such as a responsible,

take-control style, this shapes other family members’ behaviors. For

example, family members may allow the responsible member to handle

logistics. At the same time, the rest of the family members may

become less responsible. In this fashion, family members complement

rather than compete with one another. These behaviors have

occurred so many times, often without being thought about, that they

have shaped the members to fit together like pieces of a puzzle—a

perfect, predictable fit.

Family Systemic Family influences may be experienced as an “invisible force.” Family 

Influences members’ behavior can vary considerably. They may act much differently when they are with other family members than when they

are with people outside the family. By its very presence, the family

system shapes the behaviors of its members. The invisible forces (i.e.,

systemic influences) that govern the behaviors of family members are

at work every time the family is together. These “forces” include such

things as spoken or unspoken expectations, alliances, rules for managing conflicts, and implicitly or explicitly assigned roles.

9
Chapter 2 Basic Concepts of Brief Strategic Family Therapy

In the case of an adolescent with behavior problems, the family’s lack

of skills to manage a misbehaving youth can create a force (or pattern

of interaction) that makes the adolescent inappropriately powerful in

the family. For example, when the adolescent dismisses repeated

attempts by the parents to discipline him or her, family members

learn that the adolescent generally wins arguments, and they change

their behavior accordingly. Once a situation like this arises in which

family expectations, alliances, rules, and so on have been reinforced

repeatedly, family members may be unable to change these patterns

without outside help.

The Principle The idea that family members are interdependent, influencing and 

of Complementarity being influenced by each other, is not unique to BSFT. Using different

terminology, the theoretical approach underlying behaviorally oriented

family treatments might explain these mutual influences as family

members both serving as stimuli for and eliciting responses from one

another (Hayes et al. 1999). The theoretical approach underlying

existential family treatments might describe this influence as family

members either supporting or constraining the growth of other family

members (Lantz and Gregoire 2000). What distinguishes BSFT from

behaviorally oriented and existential family treatments is its focus on

the family system rather than on individual functioning.

BSFT assumes that a drug-abusing adolescent will improve his or her

behavior when the family learns how to behave adaptively. This will

happen because family members, who are “linked” emotionally, are

behaviorally responsive to each other’s actions and reactions. In

BSFT, the Principle of Complementarity holds that for every action by

a family member there is a corresponding reaction from the rest of

the family. For instance, often children may have learned to coerce

parents into reinforcing their negative behavior—for example, by

throwing a temper tantrum and stopping only when the parents give

in (Patterson 1982; Patterson and Dishion 1985; Patterson et al. 1992).

Only when the parents change their behavior and stop reinforcing or

“complementing” negative behavior will the child change.

Structure: Patterns of Family Interaction

An exchange among family members, either through actions or 

conversations, is called an interaction. In time, interactions become

habitual and repetitive, and thus are referred to as patterns of interaction (Minuchin 1974). Patterns of family interaction are the habitual

and repeated behaviors family members engage in with each other.

More specifically, the patterns of family interaction are comprised 

of linked chains of behavior that occur among family members. A

simple example can be illustrated by observing that family members

choose to sit at the same place at the dinner table every day. Where

people sit may make it easier for them to speak with each other and

10
Chapter 2 Basic Concepts of Brief Strategic Family Therapy

not with others. Consequently, a repetitive pattern of interaction

reflected in a “sitting” pattern is likely to predict the “talking” pattern.

A large number of these patterns of interaction will develop in any

system. In families, this constellation of repetitive patterns of interaction

is called the family “structure.”

The repetitive patterns of interaction that make up a family’s structure

function like a script for a play that the actors have read, memorized,

and re-enact constantly. When one actor says a certain line from the

script or performs a certain action, that is the cue for other actors to

recite their particular lines or perform their particular actions. The

family’s structure is the script for the family play. 

Families of drug-abusing adolescents tend to have problems precisely

because they continue to interact in ways that allow the youths to misbehave. BSFT counselors see the interactions between family members

as maintaining or failing to correct problems, and so they make these

interactions the targets of change in therapy. The adaptiveness of an

interaction is defined in terms of the degree to which it permits the

family to respond effectively to changing circumstances.

Strategy

The Three Ps As its second word suggests, a fundamental concept of Brief Strategic 

of Effective Strategy Family Therapy is strategy. BSFT interventions are strategic (Haley

1976) in that they are practical, problem-focused, and planned.

Practical

BSFT uses strategies that work quickly and effectively, even though

they might seem unconventional. BSFT may use any technique,

approach, or strategy that will help change the maladaptive interactions that contribute to or maintain the family’s presenting problem.

Some interventions used in BSFT may seem “outside the theory”

because they may be borrowed from other treatment modalities, such

as behavior modification. For example, behavioral contracting, in

which patients sign a contract agreeing to do or not to do certain

things, is used frequently as part of BSFT because it is one way to 

re-establish the parent figures as the family leaders. Frequently, the

counselor’s greatest challenge is to get the parent(s) to behave in a

measured and predictable fashion. Behavioral contracting may be an

ideal tool to use to accomplish this. The BSFT counselor uses whatever

strategies are most likely to achieve the desired structural (i.e., interactional) changes with maximum speed, effectiveness, and permanence.

Often, rather than trying to capture every problematic aspect of a

family, the BSFT counselor might emphasize one aspect because it

serves to move the counseling in a particular direction. For example,

a counselor might emphasize a mother’s permissiveness because it is

related to her daughter’s drug abuse and not emphasize the mother’s

relationship with her own parents, which may also be problematic.

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Chapter 2 Basic Concepts of Brief Strategic Family Therapy

Problem-Focused

The BSFT counselor works to change maladaptive interactions or to

augment existing adaptive interactions (i.e., when family members

interact effectively with one another) that are directly related to the

presenting problem (e.g., adolescent drug use). This is a way of 

limiting the scope of treatment to those family dynamics that directly

influence the adolescent’s symptoms. The counselor may realize that

the family has other problems. However, if they do not directly affect

the adolescent’s problem behaviors, these other family problems may

not become a part of the BSFT treatment. It is not that BSFT cannot

focus on these other problems. Rather, the counselor makes a choice

about what problems to focus on as part of a time-limited counseling

program. For example, the absence of clear family rules about appropriate and inappropriate behavior may directly affect the adolescent’s

drug-using behavior, but marital problems might not need to be 

modified to help the parents increase their involvement, control,

monitoring and supervision, rule setting, and enforcement of rules in

the adolescent’s life. 

Most families of drug-abusing adolescents are likely to experience

multiple problems in addition to the adolescent’s symptoms.

Frequently, counselors complain that “this family has so many problems that I don’t know where to start.” In these cases, it is important

for the counselor to carefully observe the distinction between “content”

and “process” (see “Content Versus Process: A Critical Distinction,” 

p. 13). Normally, families with many different problems (a multitude

of contents) are unable to tackle one problem at a time and keep

working on it until it has been resolved (process). These families

move (process) from one problem to another (content) without being

able to focus on a single problem long enough to resolve it. This is

precisely how they become overwhelmed with a large number of

unresolved problems. It is their process, or how they resolve problems,

that is faulty. The counselor’s job is to help the family keep working

on (process) a single problem (content) long enough to resolve it. In

turn, the experience of resolving the problem may help change the

family’s process so that family members can apply their newly

acquired resolution skills to other problems they are facing. If the

counselor gets lost in the family’s process of shifting from one content/

problem to another, he or she may feel overwhelmed and, thus, be

less likely to help the family resolve its conflicts.

Planned

In BSFT, the counselor plans the overall counseling strategy and the

strategy for each session. “Planned” means that after the counselor

determines what problematic interactions in the family are contributing

to the problem, he or she then makes a clear and well-organized plan

to correct them.

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Chapter 2 Basic Concepts of Brief Strategic Family Therapy

Content Versus Process: A Critical Distinction

In BSFT, the “content” of therapy refers to what family members talk

about, including their explanations for family problems, beliefs about

how problems should be managed, perspectives about who or what

causes the problems, and other topics. In contrast, the “process” of

therapy refers to how family members interact, including the degree

to which family members listen to, support, interrupt, undermine, and

express emotion to one another, as well as other ways of interacting.

The distinction between content and process is absolutely critical to

BSFT. To be able to identify repetitive patterns of interaction, it is

essential that the BSFT counselor focus on the process rather than the

content of therapy.

Process is identified by the behaviors that are involved in a family

interaction. Nonverbal behavior is usually indicative of process as is

the manner in which family members speak to one another.

Process and content can send contradictory messages. For example,

while an adolescent may say, “Sure Mom, I’ll come home early,” her

sarcastic gesture and intonation may indicate that she has no intention

of following her mother’s request that she be home early. Generally,

the process is more reliable than the content because behaviors or

interactions (e.g., disobeying family rules) tend to repeat over time,

while the specific topic involved may change from interaction to

interaction (e.g., coming home late, not doing chores, etc.).

The focus of BSFT is to change the nature of those interactions that

constitute the family’s process. The counselor who listens to the content and loses sight of the process won’t be able to make the kinds

of changes in the family that are essential to BSFT work. Frequently,

a family member will want to tell the counselor a story about something that happened with another family member. Whenever the

counselor hears a story about another family member, the counselor

is allowing the family to trap him or her in content. If the counselor

wants to refocus the session from content to process, when Mom

says, “Let me tell you what my son did...,” the counselor would say:

“Please tell your son directly so that I can hear how you talk about

this.” When Mom talks to her son directly, the therapist can observe

the process rather than just hear the content when Mom tells the 

therapist what her son did. Observations like these will help the therapist characterize the problematic interactions in the family.

13

Chapter 3 Diagnosing Family 

System Problems

The BSFT approach to assessing and diagnosing family system problems

differs drastically from that used by other kinds of psychotherapies.

Unlike other psychotherapies that assess and diagnose by focusing

on content, such as talking about a family’s history, BSFT assesses

and diagnoses by identifying the current family process. BSFT focuses

on the nature and characteristics of the interactions that occur in the

family and either help or hinder the family’s attempts to get rid of the

adolescent’s problem behaviors.

The following six elements of the family’s interactions are examined

in detail:

■ Organization

■ Resonance

■ Developmental stages 

■ Life context

■ Identified patient

■ Conflict resolution

Organization

As repetitive patterns of interaction in a family occur over time, they

give the family a specific form, or “organization.” Three aspects of this

organization are examined below: leadership, subsystem organization,

and communication flow.

Leadership Leadership is defined as the distribution of authority and responsibility

within the family. In functional two-parent families, leadership is in the

hands of the parents. In modern societies, both parents usually share

authority and decisionmaking. Frequently, in one-parent families, the

parent shares some of the leadership with an older child. The latter 

situation has the potential for creating problems. In the case of a single

parent living within an extended family framework, leadership may be

15
Chapter 3 Diagnosing Family System Problems

shared with an uncle, aunt, or grandparent. In assessing whether leadership is adaptive, BSFT counselors look at hierarchy, behavior control,

and guidance.

Counselors look at the hierarchy, or the way a family is ranked, to see

who is in charge of leading the family and who holds the family’s

positions of authority. BSFT assumes that the leadership should be with

the parent figures, with supporting roles assigned to older family

members. Some leadership responsibilities can be delegated to older

children, as long as those responsibilities are not overly burdensome,

are age-appropriate, and are delegated by parent figures rather than

usurped by the children. BSFT counselors look at behavior control in

the family to see who, if anyone, keeps order and doles out discipline

in the family. Effective behavior control typically means that the 

parents are in charge and the children are acting in accordance with

parental rules. Guidance refers to the teaching and mentoring functions in the family. BSFT assesses whether these roles are filled by

appropriate family members and whether the youngsters’ needs for

guidance are being met.

Subsystem Organization Families have both formal subsystems (e.g., spouses, siblings, grandparents, etc.) and informal subsystems (e.g., the older women, the

people who manage the money, the people who do the housekeeping, the people who play chess). Important subsystems must have a

certain degree of privacy and independence. BSFT looks at issues such

as the adequacy or appropriateness of the subsystems in a family. It also

assesses the nature of the relationships that give rise to these subsystems and especially looks at subsystem membership, triangulation,

and communication flow, which are discussed below.

Subsystem Membership

BSFT identifies the family’s subsystems, which are small groups

within the family that are composed of family members with shared

characteristics, such as age, gender, role, interests, or abilities. BSFT

counselors pay particular attention to the appropriateness of each

subsystem’s membership and to the boundaries between subsystems.

For example, parent figures should form a subsystem, while siblings

of similar ages should also form a subsystem, and each of these 

subsystems should be separate from the others.

Subsystems that cross generations (e.g., between a parent and one

child) cause trouble because such relationships blur hierarchical lines

and undermine a parent’s ability to control behavior. Relationships in

which one parent figure and a child unite against another parent figure

are called “coalitions.” Coalitions are destructive to family functioning

and are very frequently seen in families of drug-abusing adolescents.

In these cases, the adolescent has gained so much power through this

relationship that he or she dares to constantly challenge authority and

gets away with it. The adolescent has this power to be rebellious, 

disobedient, and out of control by having gained the support of one

16
Chapter 3 Diagnosing Family System Problems

parent who, to disqualify the other parent, enables the adolescent’s

inappropriate behavior.

Triangulation

Sometimes when two parental authority figures have a disagreement,

rather than resolving the disagreement between themselves, they

involve a third, less powerful person to diffuse the conflict. This

process is called “triangulation.” Invariably this triangulated third party,

usually a child or an adolescent, experiences stress and develops

symptoms of this stress, such as behavior problems. Triangles always

spell trouble because they prevent the resolution of a conflict

between two authority figures. The triangulated child typically

receives the brunt of much of his or her parents’ unhappiness and

begins to develop behavior problems that should be understood as a

call for help.

Communication Flow The final category of organization looks at the nature of communication.

In functional families, communication flow is characterized by directness and specificity. Good communication flow is the ability of two

family members to directly and specifically tell each other what they

want to say. For example, a declaration such as, “I don’t like it when

you yell at me,” is a sign of good communication because it is 

specific and direct. Indirect communications are problematic. Take, for

example, a father who says to his son, “You tell your mother that she

better get here right away,” or the mother who tells the father, “You

better do something about Johnny because he won’t listen to me.” In

these two examples, the communication is conducted through a third

person. Nonspecific communications are also troublesome, as in the

case of the father who tells his son, “You are always in trouble.” The

communication would be more constructive if the father would

explain very clearly what the problem is. For example: “I get angry

when you come home late.” 

Resonance

“Resonance” defines the emotional and psychological accessibility or

distance between family members. A 6-year-old son who hangs onto

his mother’s skirt at his birthday party may be said to be overly close

to her. A mother who cries when her daughter hurts is emotionally

very close. A father who does not care that his son is in trouble with

the law may be described as psychologically and emotionally distant.

One of the key concepts related to resonance is boundaries. An interpersonal boundary, just as the words imply, is a way of denoting

where one person or group of people ends and where the next one

begins. People set their own boundaries when they let others know

which behaviors entering their personal space they will allow and

which ones they will not allow. In families, resonance refers to the

psychological and emotional closeness or distance between any two

17
Chapter 3 Diagnosing Family System Problems

family members. This psychological and emotional distance is established and maintained by the boundaries that exist between family

members. In particular, the boundaries between two family members

determine how much affect, or emotion, can get through from one

person to the other. If the boundaries between two people are very

permeable, then a lot gets through, and there is high resonance—

great psychological and emotional closeness—between them. One’s

happiness becomes the other’s happiness. If the boundaries between

two people are overly rigid, then each person may not even know what

the other is feeling.

Enmeshment and The firmness and clarity of boundaries reflect the degree of differenDisengagement tiation within a family system. At one extreme, boundaries can be 

extremely impermeable. If this is the case, the emotional and psychological distance between family members is too large, and these

family members are said to be “disengaged” from each other. At 

the other extreme, boundaries can be far too permeable or almost 

nonexistent. When boundaries are that permeable, the emotional 

and psychological closeness between people is too great, and these

family members are said to be “enmeshed.” Each of these extremes

is problematic and becomes a target for intervention.

Interactions that are either enmeshed or disengaged can cause problems. When these interactions cause problems, they need to be

altered to establish a better balance between the closeness and 

distance that exists between different family members. For each 

family, there is an ideal balance between closeness and distance that

allows cooperation and separation. 

Resonance and Culture Resonance needs to be assessed in the context of culture. This is 

important because some cultures encourage family members to be very

close with each other, while other cultures encourage greater distance.

One important aspect of culture involves the racial or ethnic groups

with which families identify themselves. For example, Hispanics are

more likely than white Americans to be close and, thus, appear more

enmeshed (have higher resonance) (e.g., Woehrer 1989). Similarly, an

Asian father may be quite distant or disengaged from the women in

his family, which is considered natural in his culture (Sue 1998).

However, whether the culture dictates the distance between family

members, it is important for counselors to question if a particular way

of interacting is causing problems for the family. In other words, even

if an interaction is typical of a culture, if it is causing symptoms, then

it may need to be changed. This type of situation must be handled

with great knowledge and sensitivity to demonstrate respect for the

culture and to allow family members to risk making a change that is

foreign to their culture.

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Chapter 3 Diagnosing Family System Problems

Enmeshment Sometimes “enmeshment” (excessive closeness) and “disengagement”

(high resonance) (excessive distance) can occur at the same time within a single family.

and Disengagement This happens frequently in families of drug-abusing youths, when 

(low resonance) one parent is sometimes very protective and is closely allied with the 

youth (i.e., enabling), while the other parent may be somewhat disinterested and distant.

BSFT counselors look for certain behaviors in a family that are telltale

signs of either enmeshment or disengagement. Obviously, some of

these behaviors may happen in any family. However, when a large

number of these behaviors occur or when some occur in an extreme

form, they are likely to reflect problems in the family’s patterns of

interaction. Easily observable symptoms of enmeshment include one

person answering for another, one person finishing another’s statements,

and people interrupting each other. Observable symptoms of disengagement include one family member who wants to be separated from

another or a family member who rarely speaks or is spoken about.

Developmental Stages

Individuals go through a series of developmental stages, ranging from

infancy to old age. Certain conditions, roles, and responsibilities 

typically occur at each stage. Families also go through a series of

developmental stages. For family members to continue to function

adaptively at each developmental stage, they need to behave in ways

that are appropriate for the family’s developmental level.

Each time a developmental transition is reached, the family is confronted by a new set of circumstances. As the family attempts to

adapt to the new circumstances, it experiences stress. Failure to

adapt, to make the transition, to give up behaviors that were used

successfully at a previous developmental stage, and to establish new

behaviors that are adaptive to the new stage will cause some family

members to develop new behavior problems. Perhaps one of the

most stressful developmental changes occurs when children reach

adolescence. This is the stage at which a large number of families are

not able to adapt to developmental changes (e.g., from direct guidance

to leadership and negotiation). Parents must be able to continue to

be involved and monitor their adolescent’s life, but now they must

do it from a distinctly different perspective that allows their daughter

or son to gain autonomy.

At each developmental stage, certain roles and tasks are expected of

different family members. One way to determine whether the family

has successfully overcome the various developmental challenges that

it has confronted is to assess the appropriateness of the roles and

tasks that have been assigned to each family member, considering the

age and position of each person within the family. When a family’s

developmental stage is analyzed, four major sets of tasks and roles

19
Chapter 3 Diagnosing Family System Problems

must be assessed: (1) Parenting tasks and roles are concerned with the

parent figures’ ability to act as parents at a level consistent with the

age of the children; (2) Marital tasks and roles assess how well

spouses cooperate and share parenting functions; (3) Sibling tasks and

roles assess whether the children and adolescents are behaving in an

age-appropriate fashion; and (4) Extended family’s tasks and roles 

target the support for and intrusion into parenting functions from, for

example, grandparents, aunts, and uncles, if extended family members

are part of the household or share in parenting responsibilities.

Developmental transitions may be stressful. They are likely to cause

family shake-ups because families may continue to approach new 

situations in old ways, thus making it possible for conflict to develop.

Most often, families come to the attention of counselors precisely at

these times. Of all of these developmental milestones, reaching 

adolescence appears to be one of the most risky and critical stages in

which drug abuse can occur in most ethnic groups (Steinberg 1991;

Vega and Gil 1999). Although the adolescent is the family member

who is most likely to behave in problematic ways, often other members

of the family, such as parents, also exhibit signs of troublesome or

maladaptive behaviors and feelings (Silverberg 1996).

Assessing Appropriate Careful judgments are needed to determine what is developmentally 

Developmental appropriate and/or inappropriate for each family member. It is parFunctioning ticularly difficult to make these judgments when assessing the tasks 

and roles of children and extended family members. In every

instance, the BSFT counselor should take into account the family’s

cultural heritage when making these judgments. For example, it is

useful to know that some traditional African-American and Hispanic

families tend to protect their children longer than non-Hispanic

whites do (White 1994). Thus, it would not be unusual for children

to have a longer period of dependence among traditional Hispanic

groups than among non-Hispanic white families. Similarly, it would

not be unusual for the African-American caretaker of a 12-year-old 

to continue to behave in an authoritarian manner without the child

rebelling or considering it odd. In fact, researchers have suggested

that African-American inner city youths experience an authoritarian

command as caring, while a child from another cultural group might

experience it as rejecting (Mason et al. 1994). However, as suggested

earlier, as an adolescent in the United States grows older, his or 

her parent, who may be from any culture and in any setting, may 

have to moderate his or her level of control and increase his or her

authoritative parenting, or the youth may rebel.

Common Problems It is often difficult for parents to determine what is developmentally

in Assessing appropriate for children of different ages; for example, how much or 

Appropriateness of how little responsibility should a child 6, 10, or 16 years old have in 

Developmental Stage a household? In families of drug-abusing and conduct-disordered

adolescents, parents and their children often have a difficult time

determining what is developmentally appropriate for a child’s age.

20
Chapter 3 Diagnosing Family System Problems

One of the main problems family members encounter is how to

determine the degree of supervision and autonomy that children

should have at each age level. This is a highly complex and conflictive

area, even for the best of parents, because as children grow older,

they experience considerable pressure from their peers to demonstrate increasing independence. It is also complex because many parents

are not aware of what might be the norm in today’s society.

Therefore, they may allow too little or too much autonomy, based

either on their own comfort or discomfort level, their own experience, and/or their culture. Moreover, children’s peer groups may vary

considerably in the level of autonomy they expect from parents. In

working with the notion of “developmental appropriateness,” a BSFT

counselor needs to examine issues such as roles and functions, rights

and responsibilities, limits and consequences, as they are applied 

to the adolescents in the family. Examples of these standards are

available from adolescent development research (Steinberg 1998).

Life Context

While the dimensions of family functioning discussed up to now are

all within the family, life context refers to what happens in the family’s

relationship to its social context. The life context of the family

includes the extended family, the community, the work situation,

adolescent peers, schools, courts, and other groups that may have an

impact on the family, either as stressors or as support systems.

Antisocial Peers A careful analysis of the life context is useful in many situations 

involving the treatment of substance abuse. For example, a youngster

who uses drugs may be involved with a deviant or antisocial peer

group. These friendships affect the youth and family in an adverse

way and will certainly need to be modified to successfully eliminate

the youth’s drug use. Parents need help to identify less acceptable

and more acceptable adolescent peers so that they can encourage

their teens to associate with more desirable peers and discourage

them from associating with less desirable peers.

Parent Support Systems Parenting is a difficult task. Parents often lack adequate support systems

and Social Resources for parenting. Parents need support from friends, extended family 

members, and other parents (Henricson and Roker 2000). The availability of support systems needs to be assessed, particularly in the

case of single-parent families. The availability of social resources

needs to be assessed, both in terms of what is already being used or

what could potentially be used.

Juvenile Justice System Increasingly, probation officers and the courts have become critical 

players in the families of drug-abusing adolescents. It is the BSFT

counselor’s job to assess how juvenile justice representatives such as

probation officers interact with the family to determine whether they

21
Chapter 3 Diagnosing Family System Problems

are supporting or undermining the family. One way to assess the probation officer’s role, for example, is to invite him or her to participate

in a family therapy session.

Identified Patient

The “identified patient” is the family member who has been branded

by the family as the problem. The family blames this person, usually

the drug-abusing adolescent, for much of its troubles. However, as

discussed earlier, the BSFT view of the family is that the symptom is only

that: a symptom of the family’s problems. The more that family members insist that their entire problem is embodied in a single person,

the more difficult it will be for them to accept that it is the entire family

that needs to change. On the other hand, the family that recognizes

that several of its members may have problems is far healthier and

more flexible and will have a relatively easier time of making changes

through BSFT. The BSFT counselor believes that the problem is in the

family’s repetitive (habitual, rigid) patterns of interaction. Thus, the

counselor not only will try to change the person who exhibits the

problem but also to change the way all members of the family behave

with each other.

The other aspect to understanding a family’s identified patient is that

usually families with problematic behaviors identify only one aspect

of the identified patient as the source of all the pain and worry. For

example, families of drug-abusing youths tend to focus only on the

drug use and possibly on accompanying school and legal troubles

that are directly and overtly related to the drug abuse. These families

usually overlook the fact that the youngster may have other symptoms or problems, such as depression, attention deficit disorder, and

learning deficits.

Conflict Resolution

While solving differences of opinion is always challenging, it is much

more challenging when it is done in the context of a conflictive relationship that is high in negativity. The following are five different

ways in which families can approach or manage conflicts. Some are

adaptive and some are not. In the case of drug-abusing adolescents,

with few exceptions, the first four tend to be ineffective, whereas the

fifth tends to be effective in most situations:

■ Denial

■ Avoidance

■ Diffusion

■ Conflict emergence without resolution

■ Conflict emergence with resolution

22
Chapter 3 Diagnosing Family System Problems

Denial “Denial” refers to a situation in which conflict is not allowed to emerge.

Sometimes this is done by adopting the attitude that everything is all

right. At other times, conflict is denied by arranging situations to

avoid confrontation or establishing unwritten rules with which no

one dares to disagree outwardly, regardless of how they feel. The

classic denial case is the one in which the family says: “We have no

problems.”

Avoidance “Avoidance” refers to a situation in which conflict begins to emerge 

but is stopped, covered up, or inhibited in some way that prevents it

from emerging. Examples of avoidance include postponing (“Let’s

not have a fight now.”), humor (“You’re so cute when you’re mad.”),

minimizing (“That’s not really important.”), and inhibiting (“Let’s not

argue; you know what can happen.”).

Diffusion “Diffusion” refers to situations in which conflict begins to emerge, 

but discussion about the conflict is diverted in another direction. 

This diversion prevents conflict resolution by distracting the family’s

attention away from the original conflict. This change of subject is

often framed as a personal attack against the person who raised the

original issue. For example, a mother says to her husband, “I don’t

like it when you get home late,” but the husband changes the topic

by responding: “What kind of mother are you anyway, letting your

son stay home from school today when he is not even sick!”

Conflict Emergence “Conflict emergence” without resolution occurs when different opinions

Without Resolution are clearly expressed, but no final solution is accepted. Everyone 

knows exactly where everyone else stands, but little is done to reach

a negotiated agreement. Sometimes this occurs because the family,

while willing to discuss the problem, simply does not know how to

negotiate a compromise.

Conflict Emergence Emergence of the conflict and its resolution is generally considered 

With Resolution to be the best outcome. Separate accounts and opinions regarding a 

particular conflict are clearly expressed and confronted. Then, the

family is able to negotiate a solution that is acceptable to all family

members involved.

A Caveat In some cases, conflicts need to be postponed for more appropriate 

times. For example, if a family member is very angry, tired, or sick,

it may be reasonable to table the conflict until he or she is ready 

to have a meaningful discussion. However, in such instances, it is 

critical that the family set a specific time to address the conflict.

Indefinitely postponing conflict resolution is a sign of avoidance. A

postponement for a definite amount of time is adaptive.

23
Chapter 3 Diagnosing Family System Problems

In other instances, a person may decide that the issue at hand is not

worth having an argument about. For example, one person may want

to stay home while his or her partner wants to go dancing. Either

partner may opt to compromise by agreeing to the other’s preference.

So long as partners take turns compromising, this is adaptive and 

balanced. However, if the same person is always the one to give in,

this may reflect the use of denial by one partner to avoid conflict with

the other. 

24
Chapter 4 Orchestrating Change

This chapter describes the BSFT approach to orchestrating change in

the family. The first section describes how BSFT counselors establish

a therapeutic relationship, including the importance of joining with

the family, the role of tracking family interactions, and what is

involved in building a treatment plan. The second section describes

strategies for producing change in the family, including focusing on

the present, reframing negativity in the family, shifting patterns of

interaction through reversals of usual behavior, changing family

boundaries and alliances, “detriangulating” family members caught in

the middle of others’ conflicts, and opening up closed family systems

or subsystems by directing new interactions.

Establishing a Therapeutic Relationship

The counselor’s first step in working with a family is to establish a therapeutic relationship with the family, beginning with the very first contact with family members. The quality of the relationship between the

counselor and the family is a strong predictor of whether families will

come to, stay in, and improve in treatment (Robbins et al. 1998). In

general, studies have found that the therapeutic relationship is a strong

predictor of success in many forms of therapy (Rector et al. 1999; Stiles

et al. 1998). Validating and supporting the family as a system and

attending to each individual family member’s experience are particularly important aspects of developing and maintaining a good therapeutic relationship (Diamond et al. 1999; Diamond and Liddle 1996). 

Establishing a therapeutic relationship means that the BSFT counselor

needs to form a new system—a therapeutic system—made up of the

counselor and the family. In this therapeutic system, the counselor is

both a member and its leader. One challenge for the BSFT counselor

is to establish relationships with all family members, some of whom

are likely to be in conflict with each other. For example, drug-abusing

adolescents generally begin treatment in conflict with their parent(s)

or guardian(s). Both parties approach counseling needing support

from the counselor. The counselor’s job is to find ways to support the

individuals on either side of the conflict. For example, the counselor

might say to the adolescent, “I am here to help you explain to your

parents that regular school is not for you, that you are interested in

trade school.” To the parent, the counselor might say, “I am here to

help you keep your son off drugs.” By offering each family member

25
Chapter 4 Orchestrating Change

something he or she would like to achieve, the counselor is able to

establish a therapeutic alliance with the whole family. 

The BSFT approach is based on the view that building a good therapeutic relationship is necessary to bring about change in the family.

Several strategies for building a therapeutic relationship, joining,

tracking, and building a treatment plan, are discussed below.

Joining A number of techniques can be used to establish a therapeutic relationship. Some of these techniques fall into the category of “joining,”

or becoming a temporary member of the family.

Definition of Joining

In BSFT, joining has two aspects. Joining it is the steps a counselor

takes to prepare the family for change. Joining also occurs when a

therapist gains a position of leadership within the family. Counselors

use a number of techniques to prepare the family to accept therapy

and to accept the therapist as a leader of change. Some techniques

that the therapist can use to facilitate the family’s readiness for 

therapy include presenting oneself as an ally, appealing to family

members with the greatest dominance over the family unit, and

attempting to fit in with the family by adopting the family’s manner of

speaking and behaving. A counselor has joined a family when he or

she has been accepted as a “special temporary member” of the family

for the purpose of treatment. Joining occurs when the therapist has

gained the family’s trust and has blended with family members. To

prepare the family for change and earn a position of leadership, the

counselor must show respect and support for each family member

and, in turn, earn each one’s trust.

One of the most useful strategies a counselor can employ in joining

is to support the existing family power structure. The BSFT counselor

supports those family members who are in power by showing

respect for them. This is done because they are the ones with the

power to accept the counselor into the family; they have the power

to place the counselor in a leadership role, and they have the power

to take the family out of counseling. In most families, the most powerful member needs to agree to a change in the family, including

changing himself or herself. For that reason, the counselor’s strongest

alliance must initially be with the most powerful family member. BSFT

counselors must be careful not to defy those in power too early in the

process of establishing a therapeutic relationship. Inexperienced family

counselors often take the side of one family member against another,

behaving as though one were right and the other were obviously

wrong. In establishing relationships with the family, the counselor must

join all family members, not just those with whom he or she agrees.

In fact, frequently, the person with whom it is most critical to establish

an alliance or bond is the most powerful and unlikable family member.

Many counselors in the drug abuse field feel somewhat hopeless

about helping the families of drug-abusing youths because these 

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Chapter 4 Orchestrating Change

families have many serious problems. Counselors who feel this way

may find a discussion about becoming a member of the family

unhelpful because their previous efforts to change families have been

unsuccessful. BSFT teaches counselors how to succeed by approaching

families as insiders, not as outsiders. As outsiders, counselors typically

attempt to force change on the family, often through confrontation.

However, the counselor who has learned how to become part of the

system and to work with families from the inside should seldom need

to be confrontational. Confrontation erodes the rapport and trust that

the counselor has worked hard to earn. Confrontation can change the

family’s perception of the counselor as being an integral part of the

therapeutic system to being an outsider.

The Price of Failed Joining

An example may help illustrate what is meant by powerful family

members. The court system referred a family to counseling because

its oldest child had behavior problems. The mother was willing to

come to counseling with her son, but the mother’s live-in boyfriend

did not want the family to be in counseling. The counselor advised

the mother to come to therapy with the adolescent anyway. The

boyfriend felt that his position of power had been threatened by the

potential alliance between the mother and the counselor. As a result,

the boyfriend reasserted himself, demanding that she stop participating in counseling. She then dropped out of counseling. This is

clearly a case in which the counselor’s early challenge of the family’s

way of “operating” caused the entire family to drop out of treatment.

The counselor could and should have been more aware and respectful of the family’s existing power structure. Respect, in this case, does

not mean that the counselor approves of or agrees with the

boyfriend’s behavior. Rather, it means that the counselor understands

how this family is organized and works his or her way into the family

through the existing structure. 

A more adaptive counseling strategy might be to call the mother’s

boyfriend, with the mother’s permission, to recognize his position of

power in the family and request his help with his girlfriend’s son. 

A Cautionary Note: Family Secrets

As was already stated, joining is about establishing a relationship with

every member of the family. Sometimes a family member will try to

sabotage the joining process by using family secrets. Some secrets

can cause the counselor such serious problems that he or she is

forced to refer the family he or she had intended to help to another

counselor. Secrets are best dealt with up front. The counselor should

not allow himself or herself to get trapped in a special relationship

with one family member that is based on sharing a secret that the

other family members do not know. A counselor who keeps a secret

is caught between family members. The counselor has formed an

alliance with one family member to the exclusion of others. In some

cases, it is not just an alliance with one family member but also an

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Chapter 4 Orchestrating Change

alliance with one family member against another family member. It

means that the family member with the secret can blackmail the

counselor with the threat of revealing that the counselor knows this

secret and didn’t address it with the family. Consequently, a family

secret is a very effective strategy that family members can use to 

sabotage the treatment, if counselors let them.

For these reasons, counselors should make it a rule to announce to

each family at the onset of counseling that he or she will not keep

secrets. The counselor should also say that if anyone shares special

information with the counselor, the counselor will help them share it

with the appropriate people in the family. For example, if a wife calls

and tells the counselor that she is having an affair, her spouse will need

to know, although the children do not need to know the parents’ marital issues. In this case, the counselor would say, “This affair is indicative of a problem in your marriage. Let me help you share it with your

husband.” The counselor must do whatever is needed to continue to

help the wife see that affairs are symptoms of marital problems. The

affair can be reframed as a cry for help, a call for action, or a basic discontent. If so, these marital issues or problems need to be discussed.

It is possible that despite all the counselor’s efforts, the wife will

respond with an absolute, “No, I don’t want to tell him. He would leave

me. Besides, this affair doesn’t mean all that much.” Typically BSFT

therapy only gets into marital issues to the extent that the marital problems are interfering with the parents’ abilities to function effectively as

parents. However, the counselor has no choice but to help the wife tell

her husband about the affair. If the wife absolutely refuses, then the

counselor has lost his or her bid for leadership in the counseling

process. The wife now has control over the counseling process. For that

reason, the counselor must refer the family to another counselor.

Tracking In the example on p. 27 about the mother’s powerful boyfriend, it 

was recommended that the counselor use the way in which the family

is organized, or interacts, with the father figure in a position of

power, as a vehicle for getting the family into treatment. This strategy

in which the counselor learns how the family interacts and then uses

this information to establish a therapeutic plan of action is called

“tracking.” Tracking is a technique in which the counselor respects

how the family interacts but, at the same time, takes advantage of

those family interactions for therapeutic purposes. Sometimes families

interact spontaneously, permitting the counselor to observe the family

dynamics. When this does not happen spontaneously, the counselor

must encourage the family to interact.

Encouraging the Family to Interact

When a family is in counseling, family members like to tell the counselor stories about each other. For example, a mother might say to

the counselor, “My son did so and so.” In contrast to the way in

which the counselor functions in other therapy models, the BSFT

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Chapter 4 Orchestrating Change

counselor is not interested in the content of the family members’ stories.

Instead, the counselor is interested in observing (and correcting) problematic interactions. To observe the family’s patterns of interaction, the

counselor must ask family members to talk directly to each other

about the problem. When this occurs, the counselor can observe 

or track what happens when the family members discuss the issue.

The counselor can then watch the family’s interactions: fighting, disagreeing, and struggling with their issues. By tracking, the counselor

will not only be able to identify the interactive patterns in the family,

but also will be able to determine which of these patterns may be

causing the family’s problems or symptoms. The added benefit of this

kind of tracking is that the counselor shows respect for the family’s

ways of interacting.

Tracking Content and Process

The difference between “content” and “process” was discussed in

Chapter 2 (see p. 13). Content is the subject matter that is being 

discussed. Process refers to the interactions that underlie the communication. By observing the process, the counselor learns who is dominant,

who is submissive, what emotions are expressed in the interaction, and

the unwritten rules that appear to guide the family’s communication

and organization. For example, a mother may mention that her son’s

drug problem is a concern. The grandmother responds by shouting

that the mother is overreacting and needs to back off. The content of

the interaction—the son’s drug problem—is not nearly as important as

the process being displayed—the grandmother undermining the

mother and shutting her down. Often the counselor will track or use

the family’s content because it represents a topic that is important to

the family. In this example, the counselor might keep the focus of the

counseling session on the son’s drug problem because it is an important topic in this family. However, the focus of BSFT is entirely on

changing process. What needs to be changed here, as a first step, is

the parent figures’ inability to agree on the existence of a problem,

and, more generally, the grandmother’s tendency to invalidate the

mother’s concerns.

Mimesis

“Mimesis” is a form of tracking for the purpose of joining. It refers to

mimicking the family’s behavior in an effort to join with the family.

Mimesis can be used to join with the whole family. For example, a

counselor can act jovial with a jovial family. Mimesis also can be used

to join with one family member. Mimesis is used in everyday social

situations. For example, by attending to how others dress for a particular activity so that one can dress appropriately, one is attempting

to gain and demonstrate acceptance by mimicking the type of dress

that is worn by others (e.g., casual). People mimic other people’s

moods when they act like the other people do in certain situations.

For example, at a funeral they would act sad as others do and at a

celebration they would act joyful. When the counselor validates a family by mimicking its behavior, family members are more likely to

accept the counselor as one of their own. 

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Chapter 4 Orchestrating Change

Mimesis also refers to using a family’s own ways of speaking to join

with the family. Each family and each family member has its, his, or

her own vocabulary and perspective. For instance, if a family member

is a carpenter, it might be useful to use the language of carpentry.

The therapist might say, “Dealing with your son requires lots of 

different tools, just like jobs at work do. Sometimes you need to use

a hammer and use a lot of force, and sometimes you need to use a

soft cloth for a more gentle job.” If a family member is an accountant,

it may be helpful to speak in terms of assets and liabilities. If a person

is religious, it may be helpful to speak of God’s will. 

Whatever language a family uses should be the language the counselor

uses to converse with that family. The counselor should not talk to a

family using vocabulary that is found in this manual—words such as

“interactions,” “restructuring,” and “systems.” Instead, the BSFT counselor should use the “pots and pans” language that each of the family

members uses in his or her everyday life. For example, if families are

uncomfortable with the term “counseling,” the term “meetings” might

be used. 

Much of the work the counselor does to establish the therapeutic

relationship involves learning how the family interacts to better blend

with the family. However, the counselor cannot learn the ways in

which the family interacts unless he or she sees family members

interacting as they would when the counselor is not present. Getting

family members to interact can be difficult because families often

come into counseling thinking that their job is to tell the counselor

what happened. Therefore, it is essential that counselors decentralize

themselves by discouraging communications that are directed at

them, and instead encouraging family members to interact so that

they can be observed behaving in their usual way. 

Building a BSFT diagnoses are made to identify adaptive and maladaptive patterns 

Treatment Plan of family interaction so that the counselor can plan practical, strategically

efficient interventions. The purpose of the intervention is to improve

the family interactions most closely linked to the adolescent’s symptoms.

This, in turn, will help the family to manage those symptoms.

Enactment: Identifying Maladaptive Interactions

In BSFT, the counselor assesses and diagnoses the family’s interactions

by allowing the family to interact in the counseling session as it normally does at home. To begin, the counselor asks the family to discuss

something. When a family member speaks to the counselor about

another family member who is present, the counselor asks the family

member who is speaking to repeat what was said directly to the 

family member about whom it was said. Family interactions that occur

as they would at home and that show the family’s typical interactional

patterns are called “enactments.” An enactment can either occur spontaneously, or the counselor can initiate it by asking family members to

discuss something among themselves. Creating enactments of family

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Chapter 4 Orchestrating Change

interactions is like placing the counselor on the viewing side of a oneway mirror and letting the family “do its thing” while the counselor

observes.

Different therapy models have different explanations for why a family

or adolescent is having difficulty, and so they have different targets

of intervention. BSFT targets interactional patterns. Because BSFT is

a problem-focused therapy approach, it targets those interactional

patterns that are most directly related to the symptom for which the

family is seeking treatment. Targeting patterns most directly related to

the symptom allows BSFT to be brief and strengthens a therapist’s

relationship with a family by demonstrating that the therapist will help

the family solve the problems family members have identified.

Families that develop symptoms tend to be organized or to function

around those symptoms. That’s because a symptom works like a

magnet, organizing the family around it. This is especially true if the

symptom is a serious, life-threatening one, such as drug abuse.

Therefore, it is most efficient to work with the family by focusing on

the symptom around which the family has already organized itself.

Family Crises as Enactments

Enactments are used to observe family interactions in the present and

to identify family interactional problems. Family crises are particularly

opportune types of enactments because they are highly charged, 

and family members are emotionally available to try new behaviors.

Therefore, families in crisis should be seen immediately. In addition

to gaining valuable information about problematic family interactions, the counselor gains considerable rapport with families because

he or she is willing to be of service at a time of great need.

A Cautionary Note: Adolescents Attending Therapy Sessions on Drugs

Counselors usually refuse to work with a client who comes into the

therapy session on drugs because the client is viewed as “not being

all there” to do the treatment work. However, in the case of a family

therapy such as BSFT, determining whether to conduct the session is

a strategic decision the counselor must make. One possibility in BSFT

is to view the adolescent on drugs as an enactment of what the family

confronts at home all the time. Thus, when an adolescent comes to

therapy on drugs, it can be viewed as an opportunity for the counselor

to teach the family how to respond to the adolescent when he or she

takes drugs. The BSFT counselor can see how each family member

responds to this situation and look for the maladaptive interactions

that allow the adolescent to continue this behavior. The counselor can

then work with the non-drug-using family members to change their

usual way of responding to the adolescent on drugs. Hence, the work

in this session is not with the adolescent but with the other family

members.

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Chapter 4 Orchestrating Change

From Diagnosis to Planning

Once a therapeutic relationship has been established and a diagnosis

has been formulated, the counselor is ready to develop a treatment

plan. The treatment plan lays out the interventions that will be necessary to change those family maladaptive interactional patterns that

have been identified as related to the presenting symptom.

Problematic patterns of family interaction are diagnosed using the six

dimensions of family interaction discussed in Chapter 3 (organization,

resonance, developmental stages, life context, identified patient, and

conflict resolution). Often some dimensions are more problematic

than others. The interventions need to focus more on the most problematic interactions than on the others.

The six dimensions of the family’s interactions operate in an interdependent fashion. For this reason, it may not be necessary to plan a

separate intervention to address each problem that has been diagnosed. For example, addressing a family’s tendency to blame its

problems on the adolescent (i.e., the identified patient) may bring the

family’s ineffective conflict resolution strategies to light. In a similar

fashion, addressing a son’s role as his mother’s confidant (i.e., inappropriate developmental stage) may bring out the rigid and inflexible

boundary between the parent figures. 

Producing Change

As was stated earlier, the focus of BSFT is to shift the family from maladaptive patterns of interaction to adaptive ones. Counselors can use

a number of techniques to facilitate this shift. These techniques, all of

which are used to encourage family members to behave differently,

fall under the heading of “restructuring.” In restructuring, the counselor orchestrates and directs change in the family’s patterns of interaction (i.e., structure). Some of the most frequently used restructuring

techniques are described in this chapter.

When the family’s structure has been shifted from maladaptive

toward adaptive, the family develops a mastery of communication

and management skills. In turn, this mastery will help them solve

both present and future problems. To help family members master

these skills, the BSFT counselor works with them to develop new

behaviors and use these new behaviors to interact more constructively with one another. After these more adaptive behaviors and

interactions occur, the BSFT counselor validates them with positive

reinforcements. Subsequently, the counselor gives the family the task

of practicing these new behaviors/interactions in naturally occurring

situations (e.g., when setting a curfew or when eating meals together)

so that family members can practice mastering these skills at home.

Mastering more adaptive interactions provides families with the tools

they need to manage the adolescent’s drug abuse and related problem

behaviors. Some adaptive behaviors/interactions that validate individual

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Chapter 4 Orchestrating Change

family members are self-reinforcing. However, the counselor needs to

reinforce those behaviors/interactions that initially are not strongly

self-reinforcing (i.e., validated) to better ensure their sustainability. As

family members reinforce each other’s more adaptive skills, they master

the skills needed to behave in adaptive ways. It is very important to

note that mastery of adaptive skills is not achieved by criticizing,

interpreting, or belittling the individual. Rather, it is achieved by

incrementally shaping positive behavior. 

The rest of this chapter describes seven frequently used restructuring

techniques (i.e., to change families’ patterns of interaction). These techniques will give a counselor the basic tools needed to help a family

change its patterns of interaction. The seven restructuring techniques are:

■ Working in the present

■ Reframing negativity

■ Reversals

■ Working with boundaries and alliances

■ Detriangulation

■ Opening up closed systems

■ Tasks

Working in the Present Although some types of counseling focus on the past (Bergin and 

Garfield 1994), BSFT focuses strictly on the present. In BSFT, families

do not simply talk about their problems, because talking about problems usually involves telling a story about the past. Working in the

present with family interactional processes that are maintaining the

family’s symptoms is necessary to bring about change in BSFT.

Consequently, the BSFT counselor wants the family to engage in 

interactions within the therapy session––in the same way that it

would at home. When this happens and family members enact the

way in which they interact routinely, the counselor can respond to

help the family members reshape their behavior. Several techniques

that require working in the present with family processes are found

in subsequent sections within this chapter.

Does BSFT Ever Work in the Past?

Counselors work with the past less than 5 percent of the counseling

time. One important example of working in the past can be illustrated

by an early counseling session in which the parent and adolescent

are in adversarial roles. The parent may be angry or deeply hurt by

the youth’s behavior. One strategy to overcome this impasse in which

neither family member is willing to bend is to ask the parent, “Can

you remember when Felix was born? How did you feel?” The parent

may say nostalgically: “He was such a beautiful child. The minute I

saw him, I was enchanted. I loved him so much I thought my heart

would burst.”

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Chapter 4 Orchestrating Change

This kind of intervention is called “reconnection” (cf. Liddle 1994,

1995, 2000). When the parent is hardened by the very difficult experiences he or she has had with a troublesome adolescent, counselors

sometimes use the strategy of reconnection to overcome the impasse

in which neither the parent nor the youth is willing to bend first.

Reconnection is an intervention that helps the parent recall the positive feeling (love) that he or she once had for the child. After the parent

expresses his or her early love for the child, the counselor turns to

the youth and says: “Did you know your mother loves you so very

much? Look at the expression of bliss on her face.” 

As can be seen, the counseling session digressed into the past for a

very short time to reconnect the parent. This was necessary to change

the here-and-now interaction between two family members. The

reconnection allowed the counselor to transform an interaction characterized by resentment into an interaction characterized by affection.

Because the feelings of affection and bonding do not last long, the

counselor must move quickly to use reconnection as a bridge that

moves the counseling to a more positive interactional terrain. 

Reframing: Systemic To “reframe,” a counselor creates a different perspective or “frame” of 

Cognitive Restructuring reality than the one within which the family has been operating. He 

or she presents this new frame to the family in a convincing manner—that is, “selling” it to the family and then using this new frame

to facilitate change. The purpose of systems-oriented, cognitive

restructuring (reframing) is to change perceptions and/or meaning in

ways that will enable family members to change their interactions.

Most of the time, in families of adolescent drug abusers, negativity

needs to be reframed. Negativity is usually exhibited as blaming,

pejorative, and invalidating statements (“You are no good.” “I can’t

trust you.”), and, in general, “angry fighting.” Reframing negativity

might involve describing a mother’s criticism of her teenage son as

her desire that he be successful, or reframing fighting as an attempt

to have some sort of connection with another family member.

It has been suggested that “... high levels of negativity interfere with

effective problem-solving and communication within the family”

(Robbins et al. 1998, p. 174). Robbins and colleagues report that negativity in family therapy sessions is linked to dropping out of family

therapy. For those who remain in therapy, negativity is linked to poor

family therapy outcomes. Because negativity is bad for the family and

for the therapy, most contemporary family therapies target negativity

(Alexander et al. 1994). The best-known strategy for transforming negative interactions into positive ones is reframing (Robbins et al. 2000).

While the counselor is encouraged to permit family members to interact with each other in their usual way and to join before orchestrating

change, a caveat is necessary when intense negative feelings accompany conflictive interactions. If the family is to remain in counseling,

family members must experience some relief from the negative feelings

soon after counseling begins. Therefore, counselors are encouraged

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Chapter 4 Orchestrating Change

to use reframing abundantly, if necessary, in the first and perhaps the

first few sessions to alleviate the family’s intensive negative feelings.

Such reframes also may allow family members to discuss their pain

and grievances in a meaningful way.

An example will help illustrate the use of reframing negative feelings

to create more positive feelings among family members. Anger is a

fairly common emotion among families with an adolescent who is

involved in antisocial activities. The parents may feel angry that their

attempts to guide their child down the “right” path have failed and that

the child disrespects their guidance. The adolescent is likely to interpret this anger as uncaring and rejecting. Both parties may feel that the

other is an adversary, which severely diminishes the possibility that

they can have a genuine dialogue.

The particular reframe that needs to be used is one that changes the

emotions from anger, hurt, and fighting (negative) to caring and concern (positive). The counselor must create a more positive reality or

frame. The counselor, for example, might say to the parent, “I can see

how terribly worried you are about your son. I know you care an

awful lot about him, and that is why you are so frustrated about what

he is doing to himself.”

With this intervention, the counselor helps move both the parent’s

and the child’s perceptions from anger to concern. Typically, most

parents would respond by saying, “I am very worried. I want my

child to do well and to be successful in life.” When the youth hears

the parent’s concern, he or she may begin to feel less rejected.

Instead of rejecting, the parent is now communicating concern, care,

and support for the child. Hence, by creating a more positive sense of

reality, the counselor transforms an adversarial relationship between

the parent(s) and the adolescent, orchestrating opportunities for new

channels of communication to emerge and for new interactions to take

place between them.

Reframing is among the safest interventions in BSFT, and, consequently, the beginning counselor is encouraged to use it abundantly.

Reframing is an intervention that usually does not cause the counselor any loss of rapport. For that reason, the counselor should feel

free to use it abundantly, particularly in the most explosive situations.

Affect: Creating Opportunities for New Ways of Behaving

In BSFT, counselors are interested in affect (a feeling or an emotion)

as it is reflected in interactions. In BSFT, the counseling strategy is to

use emotion as an opportunity to “move” the family to a new, more

adaptive set of interactions. One of many possible ways of working

with emotion is found in the following example. When a mother

cries, the counselor might suggest to the drug-abusing youngster,

“Ask your mom to tell you about her tears.” An alternative would be,

“What do you think your mom’s tears are trying to say?” If the youth

responds, “I think it is...,” the counselor would follow with a directive

35
Chapter 4 Orchestrating Change

to the youth, “Ask your mother if what you think her tears mean is

why she is crying.” In this way, the crying is used to initiate an interaction among family members that acknowledges not only the emotion in crying but also the experience underlying the crying. In other

words, the crying is used to promote interactions that show respect

for the emotion as well as promote a deeper level of understanding

among family members.

In another example, a drug-abusing adolescent and her family come

to their first BSFT counseling session. The parents proceed to

describe their daughter as disobedient, rebellious, and disrespectful—

a girl who is ruining her life and going nowhere. They are angry and

reject this young girl, and they blame her for all the pain in the family. In this instance, the BSFT counselor recognizes that the family is

“stuck” about what to do with this girl and that their inability to

decide what to do is based on the view they have developed about

her and her behavior. To “open up” the family to try new ways to

reach the youngster, the BSFT counselor must present a new “frame”

or perspective that will enable the family to react differently toward

the girl. The BSFT counselor might tell the family that, although she

realizes how frustrated and exasperated they must feel about their

daughter’s behavior, “it is my professional opinion that the main

problem with this girl is that she is very depressed and is in a lot of

pain that she does not know how to handle.” Reframing is a practical

tool used to stimulate a change in family interactions. With this new

frame, the family may now be able to behave in new ways toward

the adolescent, which can include communicating in a caring and

nurturing manner. A more collaborative set of relationships within the

family will make it easier for the parents to discuss the daughter’s

drug abuse, to address the issues that may be driving her to abuse

drugs, and to develop a family strategy to help the adolescent reduce

her drug use.

Reversals When using the technique called “reversal,” the counselor changes a 

habitual pattern of interacting by coaching one member of the family

to do or say the opposite of what he or she usually would. Reversing

the established interactional pattern breaks up previously rigid patterns of interacting that give rise to and maintain symptoms, while

allowing alternatives to emerge. If an adolescent gets angry because

her father nagged her, she yells at her father, and the father and

daughter begin to fight, a reversal would entail coaching the father to

respond differently to his daughter by saying, “Rachel, I love you

when you get angry like that,” or “Rachel, I get very frightened when

you get angry like that.” Reversals make family members interact 

differently than they did when the family got into trouble.

Working With Boundaries Certain alliances are likely to be adaptive. For example, when the 

and Alliances authority or parent figures in the family are allied with each other, 

they will be in a better position to manage the adolescent’s problem

behaviors. However, when an alliance forms between a parent figure

and one of the children against another parent figure, the family is

36
Chapter 4 Orchestrating Change

likely to experience trouble, especially with antisocial adolescent

behavoir. An adolescent who is allied with an authority figure has a

great deal of power and authority within the family system.

Therefore, it would be difficult to place limits on this adolescent’s

problem behavior. One goal of BSFT is to realign maladaptive

alliances.

One important determinant of alliances between family members is

the psychological barrier between them, or the metaphorical fence

that distinguishes one member from another. BSFT counselors 

call this barrier or fence a “boundary.” Counselors aim to have 

clear boundaries between family members so that there is some 

privacy and some independence from other family members.

However, these should not be rigid boundaries, with which family

members would have few shared experiences. By shifting boundaries,

BSFT counselors change maladaptive alliances across the generations

(e.g., between parent figures and child). For example, in a family in

which the mother and the daughter are allied and support each other

on almost all issues while excluding the father, the mother may no

longer be powerful enough to control her daughter when she

becomes an adolescent and may need help. In this case, an alliance

between the mother and the father needs to be re-established, while

the cross-generational coalition between mother and daughter needs

to be eliminated.

It is the BSFT counselor’s job to shift the alliances that exist in the

family. This means restoring the balance of power to the parents or

parent figures so that they can effectively exercise their leadership in

the family and control their daughter’s behavior. The counselor

attempts to achieve these alliance shifts in a very smooth, subtle, and

perhaps even sly fashion. Rather than directly confronting the alliance

of the mother and daughter, for example, the counselor may begin

by encouraging the father to establish some form of interaction with

his daughter.

Boundary shifting is accomplished in two ways. Some boundaries

need to be loosened, while others need to be strengthened.

Loosening boundaries brings disengaged family members (e.g., father

and daughter) closer together. This may involve finding areas of common interest between them and encouraging them to pursue these

interests together. For instance, in the case of a teenaged son

enmeshed with his mother and disengaged from his father, the counselor may direct the father to involve his son in a project or to take

his son on regular outings. The counselor also may arrange the seating

in counseling sessions to help strengthen some alliances and loosen

others.

In addition to bringing family members closer together, the counselor

may need to strengthen the boundaries between enmeshed family

members to create more separation. One example is the mothergrandmother parenting system in which the grandmother enables her

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Chapter 4 Orchestrating Change

grandson’s drug use by protecting him from his mother’s attempts to

set limits. Rather than confronting the grandmother-adolescent

alliance directly, the counselor may first encourage the mother and

grandmother to sit down together and design a set of rules and

responsibilities for the adolescent. This process of designing rules

often requires the parent figures to work out some of the unresolved

conflict(s) in their relationship, without the counselor having to

address that relationship directly. This brings the mother closer to the

grandmother and distances the grandmother from the adolescent,

thereby rearranging the family’s maladaptive hierarchy and subsystem

composition.

It should be noted that, in this case, the counselor tracks the family’s

content (grandmother hiding adolescent’s drug use from mother) as

a maneuver to change the nature of the interaction between the

mother and the grandmother from an adversarial relationship to one in

which they agree on something. The adolescent’s drug use provides

the content necessary to strengthen the boundaries between the 

generations and to loosen the boundaries between the parent figures.

Clearly, bringing the mother and grandmother together to the negotiating table is only an intermediate step. After that, the tough work

of helping mother and grandmother negotiate their deep-seated

resentments and grievances against each other begins. Because the

counselor follows a problem-focused approach, he or she does not

attempt to resolve all of the problems the parent figures encounter.

Instead, the counselor tries to resolve only those aspects of their 

difficulties with each other that interfere with their ability to resolve

the problems they have with the adolescent in the family.

Behavioral Contracting as a Strategy for Setting Limits 

for Both Parent and Adolescent

From a process perspective, setting clear rules and consequences

helps develop the demarcation of boundaries between parent(s) and

child(ren). Sometimes when a parent and an adolescent have a very

intense conflictive relationship in which there is a constant battle over

the violation of rules, the rules and their consequences are vague,

and there is considerable lack of consistency in their application. In

these cases, it is recommended that the counselor use behavioral

contracting to help the parent(s) and the adolescent agree on a set of

rules and the resulting consequences if he or she fails to follow these

rules. The counselor encourages the parent(s) and the adolescent to

negotiate a set of clearly stated and enforceable rules, and encourages both parties to commit to maintaining and following these rules.

Helping parents use behavioral contracting to establish boundaries

for themselves in relationship to their adolescent is of tremendous

therapeutic value. Parents who have established boundaries can no

longer respond to the adolescent’s behavior/misbehavior according

to how they feel at the time (lax, tired, frustrated, angry). The parents

have committed themselves to respond according to agreed-upon

38
Chapter 4 Orchestrating Change

rules. From a BSFT point of view, it is very important for the counselor to begin to help the parents develop adequate boundaries with

their adolescent children who have behavior problems.

In families that have problems with boundaries, the counselor’s most

difficult task is to get the parents to stick to their part of the contract.

Counselors expect that the adolescent will not keep his or her part of

the contract and instead will try to test whether his or her parents will

try to stick to their part of the contract. When the adolescent misbehaves,

parents tend to behave in their usual way, which may be a reaction

to the way they feel at the moment. The counselor’s job is to make

the parents uphold their side of the agreement. Once parents have set

effective boundaries with their adolescent children, most misbehavior

quickly diminishes. (Of course, sometimes rules and consequences

need to be renegotiated as parents and adolescents begin to acquire

experience with the notion of enforceable rules and consequences.)

Boundaries Between the Family and the Outside World

It is important not only to understand the nature of the alliances and

boundaries that occur within the family but also to understand the

boundaries that exist between the family and the outside world. (See

Chapter 3, p. 21 on life context.)

Some families have very rigid boundaries around themselves, prohibiting their members from interacting with the outside world. Other

families have very weak boundaries around themselves that allow

outsiders to have an undue influence on family members. Either of

these extremes can be problematic and is fair ground for BSFT intervention. For example, if parents are uninvolved with their children’s

school or friends (rigid boundaries), the BSFT counselor works to get

the parents to participate more fully in their child’s school life and to

interact more with their child’s friends. 

Detriangulation As was said earlier, triangles occur when a third, usually less powerful,

person gets involved in a conflict between two others. It is a basic

assumption of BSFT that the only way conflict between two people

(called a “dyad”) can be resolved is by keeping the conflict between

them. Bringing in a third person and forming a triangle becomes an

obstacle to resolving the conflict. The third person usually is drawn

into a coalition with one of the parties in conflict and against the

other. This coalition results in an imbalance within the original dyad.

The issues involved in the conflict are detoured through the third 

person rather than dealt with directly. For example, when parent 

A has a fight with parent B, parent B may attack the adolescent in

retaliation for parent A’s behavior (or attempt to enlist the youth’s

support for his or her side of the argument) rather than expressing

his or her anger directly to parent A. Such triangulated adolescents

are often blamed for the family’s problems, and they may become

identified patients and develop symptoms such as drug abuse.

39
Chapter 4 Orchestrating Change

Because triangulation prevents the involved parties from resolving

their conflicts, the goal of counseling is to break up the triangle.

Detriangulation permits the parents in conflict to discuss issues and

feelings directly and more effectively. Detriangulation also frees the

third party, the adolescent, from being used as the escape valve for

the parents’ problems.

One of the ways in which a BSFT counselor achieves detriangulation

is by keeping the third party (i.e., the adolescent) from participating

in the discussions between the dyad. Another way to set boundaries

to detriangulate is to ask the third party not to attend a therapy session

so that the two conflicting parties can work on their issues directly.

For example, when working with a family in which the son begins to

act disrespectfully whenever his parents begin to argue, the counselor might instruct the parents to ignore the son and continue their

discussion. If the son’s misbehavior becomes unmanageable, the

counselor may ask the son to leave the room so that the parents can

argue without the son’s interference. Eventually, the counselor will

ask the parents to collaborate in controlling the son.

Attempts by the Family to Triangulate the Counselor

Triangulation does not necessarily have to involve only family members. Sometimes a counselor can become part of a triangle as well.

One of the most common strategies used by family members is to

attempt to get the counselor to ally himself or herself with one family

member against another. For example, one family member might say

to the counselor, “Isn’t it true that I am right and he is wrong?” “You

know best, you tell him.” “We were having this argument last night,

and I told her that you had said that....”

Triangulation is always a form of conflict avoidance. Regardless of

whether it is the counselor or a family member who is being triangulated, triangulation prevents two family members in conflict from

reaching a resolution. The only way two family members can resolve

their conflicts is on a one-to-one basis. 

An important reason why the counselor does not want to be triangulated is that the person in the middle of a triangle is either rendered

powerless or symptomatic. In the case of the counselor, the “symptom”

he or she would develop would be ineffectiveness as a therapist, that

is an inability to do his or her job well because his or her freedom of

movement (e.g., changing alliances, choosing whom to address, etc.)

has been restricted. A triangulated counselor is defeated. If the counselor is unable to get out of the triangle, he or she has no hope of

being effective, regardless of what else he or she does or says.

When a family member attempts to triangulate the counselor, the

counselor has to bring the conflict back to the people who are

involved in it. For example, the counselor might say, “Ultimately, it

doesn’t matter what I think. What matters is what the two of you

agree to, together. I am here to help you talk, negotiate, hear each

40
Chapter 4 Orchestrating Change

other clearly, and come to an agreement.” In this way, the counselor

places the focus of the interaction back on the family. The counselor

also might respond, “I understand how difficult this is for you, but

this is your son, and you have to come to terms with each other, not

with me.”

Opening Up Families in which conflicts are not openly expressed need help in 

Closed Systems discussing the conflict so that it can be a target for change. Sometimes 

a counselor can work with a family member who has an unexpressed

or implicit conflict and help that person discuss the problem so 

that it can be resolved. This brings conflicts out into the open and

facilitates their resolution by intensifying and focusing on covert emotional issues. In families of drug-abusing adolescents, a typical example

of unexpressed or suppressed conflict involves disengaged fathers

who tend to deny or avoid any discussion of the youth’s problems.

Asking a surly or sulking adolescent to express what is on his or her

mind whenever the father is addressed may help the father break

through his denial.

Tasks

Central Role

The use of “tasks” or assignments is central to all work with families.

The counselor uses tasks both inside and outside the counseling 

sessions as the basic tool for orchestrating change. Because the

emphasis in BSFT is in promoting new skills among family members,

at both the level of individual behaviors and in family interactional

relations, tasks serve as the vehicle through which counselors choreograph opportunities for the family to behave differently.

In the example in which mother and son were initially allied and the

father was left outside of this alliance, father and son were first

assigned the task of doing something together that would interest them

both. Later on, the mother and father were assigned the collaborative

task of working together to define rules regarding the types of behaviors they would permit in their son and the consequences that they

would assign to their son’s behavior and misbehavior.

General Rule

It is a general rule that the BSFT counselor must first assign a task for

the family to perform in the therapy session so that the counselor has

an opportunity to observe and help the family successfully carry out

the task. Only after a task has been accomplished successfully in the

therapy session can a similar followup task be assigned to the family

to be completed outside of therapy.

Moreover, the counselor’s aim is to provide the family with a successful experience. Thus, the counselor should try to assign tasks that

are sufficiently doable at each step of the counseling process. The

counselor should start with easy tasks and work up to more difficult

41
Chapter 4 Orchestrating Change

ones, slowly building a foundation of successes with the family

before attempting truly difficult restructuring moves. 

Hope for the Best; Be Prepared for the Worst

Counselors should never expect the family to accomplish the

assigned tasks flawlessly. In fact, if family members were skillful

enough to accomplish all assigned tasks successfully, they would not

need to be in counseling. When tasks are assigned, counselors

should always hope for the best but be prepared for the worst. After

all, a task represents a new way of behaving for the family and one that

may be difficult given that they have had years of practice engaging

in the old ways of behaving.

As the family attempts to carry out a task, the counselor should help

the family overcome obstacles it may encounter. However, in spite of

the counselor’s best efforts, the task is not always accomplished. The

counselor’s job is to observe and/or uncover what happened and

identify the obstacles that prevented the family from achieving the

task. When a task fails, the counselor starts over and works to overcome the newly identified obstacles. Unsuccessful attempts to complete

tasks are a great source of new and important information regarding the

interactions that prevent a family from functioning optimally.

The first task that family counselors give to all of their cases is to bring

everyone into the counseling session. Every counselor who works with

problem youths and their families knows very well that most of the

families who need counseling never reach the first counseling session.

Therefore, these families can be described as having failed the first task

given them, to come in for counseling. This task, called engagement,

is so important that we have devoted the next chapter to it.

42
Chapter 5 Engaging the Family 

Into Treatment

Previous chapters have described the basic concepts of BSFT, how to

assess and diagnose maladaptive interactions and their relationship to

symptoms, and the intervention strategies characteristic of this

approach. These concepts also are the building blocks for the techniques that are used to engage resistant families into counseling.

This chapter defines, in systems terms, the nature of the problem of

resistance to treatment and redefines the nature of BSFT joining, 

diagnosing, and restructuring interventions in ways that take into

account those patterns of interaction that prevent families from 

entering treatment.

The Problem

Regardless of their professional orientation and where or how they

practice, all counselors have had the disappointing and frustrating

experience of encountering “resistance to counseling” in the form of

missed or cancelled first appointments. For BSFT counselors, this

becomes an even more common and complex issue because more

than one individual needs to be engaged to come to treatment.

Unfortunately, some counselors handle engagement problems by

accepting the resistance of some family members. In effect, the counselor agrees with the family’s assessment that only one member is

sick and needs treatment. Consequently, the initially well-intentioned

counselor agrees to see only one or two family members for treatment. This usually results in the adolescent and an overburdened

mother following through with counseling visits. Therefore, the counselor has been co-opted into the family’s dysfunctional process.

Not only has the counselor “bought” the family’s definition of the

problem, but he or she also has accepted the family’s ideas about

who is the identified patient. When the counselor agrees to see only

one or two family members, instead of challenging the maladaptive

family interaction patterns that kept the other members away, he or

she is reinforcing those family patterns. In the example in which a

mother and son are allied against the father, if the counselor accepts

43
Chapter 5 Engaging the Family Into Treatment

the mother and son into counseling, he or she is reinforcing the

father figure’s disengagement.

At a more complex level, there are serious clinical implications for

the counselor who accepts the family’s version of the problem. In

doing this, the counselor surrenders his or her position as the expert

and leader. If the counselor agrees with the family’s assessment of

“who’s got the problem,” the family will perceive his or her expertise

and ability to understand the issues as no greater than its own. The

counselor’s credibility as a helper and the family’s perception of his or

her competence will be at stake. Some family members may perceive

the counselor as unable to challenge the status quo in the family

because, in fact, he or she has failed to achieve the first and defining

reframe of the problem.

When the counselor agrees to see only part of the family, he or she

may have surrendered his or her authority too early and may be

unable to direct change and to move freely from one family member

to another. Thus, by beginning counseling with only part of the family, excluded family members may see the counselor as being in a

coalition with the family members who originally participated in

therapy. Therefore, the family members who didn’t attend the initial

sessions may never come to trust the counselor. This means that the

counselor will not be able to observe the system as a whole as it 

usually operates at home because the family members who were not

involved in therapy from the beginning will not trust the counselor

sufficiently to behave as they would at home. The counselor, then,

will be working with the family knowing only one aspect of how the

family typically interacts.

Some counselors respond to the resistance of some family members

to attend counseling by agreeing to see only those who wish to

come. Other family counselors have resolved the dilemma of what 

to do when only some family members want to go to counseling by

taking a more alienated stance saying: “There are too many motivated

families waiting for help; the resistant families will call back when

they finally feel the need; there is no need to get involved in a power

struggle.” The reality is that these resistant families will most likely

never come to counseling by themselves. Ironically, the families who

most need counseling are those families whose patterns and habits

interfere with their ability to get help for themselves.

Dealing With Resistance When some family members do not want to participate in treatment,

to Engagement the counselor needs to find out why. In most instances, when a parent 1

has called the counselor asking for help, that parent is not powerful

enough to bring the adolescent into counseling. If the counselor

wants the family to be in counseling, he or she will have to recognize

44

1We remind the reader that the terms “mother,” “father,” and “parent” refer to 

other parent figures as well.
Chapter 5 Engaging the Family Into Treatment

that the youth (or a noncooperative parent figure) is the most powerful

person in the family. Once the reason the family is not in treatment

is understood, the counselor can draw upon the concept of tracking

(as defined in Chapter 4) to find a way to reach this powerful person

directly and negotiate a treatment contract to which the person will

agree.

Counselors should not become discouraged at this stage. Their mission

now is to identify the obstacles the family faces and help it surmount

them. It is essential to keep in mind that a family seeks counseling

because it is unable to overcome an obstacle without help. Failed

tasks, such as not getting the family to come in for treatment, tend to

be a great source of new and important information regarding the

reasons why a family cannot do what is best for them. The most

important question in counseling is, “What has happened that will

not allow some families to do what may be best for them?”

In trying to engage the family in treatment, the counselor should

apply the concept of repetitive patterns of maladaptive interaction,

which give rise to and maintain symptoms, to the problem of resistance to entering treatment. The very same principles that apply to

understanding family functioning and treatment also apply to understanding and treating the family’s resistance to entering counseling.

When the family wishes to get rid of the youth’s drug abuse symptom

by seeking professional help, the same interactive patterns that 

prevented it from getting rid of the adolescent’s symptom also prevent

the family from getting help. The term “resistance” is used to refer to

the maladaptive interactive patterns that keep families from entering

treatment. From a family-systems perspective, resistance is nothing

more than the family’s display of its inability to adapt effectively to

the situation at hand and to collaborate with one another to seek

help. Thus, the key to eliminating the resistance to counseling lies

within the family’s patterns of interaction; overcome the resistance in

the interactional patterns and the family will come to counseling.

In working to overcome resistant patterns of family interaction, tasks

play a particularly vital role because they are the only BSFT intervention used outside the therapy session. For this reason, tasks are

particularly well-suited for use during the engagement period, when

crucial aspects of the family’s work in overcoming resistance to counseling need to take place outside the office––obviously––because the

family has not yet come in. 

The central task around which engagement is organized is getting the

family to come to therapy together. Thus, in engagement, the counselor assigns tasks that involve doing whatever is needed to get the 

family into treatment. For example, a father calls a BSFT counselor

and asks for help with his drug-abusing son. The counselor responds

by suggesting that the father bring his entire family to a session so

that he or she can involve the whole family in fixing the problem.

The father responds that his son would never come to treatment and

45
Chapter 5 Engaging the Family Into Treatment

that he doesn’t know what to do. The first task that the counselor

might assign the father is to talk with his wife and involve her in the

effort to bring their son into treatment.

The Task of Coming to Treatment

The simple case. The counselor gives the task of bringing the whole

family into counseling to the family member who calls for help. The

counselor explains why this task is a good idea and promises to support the family as it works at this task. Occasionally, this is all that is

needed. Often people do not request family counseling simply

because family counseling is not well known, and thus it does not

occur to them to take such action.

Fear, an obstacle that might easily be overcome. Sometimes, family

members are afraid of what will happen in family therapy. Some of

these fears may be real; others may be simply imagined. In some

instances, families just need some reassuring advice to overcome

their fears. Such fears might include, “They are going to gang up on

me,” or “Everyone will know what a failure I am.” Once these family

members have been helped to overcome their fears, they will be

ready to enter counseling.

Tasks to change how family members act with each other. Very often,

however, simple clarification and reassurance is not sufficient to

mobilize a family. It is at this point that tasks that apply joining, diagnostic, and restructuring strategies are useful in engaging the family.

The counselor needs to prescribe tasks for the family members 

who are willing to come to therapy. These need to be tasks that

attempt to change the ways in which family members interact when

discussing coming to therapy. In the process of carrying out these

tasks, the family’s resistance will come to light. When that happens,

the counselor will have the diagnostic information needed to get

around the family’s patterns of interaction that are maintaining the

symptom of resistance. Once these patterns are changed, the family

will come to therapy. 

It should not be a surprise that families fail to accomplish the task of

getting all of their members to counseling. In fact, the therapist’s job 

is to help the families accomplish tasks that they are not able to

accomplish on their own. As discussed earlier, when assigning any

task, the counselor must expect that the task may not be performed

as requested. This is certainly the case when the family is asked to

perform the task of coming together to counseling.

The application of joining, diagnosing, and restructuring techniques

to the engagement of resistant families is discussed separately below.

However, these techniques are used simultaneously during engagement, as they are during counseling.

46
Chapter 5 Engaging the Family Into Treatment

Joining Joining the resistant family begins with the first contact with the family

member who calls for help and continues throughout the entire relationship with the family. 

With resistant families, the joining techniques described earlier have

to be adapted to match the goal of this phase of therapy. For example,

in tracking the resistant family members to engage them, it is necessary to track through the caller or initial help seeker and any other

family members who may be involved in the process of bringing 

the family to counseling. The counselor tracks by “following” from

the first family member to the next available family member to 

the next one and so on. This following, or tracking, is done without

challenging the family patterns of interaction. Rather, tracking is

accomplished by gaining the permission of one family member to

reach the others.

Establishing a An effective way for the counselor to establish a therapeutic alliance 

Therapeutic Alliance is to say to the resistant family members that he or she knows that 

they want to solve their problems and that the counselor wants the

same thing. It must be recognized, however, that each family member

may view the problem differently. For example, the mother may want

to get her son to quit using drugs, while the son may want peace at

home. 

A therapeutic alliance is built around individual goals that family

members can reach in therapy. Ideally, the counselor and the family

members agree on a goal, and therapy is offered in the framework of

achieving that goal. However, in families in which members are in

conflict over their goals, it is necessary to find something for each of

them to achieve in therapy. For example, the counselor can say to

the mother that therapy can help her son stop using drugs, to the son

that therapy can help him get his mother off his back and stop her

nagging, and to the father that therapy can help stop his being called

in constantly to play the “bad guy.” In each case, the counselor can

offer counseling as a means for each family member to achieve his

or her own personal goal.

In engaging resistant families, the counselor initially works with and

through only one or a few family members. Because the entire family

is not initially available, the counselor will need to form a bond with

the person who called for help and any other family members that

make themselves available. However, the focus of this early engagement phase is strictly to work with these people to bring about the

changes necessary to engage the entire family in counseling. The focus

is not to talk about the problem but rather to talk about getting everyone to help solve the problem by coming to therapy. By using the

contact person as a vehicle (via tracking) for joining with other members

of the family, the counselor can eventually establish a therapeutic

alliance with each family member and thereby elicit the cooperation

of the entire family in the engagement effort.

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Chapter 5 Engaging the Family Into Treatment

Diagnosing the Interactions That Keep 

the Family From Coming Into Treatment

In engagement, the purpose of diagnosis is to identify those particular

patterns of interaction that permit the resistant behavior to continue.

However, because it isn’t possible to observe the entire family, the

BSFT counselor works with limited information to diagnose those

patterns of interaction that are supporting the resistance.

To identify the maladaptive patterns responsible for the resistance,

diagnosis begins prior to therapy, when a family member first calls the

counselor. Because it is not possible to encourage and observe

enactments of family members interacting before they enter counseling,

engagement diagnosis has been modified so that it can be used during

engagement to collect the diagnostic information in other ways. 

First, the counselor asks the contact person interpersonal systems questions that allow him or her to infer what the family’s interactional 

patterns may be. For example, the counselor may ask, “How do you

ask your husband to come to treatment?” “What happens when you

ask your husband to come to treatment?” “When he gets angry at you

for asking him to come to treatment, what do you do next?” Through

these questions, the counselor tries to identify the interplay between

these spouses that contributes to the resistance. For example, is it

possible that the wife is asking the husband to come to treatment in

an accusatory way, which causes him to get angry? An example might

be, “It is your fault that your son is in trouble because you are sick.

You have to go to treatment.”

As was indicated earlier, counselors do not like to rely on what family

members tell them because each family member is very invested in

his or her own viewpoints and probably cannot provide a systemic or

objective account of family functioning. However, when counselors

have access to only one person, they work with the person they

have, strictly for the purpose of engaging that person in treatment. 

Second, counselors explore the family system for resistances to the task

of coming to therapy. This is done by assigning exploratory tasks to

uncover resistances that cause the family to fail at the task of coming to

therapy. For example, in the case above, the counselor might suggest

to the wife that she ask her husband to come for her sake and not

because there is anything wrong with him. At that point, the wife may

say to the counselor, “I can’t really ask him for my sake because I

know he’s too busy to come to the family meetings.” This statement

suggests that the wife is not completely committed to getting the husband to come to treatment. On the one hand, she claims to want him

to come to treatment, but on the other, she gives excuses for why he

cannot. The purpose of exploring the resistance, beginning with the

first phone call, is to identify as early as possible the obstacles that may

prevent the family from coming to therapy, with the aim of intervening

in a way that gets around these obstacles.

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Chapter 5 Engaging the Family Into Treatment

Complementarity: Understanding How the 

Family “Pieces” Fit Together to Create Resistance

What makes this type of early diagnostic work possible is an understanding of the Principle of Complementarity, which was described in

Chapter 2. As noted earlier, for a family to work as a unit (even maladaptively), the behaviors of each family member must “fit with” the

behaviors of every other family member. Thus, for each action within

the family, there is a complementary action or reaction. For example,

in the case of resistance, the husband doesn’t want to come to treatment (the action), and the wife excuses him for not coming to treatment

(the complementary action). Similarly, a caller tells the counselor that

whenever she says anything to her husband about counseling (the

action), he becomes angry (the complementary reaction). The counselor

needs to know exactly what the wife’s contribution is to this circular

transaction, that is, what her part is in maintaining this pattern of

resistance.

Restructuring the Resistance

In the process of engaging resistant families, the counselor initially

sees only one or a few of the family members. It is still possible,

through these individuals, to bring about short-term changes in 

interactional patterns that will allow the family to come for therapy.

A variety of change-producing interventions have already been

described in Chapter 4: reframing, reversals, detriangulation, opening

up closed systems, shifting alliances, and task setting. The counselor

can use all of these techniques to overcome the family’s resistance to

counseling. In the process of engaging resistant families, task setting is

particularly useful in restructuring.

The next section discusses the types of resistant families that have

been identified, the process of getting the family into counseling, and

the central role that tasks may play in achieving this goal. Much of

counseling work with resistant families has been done with families

in which the parents knew or believed the adolescent was using

drugs and engaging in associated problem behaviors such as truancy,

delinquency, fighting, and breaking curfew. These types of families

are typically difficult to engage in therapy. However, the examples

are not intended to represent all possible types of configurations of

family patterns of interaction that work to resist counseling.

Counselors working with other types of problems and families are

encouraged to review their caseload of difficult-to-engage families

and to carefully diagnose the systemic resistances to therapy. Some

counselors may find that the resistant families they work with are

similar to those described here, and some may find different patterns

of resistance. In any case, counselors will be better equipped to work

with these families if they have some understanding of the more common types of resistances in families of adolescent drug abusers.

49
Chapter 5 Engaging the Family Into Treatment

Types of Resistant There are four general types of family patterns of interaction that 

Families emerge repeatedly in work with families of drug-abusing adolescents 

who resist engagement to therapy. These four patterns are discussed

below in terms of how the resistant patterns of interaction are manifested, how they come to the attention of the counselor, and how the

resistance can be restructured to get the family into therapy. 

Powerful Identified Patient

The most frequently observed type of family resistance to entering

treatment is characterized by an identified patient who has a powerful

position in the family and whose parents are unable to influence him

or her. This is a problem, particularly in cases that are not courtreferred and in which the adolescent identified patient is not required

to engage in counseling. Very often, the parent of a powerful identified patient will admit that he or she is weak or ineffective and will say

that his or her son or daughter flatly refuses to come to counseling.

Counselors can assume that the identified patient resists counseling

for two reasons: It threatens his or her position of power, and counseling is on the parent’s agenda and compliance would strengthen

the parent’s power.

As a first step in joining and tracking the rules of the family, the counselor shows respect for and allies with the adolescent. The counselor

contacts the drug-abusing adolescent by phone or in person (perhaps

on his or her own turf, such as after school at the park). The counselor listens to the powerful adolescent’s complaints about his or her

parents and then offers to help the youth change the situation at

home so that the parents will stop harassing him or her. This does

not threaten the adolescent’s power within the family and, thus, is

likely to be accepted. The counselor offers respect and concern for

the youth and brings an agenda of change that the adolescent will

share by virtue of the alliance.

To bring these families who resist entering treatment into treatment,

the counselor does not directly challenge the youth’s power in the

family. Instead, the counselor accepts and tracks the adolescent’s

power. The counselor allies himself or herself with the adolescent so

that he or she may later be in a position to influence the adolescent

to change his or her behavior. Initially, in forming an alliance with

the powerful adolescent, the counselor reframes the need for counseling in a manner that strengthens the powerful adolescent in a positive way. This is an example of tracking—using the power of the

adolescent to bring him or her into therapy. The kind of reframing

that is most useful with powerful adolescents is one that transfers the

symptom from the powerful adolescent/identified patient to the family.

For example, the counselor may say, “I want you to come into counseling to help me change some of the things that are going on in your

family.” Later, once the adolescent is in counseling, the counselor will

challenge the adolescent’s position of power.

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Chapter 5 Engaging the Family Into Treatment

It should be noted that in cases in which powerful adolescents have

less powerful parents, forming the initial alliance with the parents is

likely to be ineffective because the parents are not strong enough to

bring their adolescent into counseling. Their failed attempts to bring

the adolescent into counseling would render the parents even

weaker, and the family would fail to enter counseling. Furthermore,

the youth is likely to perceive the counselor as being the parents’ ally,

which would immediately make the adolescent distrust the weak

counselor.

Contact Person Protecting Structure

The second most common type of resistance to entering treatment is

characterized by a parent who protects the family’s maladaptive patterns

of interaction. In these families, the person (usually the mother) who

contacts the counselor to request help is also the person who is—

without realizing it—maintaining the resistance in the family. The

way in which the identified patient is maintained in the family is also

the way in which counseling is resisted. The mother, for example,

might give conflicting messages to the counselor, such as, “I want to

take my family to counseling, but my son couldn’t come to the session

because he forgot and fell asleep, and my husband has so much

work he doesn’t have the time.”

The mother is expressing a desire for the counselor’s help while protecting and allying herself with the family’s resistance to being

involved in solving the problem. The mother protects this resistance

by agreeing that the excuses for noninvolvement are valid. In other

words, she is supporting the arguments the other family members 

are using to maintain the status quo. It is worthwhile to note that

ordinarily this same conflicting message that occurs in the family

maintains the symptomatic structure. In other words, someone complains about the problem behavior, yet supports the maintenance of the

behaviors that nurture the problem. This pattern is typical of families in

which the caller (e.g., the mother) and the identified patient are

enmeshed.

To bring these families into treatment, the counselor must first form

an alliance with the mother by acknowledging her frustration in

wanting to get help and not getting any cooperation from the other

family members to get it. Through this alliance, the counselor asks

the mother’s permission to contact the other family members “even

though they are busy and the counselor recognizes how difficult it is

for them to become involved.” With the mother’s permission, the

counselor calls the other family members and separates them from

the mother in regard to the issue of coming to counseling. The counselor develops his or her own relationship with other family members

in discussing the importance of coming to counseling. In doing so,

he or she circumvents the mother’s protective behaviors. Once the

family is in counseling, the mother’s overprotection of the adolescent’s misbehavior and of the father’s uninvolvement (and the adolescent’s and father’s eagerness that she continue to protect them)

51
Chapter 5 Engaging the Family Into Treatment

will be addressed because it also may be related to the adolescent’s

problem behaviors.

Disengaged Parent

These family structures in which one parent protects the family’s 

maladaptive patterns of behavior are characterized by little or no

cohesiveness and lack of an alliance between the parents or parent

figures as a subsystem. One of the parents, usually the father, refuses

to come into therapy. This is typically a father who has remained 

disengaged from the problems at home. The father’s disengagement

not only protects him from having to address his adolescent’s problems but also protects him from having to deal with the marital 

relationship, which is most likely the more troublesome of the two

relationships he is avoiding. Typically, the mother is over-involved

(enmeshed) with the identified patient and either lacks the skills to

manage the youth or is supporting the identified patient in a covert

fashion. 

For example, if the father tries to control the adolescent’s behavior,

the mother complains that he is too tough or makes her afraid that

he may become violent.2 The father does not challenge this portrayal

of himself. He is then rendered useless and again distances himself,

re-establishing the disengagement between husband and son and

between husband and wife. In this family, the dimension of resonance

is of foremost importance in planning how to change the family and

bring it into therapy. The counselor must use tasks to bring the

mother closer to the father and distance her from the son. That is, the

boundary between the parents needs to be loosened to bring them

closer together, and the boundary between mother and son needs to

be strengthened to create distance between them.

To engage these families into treatment, the counselor must form an

alliance with the person who called for help (usually the mother).

The counselor then must begin to direct the mother to change her

patterns of interaction with the father to improve their cooperation,

at least temporarily, in bringing the family into treatment. The counselor should give the mother tasks to do with her husband that pertain

only to getting the family into treatment and taking care of their son’s

problems. The counselor should assign tasks in a way that is least

likely to spark the broader marital conflict. To set up the task, the

counselor may ask the mother what she believes is the real reason

her husband does not want to come to counseling. Once this reason

is ascertained, the counselor coaches the mother to present the issue

of coming to treatment in a way that the husband can accept. For

example, if he doesn’t want to come because he has given up on his

son, she may be coached to suggest to him that coming to treatment

will help her cope with the situation.

52

2Of course, some fathers are violent, and the fear may be warranted. However,

even in these cases, the violent father must be brought to therapy to change 

his behavior and to ensure that the parents collaborate in parenting.
Chapter 5 Engaging the Family Into Treatment

Although the pattern of resistance is similar to that of the contact person protecting the structure, in this instance, the resistance emerges

differently. In this case, the mother does not excuse the father’s distance. To the contrary, she complains about her spouse’s disinterest;

this mother is usually eager to do something to involve her husband;

she just needs some direction to be able to do it.

Families With Secrets

Sometimes counseling is threatening to one or more individuals in

the family. Sometimes the person who resists coming to counseling

is either afraid of being made a scapegoat or afraid that dangerous

secrets (e.g., infidelity) will be revealed. These individuals’ beliefs or

frames about counseling are usually an extension of the frame within

which the family is functioning. That is, it is a family of secrets.

The counselor must reframe the idea or goal of counseling in a way

that eliminates its potential negative consequences and replaces them

with positive aims. One example of how to do this is to meet with

the person who rejects counseling the most and assure him or her

that counseling does not have to go where he or she does not want

it to go. The counselor needs to make it clear that he or she will

make every effort to focus on the adolescent’s problems instead of

the issues that might concern the unwilling family member. The

counselor also should assure this individual that in the counseling

session, “We will deal only with those issues that you want to deal

with. You’ll be the boss. I am here only to help you to the extent that

you say.”

53

Chapter 6 Clinical Research Supporting 

Brief Stategic Family Therapy

This chapter describes past research on the effectiveness of BSFT

with drug-abusing adolescents with behavioral problems. BSFT has

been found to be effective in reducing adolescents’ conduct problems,

drug use, and association with antisocial peers and in improving family

functioning. In addition, BSFT engagement has been found to increase

engagement and retention in therapy. Additional studies testing an

ecological version of BSFT with this population are currently underway. 

As presented in this manual, BSFT’s primary emphasis is on identifying

and modifying maladaptive patterns of family interaction that are

linked to the adolescent’s symptoms. The ecological version of BSFT,

BSFT-ecological (Robbins et al. in press) applies this principle of

identifying and modifying maladaptive patterns of interaction to the

multiple social contexts in which the adolescent is embedded (cf.

Bronfenbrenner 1979). The principal social contexts that are targeted

in BSFT-ecological are family, family-peer relations, family-school

relations, family-juvenile justice relations, and parent support systems.

Joining, diagnosing, and restructuring, as developed in BSFT to use

within the family system, are applied to these other social contexts or

systems that influence the adolescent’s behaviors. For instance, the

BSFT counselor assesses the maladaptive, repetitive patterns of interaction that occur in each of these systems or domains. As an example,

the BSFT counselor would diagnose the family-school system in 

the same way that he or she would diagnose the family system. In

diagnosing structure, the counselor would ask, “Do parents provide

effective leadership in their relationship with their child’s teachers?”

In diagnosing resonance, the counselor would ask, “Are parents and

teachers disengaged?” In diagnosing conflict resolution, the counselor’s

questions would be, “What is the conflict resolution style in the parentteacher relationship? Might parents and teachers avoid conflict with

each other (by remaining disengaged) or diffuse conflicts by blaming

each other?” In BSFT-ecological, joining the teacher in the parentteacher relationship employs the same joining techniques developed

for BSFT. Similarly, in BSFT-ecological, BSFT restructuring techniques

are used to modify the nature of the relationship between a parent

and his or her child’s teacher.

55
Chapter 6 Clinical Research Supporting Brief Strategic Family Therapy

Outpatient Brief Strategic Family Therapy Versus 

Outpatient Group Counseling

A recent study (Santisteban et al. in press) examined the efficacy of BSFT

in reducing an adolescent’s behavioral problems, association with

antisocial peers, and marijuana use, and in improving family functioning. In this study, outpatient BSFT was compared to an outpatient

group counseling control treatment. Participants were 79 Hispanic

families with a 12- to 18-year-old adolescent who was referred to

counseling for conduct and antisocial problems by either a school

counselor or a parent. Families were randomly assigned to either

BSFT or group counseling. Analyses of treatment integrity revealed

that interventions in both therapies adhered to treatment guidelines

and that the two therapies were clearly distinguishable.

Conduct disorder and association with antisocial peers were assessed

using the Revised Behavior Problem Checklist (RBPC) (Quay and

Peterson 1987), which is a measure of adolescent behavior problems

reported by parents. Conduct disorder was measured using 22 items,

and association with antisocial peers was measured using 17 items.

Each item asks the parent(s) to rate whether a specific aspect of the

adolescent’s behavior (e.g., fighting, spending time with “bad” friends)

is no problem (0), a mild problem (1), or a severe problem (2).

Ratings for all items on each scale are then added together to derive

a total score.

The effects of BSFT on conduct disorder, association with antisocial

peers, and marijuana use were evaluated in two ways. First, analyses

of variance were conducted to examine whether BSFT reduced 

conduct disorder, association with antisocial peers, and marijuana use

to a significantly greater extent than did group counseling. Second,

exploratory analyses were conducted on clinically significant changes

in conduct problems and association with antisocial peers. These

exploratory analyses used the twofold clinical significance criteria

recommended by Jacobson and Truax (1991). To be able to classify a

change in symptoms for a given participant as clinically significant, two

conditions have to occur. First, the magnitude of the change must be

large enough to be reliable—that is, to rule out random fluctuation as

a plausible explanation. Second, the participant must “recover” from

clinical to nonclinical levels, i.e., cross the diagnostic threshold. 

Conduct Disorder. Analyses of variance indicated that conduct disorder

scores for adolescents in BSFT compared to those for adolescents in

group counseling were significantly reduced between pre- and posttreatment. In the clinical significance analyses, a substantially larger

proportion of adolescents in BSFT than in group counseling demonstrated clinically significant improvement. At intake, 70 percent of

adolescents in BSFT had conduct disorder scores that were above

clinical cutoffs. That is, they scored above the empirically established

threshold for clinical diagnoses of conduct disorder. At the end of

56
Chapter 6 Clinical Research Supporting Brief Strategic Family Therapy

treatment, 46 percent of these adolescents showed reliable improvement, and 5 percent showed reliable deterioration. Among the 46 percent who showed reliable improvement, 59 percent recovered to

nonclinical levels of conduct disorder. In contrast, at intake, 64 percent

of adolescents in group counseling had conduct disorder scores

above the clinical cutoff. Of these, none showed reliable improvement, and 11 percent showed reliable deterioration. Therefore, while

adolescents in BSFT who entered treatment at clinical levels of conduct

disorder had a 66 percent likelihood of improving, none of the 

adolescents in group counseling reliably improved. 

Association With Antisocial Peers. Analyses of variance indicated that,

for adolescents in BSFT, scores for association with antisocial peers were

significantly reduced between pre- and post-treatment, compared to

those for adolescents in group counseling. In the clinical significance

analyses, 79 percent of adolescents in BSFT were above clinical cutoffs for association with antisocial peers at intake. Among adolescents

in BSFT meeting clinical criteria for association with antisocial peers,

36 percent showed reliable improvement, and 2 percent showed 

reliable deterioration. Of the 36 percent of adolescents in BSFT with

reliable improvement, 50 percent were classified as recovered. Among

adolescents in group counseling, 64 percent were above clinical cutoffs for association with antisocial peers at intake. Among adolescents

in group counseling meeting these clinical criteria at intake, 11 percent

reliably improved, and none reliably deteriorated. Of the 11 percent of

adolescents in group counseling evidencing reliable improvement in

association with antisocial peers, 50 percent recovered to nonclinical

levels. Hence, adolescents in BSFT who entered treatment at clinical

levels of association with antisocial peers were 2.5 times more likely

to reliable improve than were adolescents in group treatment. 

Marijuana Use. Analyses of variance revealed that BSFT was associated

with significantly greater reductions in self-reported marijuana use than

was group counseling. To investigate whether clinically meaningful 3

changes in marijuana use occurred, four use categories from the substance use literature (e.g., Brooks et al.1998) were employed. These

categories are based on the number of days an individual uses marijuana in the 30 days before the intake and termination assessments:

■ abstainer – 0 days

■ weekly user – 1 to 8 days

■ frequent user – 9 to 16 days

■ daily user – 17 or more days

57

3Formal tests of clinically significant change in marijuana use were not possible

because the measure of marijuana use does not provide both clinical and 

nonclinical norms.
Chapter 6 Clinical Research Supporting Brief Strategic Family Therapy

In BSFT, 40 percent of participants reported using marijuana at intake

and/or termination. Of these, 25 percent did not show change, 60 percent

showed improvement in drug use, and 15 percent showed deterioration.

Of the individuals in BSFT who shifted into less severe categories, 

75 percent were no longer using marijuana at termination. In group

counseling, 26 percent of participants reported using marijuana at

intake and/or termination. Of these, 33 percent showed no change,

17 percent showed improvement, and 50 percent deteriorated. The 

17 percent of adolescents in group counseling cases that showed

improvement were no longer using marijuana at termination. Hence,

adolescents in BSFT were 3.5 times more likely than were adolescents

in group counseling to show improvement in marijuana use.

Treatments also were compared in terms of their influence on family

functioning. Family functioning was measured using the Structural

Family Systems Ratings (Szapocznik et al. 1991). This measure was

constructed to assess family functioning as defined in Chapter 3.

Based on their scores when they entered therapy, families were 

separated by a median split into those who had good and those who

had poor family functioning. Within each group (i.e., those with good

and those with poor family functioning), a statistical test that compares

group means (analysis of variance) tested changes in family functioning from before to after the intervention.

Among families who were admitted with poor family functioning, the

results showed that those assigned to BSFT had a significant improvement in family functioning, while those families assigned to group

counseling did not improve significantly. 

Among families who were admitted with good family functioning, the

results showed that those assigned to BSFT retained their good levels of family functioning, while families assigned to group counseling

showed significant deterioration. These findings suggest that not all

families of drug-abusing youths begin counseling with poor family

functioning, but if the family is not given adequate help to cope with

the youth’s problems, the family’s functioning may deteriorate.

One Person Brief Strategic Family Therapy

With the advent of the adolescent drug epidemic of the 1970s, the

vast majority of counselors who worked with drug-using youths

reported that, although they preferred to use family therapy, they

were not able to bring whole families into treatment (Coleman and

Davis 1978). In response, a procedure was developed that would

achieve the goals of BSFT (to change maladaptive family interactions

and symptomatic adolescent behavior) without requiring the whole

family to attend treatment sessions. The procedure is an adaptation

of BSFT called “One Person” BSFT (Szapocznik et al. 1985;

Szapocznik and Kurtines 1989; Szapocznik et al. 1989a). One Person

BSFT capitalizes on the systemic concept of complementarity, which

suggests that when one family member changes, the rest of the system

58
Chapter 6 Clinical Research Supporting Brief Strategic Family Therapy

responds by either restoring the family process to its old ways or

adapting to the new changes (Minuchin and Fishman 1981). The goal

of One Person BSFT is to change the drug-abusing adolescent’s 

participation in maladaptive family interactions that include him or

her. Occasionally, these changes create a family crisis as the family

attempts to return to its old ways. The counselor uses the opportunity

created by these crises to engage reluctant family members. 

A clinical trial was conducted to compare the efficacy of One Person

BSFT to Conjoint (full family) BSFT (Szapocznik et al. 1983, 1986).

Hispanic families with a drug-abusing 12- to 17-year-old adolescent

were randomly assigned to the One Person or Conjoint BSFT modalities. Both therapies were designed to use exactly the same BSFT 

theory so that only one variable (one person vs. conjoint meetings)

would differ between the treatments. Analyses of treatment integrity

revealed that interventions in both therapies adhered to guidelines

and that the two therapies were clearly distinguishable. The results

showed that One Person was as efficacious as Conjoint BSFT in 

significantly reducing adolescent drug use and behavior problems as

well as in improving family functioning at the end of therapy. These

results were maintained at the 6-month followup (Szapocznik et al.

1983, 1986).

One Person BSFT is not discussed in this manual because it is considered a very advanced clinical technique. More information on One

Person BSFT is available in Szapocznik and Kurtines (1989).

Brief Strategic Family Therapy Engagement

As discussed in Chapter 5, in response to the problem of engaging

resistant families, a set of engagement procedures based on BSFT

principles was developed (Szapocznik and Kurtines 1989; Szapocznik

et al. 1989b). These procedures are based on the premise that resistance

to entering treatment can be understood in family interactional terms.

One Person BSFT techniques are useful in this initial phase. That’s

because the person who contacts the counselor to request help may

become the one person through whom work is initially done to

restructure the maladaptive family interactions that are maintaining

the symptom of resistance. The success of the engagement process is

measured by the family’s and the symptomatic youth’s attendance in

family therapy. In part, success in engagement permits the counselor

to redefine the problem as a family problem in which all family members have something to gain. Once the family is engaged in treatment,

the focus of the intervention is shifted from engagement to removing

the adolescent’s presenting symptoms.

The efficacy of BSFT engagement has been tested in three studies with

Hispanic youths (Szapocznik et al. 1988; Santisteban et al. 1996;

Coatsworth et al. 2001). The first study (Szapocznik et al. 1988) included

mostly Cuban families with adolescents who had behavior problems

59
Chapter 6 Clinical Research Supporting Brief Strategic Family Therapy

and who were suspected of or observed using drugs by their parents

or school counselors. Of those engaged, 93 percent actually reported

drug use. Families were randomly assigned to one of two therapies:

BSFT engagement or engagement as usual (the control therapy). The

engagement-as-usual therapy consisted of the typical engagement

methods used by community treatment agencies, which were identified prior to the study using a community survey of outpatient agencies serving drug-abusing adolescents. All families who were

successfully engaged received BSFT. In the experimental therapy,

families were engaged and retained using BSFT engagement techniques. Successful engagement was defined as the conjoint family

(minimally the identified patient and his or her parents and siblings

living in the same household) attending the first BSFT session, which

was usually to assess the drug-using adolescent and his or her family.

Treatment integrity analyses revealed that interventions in both

engagement therapies adhered to prescribed guidelines using six 

levels of engagement effort that were operationally defined and that

the therapies were clearly distinguishable by level of engagement effort

applied. 

The six levels of engagement effort, as enumerated in Szapocznik et

al. (1988, p. 554), are:

■ Level 0 – expressing polite concern, scheduling an intake

appointment, establishing that cases met criteria for inclusion 

in the study, and making clear who must attend the intake

assessment;

■ Level 1 – attempting minimal joining, encouraging the caller 

to involve the family, asking about the depth and breadth of

adolescent problems, and asking about family members; 

■ Level 2 – attempting more thorough joining; asking about family

interactions; seeking information about the problems, values,

and interests of family members; supporting and establishing an

alliance with the caller; beginning to establish leadership; and

asking whether all family members would be willing to attend

the intake appointment; 

■ Level 3 – restructuring for engagement through the caller, advising

the caller about negotiating and reframing, and following up

with family members (either over the phone or personally with the

caller at the therapist’s office) to be sure that intake appointments

would be kept;

■ Level 4 – conducting lower level ecological engagement interventions, joining family members or conducting intrapersonal

restructuring (with family members other than the original caller)

over the phone or in the therapist’s office, and contacting 

significant others (by phone) to gather more information; and

60
Chapter 6 Clinical Research Supporting Brief Strategic Family Therapy

■ Level 5 – conducting higher level ecological interventions, making

out-of-office visits to family members or significant others, and

using significant others to help conduct restructuring.

Level 0–1 behaviors were permitted for both the BSFT engagement

and engagement-as-usual conditions. Level 2–5 behaviors were permitted only for the BSFT engagement condition. Efficacy was measured in

rates of both family treatment entry as well as retention to treatment

completion.

The efficacy of the two methods of engagement was measured by the

percentage of families who entered treatment and the percentage of

families who completed the treatment. The results revealed that 42

percent of the families in the engagement-as-usual therapy and 

93 percent of the families in the BSFT engagement therapy were 

successfully engaged. In addition, 25 percent of engaged cases in the

engagement-as-usual treatment and 77 percent of engaged cases in

the BSFT engagement treatment successfully completed treatment.

These differences in engagement and retention between the two methods of engagement were both statistically significant. Improvements in

adolescent symptoms occurred but were not significantly different

between the two methods of engagement. Thus, the critical distinction

between the treatments was in their different rates of engagement

and retention. Therefore, BSFT engagement had a positive impact on

more families than did engagement as usual.

In addition to replicating the previous engagement study, the second

study (Santisteban et al. 1996) also explored factors that might moderate the efficacy of the engagement interventions. In contrast to the

previous engagement study, Santisteban et al. (1996) more stringently

defined the success of engagement as a minimum of two office visits:

the intake session and the first therapy session. The researchers randomly assigned 193 Hispanic families to one experimental and two

control treatments. The experimental therapy was BSFT plus BSFT

engagement. The first control therapy was BSFT plus engagement as

usual, and the second was group counseling plus engagement as

usual. In both control treatments, engagement as usual involved no

specialized engagement strategies. 

Results showed that 81 percent of families were successfully engaged

in the BSFT plus BSFT engagement experimental treatment. In contrast,

60 percent of the families in the two control therapies were successfully engaged. These differences in engagement were statistically 

significant. However, the efficacy of the experimental therapy procedures was moderated by the cultural/ethnic identity of the Hispanic

families in the study. Among families assigned to BSFT engagement,

93 percent of the non-Cuban Hispanics (composed primarily of

Nicaraguan, Colombian, Puerto Rican, Peruvian, and Mexican families)

and 64 percent of the Cuban Hispanics were engaged. These findings

61
Chapter 6 Clinical Research Supporting Brief Strategic Family Therapy

have led to further study of the mechanism by which culture/ethnicity

and other contextual factors may influence clinical processes related

to engagement (Santisteban et al. 1996; Santisteban et al. in press).

The results of the Szapocznik et al. (1988) and Santisteban et al.

(1996) studies strongly support the efficacy of BSFT engagement.

Further, the second study with its focus on cultural/ethnic identity

supports the widely held belief that therapeutic interactions must be

responsive to contextual changes in the treatment population (Sue et

al. 1994; Szapocznik and Kurtines 1993).

A third study (Coatsworth et al. 2001) compared BSFT to a community

control intervention in terms of its ability to engage and retain adolescents and their families in treatment. An important aspect of this

study was that an outside treatment agency administered the control

intervention. Because of that, the control intervention (e.g., usual

engagement strategies) was less subject to the influence of the investigators. Findings in this study, as in previous studies, showed that

BSFT was significantly more successful, at 81 percent, in engaging

adolescents and their families in treatment than was the community

control treatment, at 61 percent. Likewise, among those engaged in

treatment, a higher percentage of adolescents and their families in

BSFT, at 71 percent, were retained in treatment compared to those in

the community control intervention, at 42 percent. In BSFT, 58 percent of adolescents and their families completed treatment compared

to 25 percent of those in the community control intervention.

Families in BSFT were 2.3 times more likely both to be engaged and

retained in treatment than were families randomized to the community

control treatment.

An additional finding of the Coatsworth et al. (2001) study warrants

special mention. In BSFT, families of adolescents with more severe

conduct problem symptoms were more likely to remain in treatment

than were families of adolescents whose conduct problem symptoms

were less severe. The opposite pattern was evident in the community

control intervention, with families that were retained in treatment

showing lower intake levels of conduct problems than did families

who dropped out. These findings are particularly important because

they suggest that adolescents who are most in need of services are

more likely to stay in BSFT than in traditional community treatments.

62
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68
Appendices

69

Appendix A Training Counselors in Brief

Strategic Family Therapy

One of BSFT’s strengths is its considerable flexibility, which makes it

extremely adaptable to a broad range of family and youth situations

and problems. The disadvantage of BSFT is that it is not a simple-tofollow recipe (a pinch of empathy and an ounce of joining). Rather,

BSFT is an advanced clinical model that requires the counselors who

use it to have considerable skill.

Selecting Counselors

Counselors need three levels of training and experience to conduct

BSFT counseling. If a counselor does not have basic counseling skills,

he or she would have to learn them. If a counselor does not have

systemic skills, he or she would have to learn them. However, if the

counselor already has basic skills and systemic skills, he or she only

would have to learn skills specific to BSFT. The nature of the training

and skills of the counselor should be an important consideration in

selecting counselors for training in BSFT. Each of the following levels

of training are discussed in more detail below:

■ Basic clinical skills common to many behavioral interventions

■ Training in basic family systems theory, as used in many family

therapy approaches

■ Training specific to BSFT

Level One: Training Level one training is the kind of training that teaches counselors basic 

in Basic Clinical Skills clinical skills common to many kinds of behavioral interventions, 

Common to Many such as:

Behavioral Interventions

■ Interviewing skills

■ Active listening – reflecting back or repeating to the client the

content and feelings the client has expressed

■ Timing – knowing the right moment to say or do what the client

needs

71
Appendix A Training Counselors in Brief Strategic Family Therapy

■ Empathy – understanding the client’s experience at a cognitive

and affective level and being able to express it

■ Treating all clients with respect

■ Providing counseling for the benefit of the client and not for the

benefit of the counselor; placing the client’s needs above the

counselor’s needs

■ Understanding oneself – feelings, reactions, what pushes one’s

buttons

■ Providing validation and support to clients

Level Two: Training Level two training is the kind of training that is often provided in 

in Basic Family clinically oriented, master’s level programs in social work, marriage 

Systems Theory and family therapy, and, occasionally, in counseling psychology. In 

this kind of training, counselors learn how to understand families as

systems rather than as a conglomerate of individuals. Systemic work,

as defined in Chapter 2, is based on the notion that family members

are interdependent and that the family is more than the sum of its

parts. That is, family members behave very differently when they are

together than when they are apart. Consequently, the counselor may

not always be able to predict how a family member behaves in the

family as compared to the behavior of the family member outside the

family. Similarly, family members’ perceptions or reports of family

interactions may be severely flawed. Counselors are taught to think

and act in systems terms. That means that counselors are taught to

consider how social context affects individual behavior. Counselors also

have been taught the basics of entering a system, such as identifying

and respecting the system’s power structure.

Level Three: Counselors who have basic clinical skills and family systems training 

Brief Strategic Family can be trained in BSFT concepts and techniques. However, counselors

Therapy Specific Training who lack basic skills training are required to take extensive prerequisite preparatory training. Counselors who lack family systems

training must be trained in family systems (see Chapter 2) before they

can be trained in BSFT concepts and techniques. It is suggested that

counselors and their administrators should not underestimate 

the importance of obtaining the more basic counseling skills or the

intensity of training required to obtain these more basic skills.

Required Brief Strategic Family Therapy Training: Four Phases

The required BSFT training has four phases.

■ Phase 1 – counselors learn the methods of BSFT

■ Phase 2 – counselors review videotapes to learn how to identify

family process and family interactions

72
Appendix A Training Counselors in Brief Strategic Family Therapyo

■ Phase 3 – counselors review videotapes to learn how family

counseling interventions are conducted

■ Phase 4 – A BSFT supervisor supervises the BSFT counselors’

therapy sessions or reviews videotapes of the therapy

In the first phase of training, the counselors must learn the methods

of BSFT presented in this manual. As part of teaching these methods,

considerable role playing is conducted to illustrate various aspects of

the BSFT model. 

In the second phase of training, counselors review a series of videotapes of families that were treated at the University of Miami Center

for Family Studies, where BSFT was developed. This set of videotapes

shows families by themselves (without a therapist present) responding

to three standard stimuli. The three standard stimuli are tasks the family

has been asked to do: (1) plan a menu together with which everyone agrees; (2) say what each likes and doesn’t like about each other;

and (3) talk about a recent argument, including what it was about,

who was involved, and what happened. These videotapes are used

to teach the counselors how to identify family process and family

interactions at the most minute level, as discussed in Chapter 3. In

other words, counselors are taught to identify who the family’s leader

is, how the family handles conflicts, who is allied with whom, and

who the family’s identified patient is. The counselors also learn how

to tell if the family views itself as having problems other than the

problems of the identified patient and which family members are

enmeshed, which are disengaged, and so on. As part of this phase,

counselors will be trained to identify how the behaviors of one family

member are linked to those of another. For example, there may be two

family members who always agree or always disagree with each other;

this denotes an enmeshed alliance between these family members.

In the third phase of training, the counselors review videotapes of

therapy sessions BSFT counselors conducted at the Center for Family

Studies with families of drug-abusing adolescents. These sessions will

be used to illustrate how counselors respond to various family

processes, for example, how to join with a family, reframe negativity,

shift boundaries, and other techniques. Trainees will observe what

trained BSFT counselors do in the context of specific family interactions (e.g., blaming the identified patient). For example, it is important

to note whether the counselor reframes or diverts the conversation,

permits negativity to go unchecked for a long time, centralizes the

conversation around himself or herself, or decentralizes the conversation so that most of the conversation is among family members. It is

also important to note how the counselor brings about these various

therapeutic maneuvers, both those that are effective and those that

are not. 

In the fourth and final phase of training, a BSFT trainer supervises a

counselor’s work in BSFT sessions as it takes place whenever possible,

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Appendix A Training Counselors in Brief Strategic Family Therapy

or if live supervision is not possible, reviews the counselor trainee’s

videotapes of the family sessions. BSFT trainees are taught to be comfortable with someone videotaping their work, to discuss videotaping

with families, and to obtain a signed videotape permission form from

the families. In addition, the BSFT counselor trainee also will be

taught to explain the nature of the training activity and the supervisory relationship to the families so that they are fully informed that

they are participating in the training of the counselor. 

While counselors often fear that the families they work with might

object to being videotaped, 30 years of experience has shown that

families are willing and comfortable when the counselors themselves

are comfortable with having their work videotaped. Thus, the highest priority is to help counselors become comfortable with having

their work videotaped. Drug-abusing adolescents and their families

usually do not have a problem with being videotaped. However, in

our experience, when a parent is involved in high-level criminal

activity, that parent is likely to refuse videotaping.

While some counseling modalities may be primarily concerned with

the internal experience of clients and counselors, BSFT is primarily

concerned with interactions, or linked behaviors. Both the interactions between family members and the interactions between the

counselor and family members help the BSFT counselor understand

the problematic interactions in a family. To diagnose a family’s 

problems, the BSFT counselor observes the way families interact in

the present (i.e., process), rather than attending to the details of the

aspects of family life that they discuss (i.e., content). Similarly, to

understand how a counselor interacts with a family, BSFT assumes

that it is extremely difficult to adequately describe interactions

between the counselor and the family, and so requires the use of live

supervision or supervision using videotaped therapy sessions.

The authors’ preference is to collaborate with counselor trainees in

their therapy as a way of teaching BSFT. Therefore, BSFT trainers will

be at the other end of a one-way mirror or a camera to help counselor

trainees with their first BSFT cases. This is called “live supervision.” In

most training settings, the most likely approach to live supervision

will be through a camera. The wide-angle lens camera is set in the

therapy room, and it is connected by cable to a monitor in another

room. In this fashion, the trainer can watch the session live on the

monitor as it is being conducted in the therapy room.

In live supervision, the trainer is a collaborator who, along with the

counselor, takes responsibility for the success of the session. From

time to time, the trainer will knock on the door to have the counselor

come out to discuss the direction of the session and to make recommendations. If phones connect the therapy and viewing rooms, the

trainer is likely to call the counselor trainee with suggestions. Sometimes, in the case of very difficult families, the trainer may actually

join the counselor trainee in the counseling session to co-conduct the

session.

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Appendix A Training Counselors in Brief Strategic Family Therapy

Required Supervision

BSFT was developed and evaluated for efficacy with counselors who

had a lot of supervision. Therefore, to be implemented faithfully,

BSFT must be implemented with plenty of supervision. There are 

several reasons why this is important. First, supervision is a support

system for the counselor. Such support systems can help the trainee

remain faithful to the model. Second, a counselor who works with

families may encounter certain dangers that supervision and/or a

supervisory support system can prevent. The most significant danger

is that the counselor will be incorporated into the family system in a

way that prevents the counselor from helping the family change.

Because of this, beginning and intermediate BSFT counselors must be

supervised abundantly during their therapy sessions. Supervisors are

responsible for ensuring that counselor skills continuously improve

and that counselors are faithful to the BSFT model.

There are four levels of counseling expertise:

■ Trainee

■ Counselor

■ Senior counselor

■ Master counselor

The BSFT trainee is in the early stages of learning. The BSFT counselor

already knows the model but requires additional practice. The senior

BSFT counselor is able to teach the model and may still require occasional supervision. The master BSFT counselor has treated several

hundred families under supervision and is widely recognized as an

excellent teacher. His or her videotaped sessions are used as examples

to train other counselors. The master BSFT counselor conducts live

demonstrations of BSFT in front of large audiences. The master counselor’s skills must be of such high quality that he or she can conduct

a counseling session with an unknown family, at an unknown venue,

in front of a large audience, usually of more than 100 counselors, and

do a great job.

How rapidly counselors advance in their careers depends on the

amount of clinical work they do, the amount of supervision available,

and how diligently they study their own videotapes, participate in

self-study and supervisory groups, and seek additional training. Of

course, how rapidly trainees move from stage to stage also depends

on their beginning level of clinical and family systems expertise and

on the amount of prior family counseling training and experience

they have.

75

Appendix B Case Examples

This appendix presents two examples of families who have undergone BSFT. These families come to therapy with different problems

and illustrate different types of problematic family interactions.

Dissimilar examples are provided to illustrate how BSFT can be used

to work with different types of family problems.

These case examples reflect, as much as possible, the realities of the

cases from which they were drawn. However, all identifying information has been changed to protect the identities of the family members. 

Case Example I: The Guerrero Family

Clinical Presentation The Guerrero family consists of a mother, a father, and 11- and 14-

year-old sons. They were referred to the clinic by the 14-year-old’s

school counselor after he was caught smoking marijuana in the

school bathroom. The counselor visited the home and found the

youngest son and the mother eating dinner. The identified patient

and the father were not there. The mother immediately began to list

excuses why her oldest son was not home when he should have

been. She had trouble accepting what the school counselor had done

and insisted that the teacher who had reported him “has it out for my

son.”

Toward the end of the counselor’s first visit, the father came home. He

ignored his wife and younger son and went directly to the kitchen.

Upon finding no food ready for him, he shouted over his shoulder at

his wife, asking her why she had not made him dinner. When the

father was asked to join the session, he declined, saying that his wife

was in charge of discipline and that she was not doing a good job at

it. The 14-year-old did not come home during the counselor’s visit.

Establishing the When the counselor first arrived at the Guerrero home, he began to 

Therapeutic System join with the mother. He sat at the dinner table with the mother and 

the younger son and validated the mother as she complained about

the father’s disengagement and the oldest son’s out-of-control behavior.

The younger son chimed in periodically about his older brother’s

sour attitude, and the counselor empathized with his grievances.

77
Appendix B Case Examples

Although the counselor’s initial attempts to join with the father were

unsuccessful, the counselor later adopted a more focused approach.

When he spoke to the father, the counselor emphasized that his 

participation was needed to keep his son from getting into more 

serious trouble. The counselor also assured the father that participating in therapy could help reduce his wife’s nagging about his 

disengagement from the family.

Joining with the drug-abusing son was somewhat more difficult. He

resisted the counselor’s first few attempts to join with him over the

phone and was absent from the home during the counselor’s first few

visits. Finally, the counselor approached the adolescent at the park

after he and his father had had a major fight. The counselor assured

the youth that being in BSFT could help ensure that that type of fight

would not happen again.

Diagnosis When the counselor met with the whole family, the mother began to 

tell him about her son’s problems. The counselor asked the mother

to tell her son about her concerns. As the counselor encouraged the

family members to speak with each other, he also observed the patterns of interaction along the following BSFT diagnostic dimensions.

Organization

A strong alliance exists between the mother and her 14-year-old

(problem) son; the father is uninvolved. The children communicate

with the father mostly through the mother. The mother and the father

do not share much time as a couple. The mother is responsible 

for child-rearing nearly all the time. The mother and father ally 

occasionally, but only regarding unimportant issues such as what to

eat for dinner.

Resonance

The mother indicates what her 14-year-old son prefers to eat, and the

mother and her 14-year-old son laugh together, both signs of

enmeshment. The father is frequently “too busy” to participate in family activities, a sign of disengagement. Complaints of family members

about other family members during the interview are highly specific,

a sign of adaptive functioning along this dimension.

Developmental Stage

The children are not allowed to play outdoors at night. The mother

uses her 14-year-old son as her confidante, complaining to him that

his father comes home late. 

Life Context

The father has a demanding job, while the mother finishes her work

early and is home by 3 p.m. The family lives in a high crime neighborhood; drug dealing gangs recruit in the neighborhood. The mother

and father are not involved in arranging or supervising activities for

their adolescent son and his peers. The 14-year-old son is associating

with antisocial youth in the neighborhood.

78
Appendix B Case Examples

Identified Patient

The father comes home late and does not help with chores at home.

His 14-year-old son is rebellious, refuses to do chores at home, and

has conduct problems at home and in school. He also comes home

late, often very excited and irritable. He stays up much of the night

listening to music, then sleeps deep into the day. The 11-year-old son

is a model child. 

Conflict Resolution

Conflicts are diffused through angry blaming and recriminations.

General Discussion of the Diagnosis

In the Guerrero family, the parents have assigned themselves separate role responsibilities. The mother is fully responsible for all child

rearing, while the father’s responsibility in this area is very limited.

Because there appears to be an unspoken agreement between the

parents to be distant from each other, it can be assumed that they both

prefer their separate role responsibilities for their own reasons. This

is maladaptive behavior in terms of child-rearing issues because the

father and mother do not cooperate in parenting functions. Rather, it

may appear that the mother and the troubled son are the ones allied,

with father off on the side. If one looks a little further, it would not

be surprising to find that the same patterns of interaction occur

around content areas other than child rearing. In fact, these kinds of

interactive patterns or structures are almost always found to re-occur

in most aspects of family life. If they occur around one content, they

are almost invariably occurring around most, if not all, contents. The

lack of a strong parental alliance with regard to child-rearing issues

undermines the family’s ability to chart an effective and successful

course of action. This is particularly troublesome when there are

forces external to the family that influence the adolescent’s development of behavior problems. These forces include the adolescent’s

peer group and the behavioral expectations that exist or to which the

youth is exposed outside the home. These ecological forces provide

training and opportunity for a full rebellion on the part of the 

adolescent.

A BSFT intervention will target changing the interactional patterns

that are preventing the family from successfully charting the youth’s

path away from antisocial peer groups and externalizing behaviors.

This intervention involves restoring parental leadership capabilities

by first creating a parental leadership alliance.

In resonance, it becomes clear that because the father is outside of

the mother-child alliance, he is less concerned about what goes on

within that alliance. Because he “stays out,” he is emotionally distant

(disengaged) from both his wife and his son. In contrast to this, the

mother and her 14-year-old son are much closer emotionally and 

psychologically, and, thus, they are likely to be enmeshed. Whether

or not one defines the mother as enmeshed with the son or the

mother and son as disengaged from the father, it is obvious that there

79
Appendix B Case Examples

is a difference in the psychological and emotional distance that exists

between father and mother and father and son on the one hand, and

mother and son on the other.

On the dimension of developmental stage, it appears that the 14-yearold son may be burdened with emotional responsibilities that are

more appropriately assigned to a spouse, such as being the mother’s

confidante. The other child is not allowed out after dark. This seems

appropriate given the dangerousness of the neighborhood.

In this family, the identified patient is sometimes the troubled son

and sometimes the isolated father. While the negativity the mother

and the 14-year-old show toward the father functions to keep him out

of the family, both the mother and father blame their current problems

on their oldest son. If he were not rebellious, their separate role

arrangement would work quite well for each of them. Unfortunately,

conflicts between the mother and the father are not being resolved

because their attempts to address their differences of opinion degenerate into blaming wars. 

Planning Treatment Understanding the dimensions that describe family interactions goes 

Based on Diagnosis a long way toward helping the BSFT counselor define what he or she 

must do as a counselor: diagnose the problem in terms of specific

dimensions of family interactions and then implement strategies to

correct problems along these dimensions. Often some dimensions are

more problematic than others and need to be the greater focus of the

intervention. The counselor diagnosed the oldest son’s drug abuse

problem in terms of ineffective behavior control resulting from:

■ Organization: absence of a parental subsystem that works

together. Mother and father need to be assigned collaborative

tasks that will bring them together.

■ Organization: improper alliances. Boundaries must be strengthened between mother and 14-year-old son.

■ Resonance: maladaptive boundaries in which one parent is too

close (enmeshed) to the problem child, while a second parent is

too far (disengaged) from the spouse and that same child.

Boundaries need to be shifted so that the parents are closer to

one another emotionally and interactionally, the children are

more “in tune” with each other, and a healthy separation exists

between the parents and the children.

■ Developmental Stage: developmental stage may be inappropriate

in that the enmeshed child is burdened and confused by a

spousal role (confidante to mom’s unhappiness with dad). The

counselor should encourage the mother and father to serve as

each other’s support system.

80
Appendix B Case Examples

■ Identified Patient: enmeshed child is identified by the family as

its major problem. The counselor needs to shift the family’s

attention to help family members understand that the “whole

system,” rather than only the adolescent, is part of the problem.

Also, family members need to eliminate negative attitudes and

enabling behaviors they display toward the adolescent identified

patient to “free” him to act in a socially appropriate manner.

■ Life Context: 14-year-old identified patient is involved with a

deviant peer group. The mother, father, and identified patient

should negotiate rules and consequences for the adolescent’s

misbehavior, and boundaries between the family and the outside

world need to be strengthened. Additionally, the parents may

need to be more involved with the parents of their son’s peers

to make it easier to more effectively supervise their adolescent’s

activities.

■ Conflict Resolution: family may have certain conflicts repeatedly

occur and never get resolved because each time differences

emerge, they (sometimes) are avoided and/or (most often) are

diffused through blaming wars. The counselor should refocus

the interaction on the problem each time family members

attempt to avoid the issue or to change the subject so that the

conflict may be negotiated and resolved.

Producing Change Having diagnosed the problem in terms of these dimensions, the 

counselor was able to target interventions directly at the problematic

interactions within these dimensions. One of the BSFT counselor’s

first moves was to help the disengaged father get closer to his

estranged 14-year-old son. At the same time, the counselor initiated a

dialogue between the two parents about this youth to try to establish

an alliance between the parents around the content of their mutual

concern for their son. The next step was help the parents negotiate

rules for the youth that, once implemented, would bring his “outof-control” behavior under control. As these changes were being

negotiated, the family displayed frequent conflict avoidance and 

diffusion. When the family attempted to diffuse or avoid the conflict,

the counselor would intervene and return the topic of conversation

to the original conflict. In the process, the family acquired new conflict

resolution skills. The parents were able to agree on rules and consequences for the identified patient’s behavior, and these were 

discussed and, where appropriate, negotiated between the parents

and the son. Ultimately, the parents were able to set consistent limits,

and the adolescent’s behavior improved.

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Appendix B Case Examples

Case Example II: The Hernandez Family

Clinical Presentation The Hernandez family was referred to the clinic by the public 

defender at the time of Isabelita’s third arrest, this time for drug possession. Isabelita was 15 years old, and she lived with her mother, a

single parent, and a 12-year-old brother. Because the mother only

spoke Spanish, the case was assigned to a Hispanic BSFT counselor

who called the home and heard screaming and fighting in the background. The counselor spoke with the mother, who sounded overwhelmed. When the counselor explained that he was calling to set

up a family session, Ms. Hernandez angrily told the counselor that

she could never get Isabelita to attend.

The counselor asked Ms. Hernandez for permission to come to the

home when she and Isabelita were both likely to be home. Because

Ms. Hernandez worked as a domestic during the day, the appointment

was set for 7 o’clock the next evening. When the counselor arrived

at the home, he found the mother alone with her 12-year-old son. 

Ms. Hernandez explained that Isabelita often stayed out with her

friends, and she could not predict what time Isabelita would be

home. The 12-year-old son was quick to confirm his mother’s story

and added that Isabelita was always upsetting his mother and that he

wished she would just go away.

Establishing the The counselor began to join with Ms. Hernandez by listening to 

Therapeutic System the story of her hardships in this country and with Isabelita. 

Ms. Hernandez said how overwhelmed she felt by Isabelita’s behavior

and that she did not know what she could do. In fact, she said that,

“It is all in God’s hands now,” as if there was nothing else she could

possibly do. It appeared from the story that Ms. Hernandez did not

have well-established rules or consequences for Isabelita’s behavior.

It also appeared that most of the communication that occurred

between daughter and mother was angry, blaming, and fighting. 

Ms. Hernandez felt that they could argue for hours about the same

thing and then have the same argument all over again the next day. 

It was about 8:15 p.m., when Isabelita arrived. It was obvious to the

counselor that her gait was unsteady and her speech was slurred. Her

eyes were red. She barged into the home and went straight to the

kitchen. When Ms. Hernandez said to Isabelita, “Come here, there is

someone here who has come to see you about your arrest,” Isabelita

answered, “F––k them, I am hungry.”

Ms. Hernandez went to the kitchen to serve Isabelita her dinner,

screaming at her “Your food is already cold. You are late again. We

had dinner two hours ago.” The screaming between mother and

daughter continued for another 10 minutes before the counselor

came to the kitchen to attempt to introduce himself to Isabelita, as a

way of extending the joining process. In this first encounter, the

counselor listened and joined.

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Appendix B Case Examples

Diagnosis While the counselor listened and joined, he also observed the interaction between mother and daughter. Armed with these observations,

the counselor understood the family’s interactions along the following BSFT diagnostic dimensions.

Organization

There is a problem with this family’s hierarchy and leadership. The

identified patient is in a powerful position, while the mother is powerless and feels overwhelmed. The mother has no control over the

identified patient’s behavior. There is no sibling subsystem. The 12-

year-old son triangulates between the mother and the identified

patient.

Resonance

The family is very enmeshed. The quality of the enmeshment

between the mother and the identified patient is conflictive and 

hostile.

Developmental Stage

All three members of this family appear to be functioning below what

would be appropriate for their ages and roles. The identified patient’s

demands on her mother are those of a younger child, and she does

not help out at home. The mother is overwhelmed and does not

know how to control the identified patient. The son is too attached

to his mother and involved in supporting her, and he does not

engage in age-appropriate social and play activities. 

Life Context

The family is new to the United States, and the mother is disconnected from her host society (e.g., she has no English skills). The

identified patient spends most of her time with acculturated peers

who participate in drug use and risky sex.

Identified Patient

The identified patient is extremely rigid. The identified patient centralizes herself with her negative behavior. The relationships between the

identified patient and other family members are characterized by

intense negativity. This family has not identified other problems or

persons as a concern.

Conflict Resolution

The typical pattern of interacting in the family is continuous conflict

emergence without resolution.

General Discussion of the Diagnosis

In the Hernandez family, the mother is overwhelmed and is unable

to manage her drug-abusing daughter’s behavior. The daughter, in

turn, has distanced herself from the family and spends the majority

of her time with sexually active and drug-using friends. When the

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Appendix B Case Examples

daughter is home, she and her mother fight constantly, with the

brother intervening to take the mother’s side against his sister. The

brother’s triangulating maneuvers serve only to further isolate the

identified patient from her family.

Cultural issues also need to be taken into account in diagnosing the

Hernandez family. Upon their arrival in the United States from

Colombia 3 years earlier, the members of this family began to drift

apart from one another. Isabelita began learning English and associating with Americanized peers, whereas her mother remained socially

and culturally isolated. Ms. Hernandez had become increasingly

uncomfortable with Isabelita’s acculturating behavior and choices of

friends, but the widening chasm between mother and daughter discouraged Ms. Hernandez from addressing these issues with Isabelita.

By the time Isabelita was referred to treatment, the family system had

become completely dysfunctional, and Ms. Hernandez had ceded

nearly all of her power and authority to her daughter.

Planning Treatment Based on Diagnosis

A powerful identified patient is typically joined first in order to

engage the family into treatment. In this case, however, Isabelita did

not present an engagement problem. Although angry and rebellious

in her behavior, she was present in therapy and willing to voice her

complaints and feelings. The counselor thus starts by joining both the

mother and the identified patient. It is important very early in the

therapy to work to restructure the dysfunctional family hierarchy. By

supporting the mother, the counselor needs to help her break the

cycle of conflict between herself and her daughter so that the mother

can begin to recapture some control. Essentially, the counselor needs

to help move the mother into an appropriate parental role. The

brother’s attempts at triangulation need to be blocked, allowing the

mother and daughter to resolve their issues directly, between the two

of them. This also would permit the brother to engage in more ageappropriate activities. Isabelita’s disobedient behavior needs to be

reframed as a cry for help in order to change the affective tone of her

relationship with her mother, and, thus, to permit them to interact

more positively.

The treatment plan that the BSFT counselor formulated for the

Hernandez family addressed all six of the structural dimensions introduced in Chapter 3:

■ Organization: A dysfunctional hierarchy exists in which the

daughter holds the power and the mother is powerless and overwhelmed. Power must be transferred back to the mother.

■ Organization: The son is triangulated into the relationship

between the mother and the daughter. The son’s attempts to 

triangulate must be blocked.

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Appendix B Case Examples

■ Resonance: The mother and the daughter are enmeshed in a

conflictive and explosive relationship; the daughter’s behavior

must be reframed as a call for help to reduce the negativity.

■ Developmental Stage: The daughter’s behavior at home is immature

and demanding, the son is playing a “mother’s partner” role, and

the mother does not assume appropriate parenting leadership.

The daughter must be shown how to express her feelings, the

mother must be encouraged to elicit and validate the daughter’s

feelings, and the son must be prompted to participate in ageappropriate social activities.

■ Identified Patient: The daughter is designated as the source of

the family’s problems. The problem must be framed in terms of

the whole family and addressed by changing the family’s patterns

of interaction.

■ Life Context: Acculturation differences compound normative 

parent-adolescent disagreements and exacerbate the distance

between the mother and the daughter. The counselor must help

the two of them “get on the same page” in their interactions.

■ Life Context: The daughter is associating with high-risk peers. As

power is transferred back to the mother, peer selection must be

brought up, and the mother needs to encourage the daughter to

select different peers.

■ Life Context: The mother and the son are socially isolated. The

mother needs to familiarize herself with the English language

and with American culture, and the son needs to associate with

friends his own age.

■ Conflict Resolution: The mother and the daughter tend to shout

at and insult one another with no resolution. The family must be

taught to stay on topic and resolve issues without leaving the

room or resorting to personal attacks.

Producing Change One week later, the counselor came for the second session, and the 

same exact incident re-occurred, with Isabelita coming home late,

clearly on drugs. The counselor had already established a therapeutic

relationship with the whole family. While the counselor sat with 

Ms. Hernandez waiting for Isabelita to show up, he used the time to

explain how Ms. Hernandez could respond differently to Isabelita

when she arrived home late (i.e., a reversal). In BSFT, therapy can be

conducted with family members even when the identified patient is

not present, as happened in this case. The counselor coached 

Ms. Hernandez to remain calm, not let Isabelita engage her in a

screaming match, and not provide or help her with food. When

Isabelita arrived, her portion of the family dinner had been placed in

the freezer. Upon her arrival, Isabelita as usual bolted to the kitchen

and demanded food. Encouraged by the counselor, Ms. Hernandez

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Appendix B Case Examples

continued to sit in the living room, which, in their small home, was

just next to the kitchen. Isabelita came into the living room and

began shouting at her mother about the food. The mother yelled

back to Isabelita, “You are a drug addict,” and this began anew the

cycle of blaming and recrimination. The counselor stood up, walked

up to Ms. Hernandez, placed his hand on Ms. Hernandez’s shoulder,

and said, “You need to stay calm and not let her control you with her

fighting.” After several such interventions, Ms. Hernandez finally

looked at the counselor and said, “I am trying to do it, but it is very

hard.” This statement represented Ms. Hernandez’s initial step in

using the counselor to help her detach from the conflict with her

daughter. Furthermore, when the son stepped in, the counselor

encouraged the mother to hold him back as well. 

Isabelita continued to scream at her mother without getting a

response for another 15 minutes before storming to her bedroom in

a fury. Having been unsuccessful in engaging either her mother or

brother in a fight, she was frustrated and gave up. After the counselor

gave the mother ample support and praise for having controlled the

situation and avoided a fight, the counselor moved the conversation

to the next step. He discussed other ways in which Isabelita would

“push her mother’s buttons,” and he gave Ms. Hernandez the task of

using the newly learned skills on these other occasions.

This was a great gain for a single session, and it was clear that the

gains from this session needed to be followed up and extended as

soon as possible. The counselor told Ms. Hernandez that “we can

keep making things better if we meet again in a few days.” To

Isabelita, the counselor said, “You see, these fights between you and

your mom don’t have to happen. If you’ll agree to have me here

again next week, we can keep working toward having peace in your

life.” As a result, both Ms. Hernandez and Isabelita agreed to hold

another session the following week.

At the beginning of the next session, the counselor followed up on

the previous week’s gains by reviewing how Ms. Hernandez and

Isabelita had made progress around the issue of fighting. The counselor

intervened to block the brother’s attempts to triangulate himself into

interactions between Ms. Hernandez and Isabelita. Throughout the

session, the counselor praised Ms. Hernandez whenever she avoided

a fight, and empathized with her when she did not (“I understand

how hard it is, but I know you tried.”). The counselor also praised

Isabelita amply for her ability to follow her mother’s lead in avoiding

fights that are “so upsetting to you.” Hence, both the mother and

Isabelita received credit and praise for accomplishing changes in their

relationship. Having experienced a major accomplishment in placing

the mother in control of the interactions, the counselor was now

ready to move to the next level: negotiation of rules and consequences. The counselor also began to reinforce changes in Isabelita’s

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Appendix B Case Examples

behavior, no matter how small, by showing empathy for “how difficult

all of this must be for you.” The counselor also took an active role in

helping Ms. Hernandez move into a more appropriate parental role

by gradually praising each of the mother’s attempts to guide or set

limits for her daughter. The counselor also consistently reframed

Isabelita’s disrespectful behavior as a cry for help and as her way of

expressing pain.

Gradually, over time, Isabelita’s externalizing behavior and drug

abuse decreased. Ms. Hernandez learned to befriend her daughter

and to remain calm and not engage in conflict (i.e., a reversal) whenever Isabelita would throw a tantrum. Isabelita began to phrase her

complaints in the form of respectful disagreements rather than hostile

attacks. The brother, sensing that the tension between his sister and

mother was decreasing, slowly backed away from the triangulated

relationship with them and began to seek out his own social activities.

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