U.S. Department of Justice

Office of Justice Programs

Office of Juvenile Justice and Delinquency Prevention

John J. Wilson, Acting Administrator

From the Administrator

Just as a child is influenced by his or

her family, the child’s family, in turn, is

affected by the culture of which it is

an integral part. If we are to succeed

in preventing and combating delinquency, we must work to strengthen

the role of the family within the community in which it resides.

This Bulletin features a familystrengthening strategy—brief strategic family therapy—that integrates

theory with decades of research and

practice at the University of Miami in

an intensive, short-term, problemfocused intervention, generally

lasting 3 months.

The Bulletin also describes the

therapy’s implementation by the

Spanish Family Guidance Center.

The Center, which was established

by the University of Miami’s School

of Medicine, serves the local Hispanic community, consisting largely

of Cuban immigrants. In adapting

brief strategic family therapy to the

needs of its clients, the Center took

into account the strengths and weaknesses these minority youth and

families bring to therapy, and those

special risk and protective factors

are also highlighted in these pages.

The needs of families are addressed

most effectively within the social and

cultural milieus of those families.

Brief strategic family therapy is a

time-tested approach to that end.

John J. Wilson

Acting Administrator

April 2000

Brief Strategic

Family Therapy

Michael S. Robbins and José Szapocznik

The Office of Juvenile Justice and Delinquency Prevention (OJJDP) is dedicated to

preventing and reversing trends of increased

delinquency and violence among adolescents. These trends have alarmed the public during the past decade and challenged

the juvenile justice system. It is widely accepted that increases in delinquency and

violence over the past decade are rooted in

a number of interrelated social problems—

child abuse and neglect, alcohol and drug

abuse, youth conflict and aggression, and

early sexual involvement—that may originate within the family structure. The focus

of OJJDP’s Family Strengthening Series is to

provide assistance to ongoing efforts across

the country to strengthen the family unit by

discussing the effectiveness of family intervention programs and providing resources

to families and communities.

The 1970’s witnessed a tremendous increase in the number of Hispanic adolescents involved with drugs. In response to

this problem, the University of Miami (FL)

School of Medicine, Department of Psychiatric and Behavioral Sciences, established the Spanish Family Guidance Center in Miami to provide services to the

local Hispanic community, which was predominately recent immigrants from Cuba.

The Center was initially funded by the

U.S. Department of Health, Education, and

Welfare, Office of Economic Opportunity.

One of the first challenges the Spanish

Family Guidance Center’s clinical program

encountered involved identifying and developing a culturally appropriate and acceptable treatment intervention for Cuban youth with behavior problems. To

understand Cuban culture and how it resembled, and differed from, mainstream

culture, the Center’s staff conducted a

comprehensive study on value orientations. The study determined that the

Cuban community expected a familyoriented approach in which therapists

take active, directive, present-oriented

leadership roles (Szapocznik, Scopetta,

et al., 1978).

The Center’s second challenge involved

developing interventions to help recent

immigrant Hispanic families work together to deal with the stress of acculturation. In these families, it was quite

common for conflicts to emerge or intensify when the children or adolescents

began to behave in ways that were not

consistent with the families’ traditional

cultural values. Typically, these conflicts

occurred as children and adolescents assimilated more rapidly than their parents

to the bicultural environment in which

they were living, and often involved a clash

between the American value of individualism and the Hispanic value of familism.

Such intergenerational (parent versus

Family Strengthening Series
2

adolescent) and cultural differences often

yielded intense conflict within the family

and resulted in parents and adolescents

feeling alienated from one another.

In 1975, the Spanish Family Guidance Center

adopted structural family therapy (SFT) as

its core approach, and SFT has been at the

heart of the Center’s efforts to develop

interventions for use in culturally diverse

contexts (Szapocznik and Kurtines, 1993).

Over time, the structural approach of SFT

has been refined to meet the needs of the

Hispanic community in Miami. For example,

SFT uses treatment methods that are both

strategic (i.e., problem focused and pragmatic) and time limited. Thus, the structural

approach has evolved into a time-limited,

family-based approach that combines both

structural and strategic interventions. This

approach, called brief strategic family

therapy (BSFT), has become the most common intervention used by the Spanish

Family Guidance Center for families that

include youth with behavior problems.

BSFT evolved from more than 25 years of

research and practice at the University of

Miami. The structural orientation of BSFT

draws on the work of Minuchin (Minuchin,

1974; Minuchin and Fishman, 1981; and

Minuchin, Rosman, and Baker, 1978), and

the strategic aspects of BSFT are influenced

by Haley (1976) and Madanes (1981). By

integrating theory, research findings, and

clinical practice, BSFT has been continuously refined to improve its effectiveness

with youth with behavior problems.

Since its modest beginning in a small storefront location, the Spanish Family Guidance Center has grown in response to the

needs of the minority community in Miami. In particular, work with youth with

behavior problems has expanded to include minority families from a variety of

backgrounds, including both Hispanic

(from the Caribbean Islands and Central

and South America) and African American

youth and families. To accommodate this

expansion, the Center for Family Studies

was established as an umbrella organization to serve inner-city minority youth

and families in Miami. The mission of the

Center for Family Studies is to identify the

needs of minority families and develop

and refine culturally appropriate interventions to meet those needs. The Center for

Family Studies uses BSFT to help children

and adolescents with conduct, delinquency, and other behavior-related problems, including alcohol and substance

abuse. To improve youth behavior, BSFT

attempts to change family interactions

and cultural/contextual factors that influence youth behavior problems. BSFT is

based on the fundamental assumption

that the family is the “bedrock” of child

development; the family is viewed as the

primary context in which children learn

to think, feel, and behave. Family relations are thus believed to play a pivotal

role in the evolution of behavior problems

and, consequently, they are a primary target for intervention.

BSFT recognizes that the family itself is part

of a larger social system and—as a child is

influenced by her or his family—the family

is influenced by the larger social system

in which it exists. Sensitivity to contextual

factors begins with an understanding of

the influence of peers, schools, and neighborhoods on the development of children’s

behavior problems. However, BSFT also

focuses on parents’ relationships with

children’s peers, schools, and neighborhoods and on the unique relationships

that parents have with individuals and

systems outside the family (e.g., work or

groups such as Alcoholics Anonymous).

Program Objectives

BSFT has been revised to respond to the

unique strengths and weaknesses minority youth and families in Miami bring to

therapy. Several of these risk and protective factors are described below.

Mitigating Risk Factors

Immigration. Many of the families served

by the Spanish Family Guidance Center

have recently immigrated to the United

States. The immigration process creates

specific problems that must be addressed

in treatment. For example, many families

emigrate in stages; it is not uncommon for

one parent, usually the mother, to come

to the United States alone to establish a

place and economic means for the family,

and then bring the children to this country. For many families, this process is protracted, and they are separated for many

years. Moreover, the reunification process

often fails to meet family members’ expectations. Children are often disappointed

when they arrive in the United States and

see that they are living in an impoverished, dangerous, inner-city community.

Likewise, parents are often disappointed

when they are confronted with angry and

emotionally detached children. As a result, treatment often involves attempting

to reestablish parent-child bonds and create new family structures that include the

parent who was separated from the family.

High conflict. Intense and persistent

conflict is a common characteristic of

families of youth with behavior problems. High levels of conflict interfere

with parents’ ability to resolve problems,

communicate effectively, nurture, and

guide their children. BSFT focuses on

assessing the family’s conflict resolution

style and developing specific interventions to help families negotiate and resolve their differences more effectively.

Inner city. The powerful influence of

neighborhoods cannot be ignored when

working with inner-city youth and families. In fact, accumulating evidence

shows that the positive changes made in

family therapy are often overwhelmed

by the harsh and deteriorated conditions

of the inner city. As a result, the focus of

BSFT has expanded from individual families to include the relationship between

families and the multiple systems that influence children. Developments in the

clinical model have been heavily influenced
3

by the theoretical work of Urie Bronfenbrenner (1977, 1979, 1986) and the

groundbreaking clinical work of Scott

Henggeler and his colleagues (Henggeler

and Borduin, 1990; Henggeler, Melton,

and Smith, 1992). In particular, BSFT has

expanded to include attention to the relationship between families, on one hand,

and schools, peers, juvenile justice agencies, and neighborhoods, on the other.

Enhancing Protective

Factors

Extended families. One of the most effective protective factors is the availability of

strong extended family networks. It is not

uncommon, for example, for treatment to

include grandparents, aunts, uncles, cousins, or even close friends (“fictive kin”) who

grew up with the child’s parents. Although

these networks may also be sources of

problems for the family, they are frequently

sources of strong support. In BSFT, these

networks are often used to bolster or serve

the important functions of the family. For

example, extended family members are

frequently engaged in treatment to help

monitor the children while parents are at

work. At times, members of the extended

family or fictive kin assume primary leadership roles in the family when parents are

unable or unwilling to perform these tasks.

In most instances, BSFT seeks to strengthen

social connections by increasing mutual

support and decreasing tension and conflict between the family and the extended

support network.

Family focus. A second protective factor

that has helped minority families in Miami

is their strong sense of family unity. Highlighting the needs of the family above the

needs of individual family members motivates many adults to participate in interventions. In fact, the Spanish Family Guidance Center initially selected a family

approach because of the Cuban (the target

population in the 1970’s) emphasis on family values. As the Center reached out to

many different Hispanic populations in the

1980’s and to African Americans in the

1990’s, the emphasis on the importance of

families remained consistent. Minority

groups in the United States generally place

great value on their natural reference group

(e.g., family, extended network, or tribe).

Target Population

BSFT targets children and adolescents between the ages of 8 and 17 who are displaying or are at risk for developing behavior

problems, including substance abuse.

BSFT has been implemented as a prevention, early intervention, and intervention

strategy for delinquent and substanceabusing adolescents.

Theoretical

Underpinnings

The goal of BSFT is to improve youth

behavior by:

◆ Improving family relationships that

are presumed to be directly related

to youth behavior problems.

◆ Improving relationships between the

family and other important systems that

influence the youth (e.g., school, peers).

To understand the specific way in which

BSFT produces changes in these relationships and subsequent changes in behavior

problems, it is necessary to understand

some of the basic principles on which BSFT

is based.

Systems

BSFT assumes that each family has its

own unique characteristics and properties that emerge and are apparent only

when family members interact. This family “system” influences all members of the

family. Thus, the family must be viewed as

a whole organism rather than merely as

the composite sum of the individuals or

groups that compose it. In BSFT, this view

of the family system is evident in the following assumptions:

◆ The family is a system with interdependent/interrelated parts.

◆ The behavior of one family member can

only be understood by examining the

context (i.e., family) in which it occurs.

◆ Interventions must be implemented at

the family level and must take into account the complex relationships within

the family system.

Structure

BSFT also focuses on “structure.” While

the concept of a system is useful, one

must understand the system’s basic

structure to recognize the mechanism

through which it operates. Thus, as

noted above, the existence of a system

explains how the behaviors of family

members are interdependent. These interdependent or linked behavioral interactions among individuals tend to recur

and create patterns of interactions

among family members. In BSFT, these

repetitive patterns compose a family

system’s structure. This view of structure

is evident in the following assumptions:

◆ Structure refers to the repetitive patterns of interactions that characterize

the family system.

◆ Repetitive interactions (i.e., ways family members behave with one another)

are either successful or unsuccessful

in achieving the goals of the family or

its individual members.

◆ BSFT targets repetitive patterns of interaction (i.e., the habitual ways in

which family members behave with

one another) that are directly related

to the youth’s behavior problems.

Strategy

BSFT believes in a strategic approach that

uses pragmatic, problem-focused, and

planned interventions. This strategic approach emerged from an explicit focus on

developing an intervention that was quick

and effective in eliminating symptoms. In

BSFT, this strategic approach is evident

in the following assumptions:

◆ Interventions are practical. That is,

interventions are tailored to the unique

characteristics of families and are

implemented to achieve attainable

treatment goals.

◆ Interventions are problem focused. A

problem-focused approach targets first

those patterns of interactions that most

directly influence the youth’s psychosocial adjustment and antisocial behaviors and targets one problem at a time.

◆ Interventions are well planned, meaning

that the therapist determines what seem

to be the maladaptive interactions (i.e.,

interactions that are directly related to

the youth’s behavior problems), determines which of these might be targeted,

and establishes a plan to help the family develop more effective patterns of

interaction.

Process Versus Content

As noted above, BSFT is primarily concerned with identifying and ameliorating

patterns of interaction in the family system

that are presumed to be directly related to

behavioral symptoms. This focus on patterns of interactions is also referred to as a

“process” focus. Rather than focusing simply on what happens in the family (e.g.,

what dad said when he yelled at the children), BSFT focuses on how interactions

occur (e.g., who was involved in the conflict, when it occurred, who responded to

whom, what preceded and followed the
4

incident). This important distinction between process (patterns of interaction) and

content (specific and concrete information)

is a fundamental concept of BSFT. This process focus is evident in the following

assumptions:

◆ Process refers to what behaviors are

involved in an interaction and how

they occur. Secondarily, process refers

to the message that is communicated

by the nature of interactions or by the

style of communication, including all

that is communicated nonverbally,

such as emotion, tone, and the underlying power relationship.

◆ Content refers to the specific and concrete facts used in the communication.

Content includes such things as the

reasons that family members offer for

a given interaction.

◆ BSFT is process oriented at all times.

The emphasis is on identifying the nature of the interactions in the family

and changing those interactions that

are maladaptive.

Components of

Intervention

There are three intervention components in BSFT: joining, diagnosis, and

restructuring.

Joining

Individuals from families that include youth

with behavior problems are very difficult to

engage in treatment. For the past 15 years,

the Center’s staff have focused explicitly on

family resistance and have developed specialized procedures for engaging families in

treatment. These procedures, which are

described in more detail below (see “Engaging Hard-To-Reach Families” on page 8), are

based on two fundamental assumptions:

◆ Engagement or joining begins from the

very first contact with the family.

◆ Resistance can be understood in the

same way as any other pattern of

family interaction.

In BSFT, joining occurs at two levels. First,

at the individual level, joining involves establishing a relationship with each participating family member. Second, at the level

of the family, the therapist joins with the

family system to create a new therapeutic

system. Joining thus requires both sensitivity and an ability to respond to the

unique characteristics of individuals and

quickly discern the family’s governing

processes.

A number of specific techniques can be

used to join the family, including maintenance (e.g., supporting the family’s structure and entering the system by accepting

their rules that regulate behavior), tracking (e.g., using what the family talks about

(content) and how their interactions unfold (process) to enter the family system), and mimesis (e.g., matching the

tempo, mood, and style of family member

interactions).

Diagnosis

In BSFT, diagnosis refers to identifying interactional patterns (structure) that allow or

encourage problematic youth behavior. In

other words, diagnosis determines how the

nature and characteristics of family interactions (how family members behave with

one another) contribute to the family’s

failure to meet its objective of eliminating

youth problems. To derive complex diagnoses of the family, therapists carefully examine family interactions along five interactional dimensions (see the table on pages

6 and 7): structure, resonance, developmental stage, identified patient, and conflict resolution.

Assessment refers to the systematic review

of the detailed or molecular aspects of family interaction to identify specific qualities

in the patterns of interaction of each family

along the five dimensions presented in the

table. In contrast, clinical formulation refers

to the process of integrating the information obtained through assessment into

larger patterns or processes that characterize the family’s interactions. In family systems therapy, clinical formulation explains

the patient’s presenting symptom in relationship to the family’s characteristic patterns of interaction. For example, a child’s

acting out may be seen as resulting from a

lack of parental supervision and monitoring

that, in turn, are influenced by a poor marital relationship and disagreement about

parenting practices.

In addition to the family interactional factors

that are central to BSFT, individual and social factors must be considered for a complete clinical formulation. At the individual

level, psychological factors (e.g., beliefs, attitudes, intelligence, and psychopathology)

and biological factors (e.g., family predisposition toward alcohol abuse or bipolar disorder) must be considered when evaluating

the impact of family interactions on the

problems experienced by youth. Moreover,

other social systems that the family comes

into contact with may have a profound impact on the family, and consequently, must

be considered in the clinical formulation.

For example, youth interactions at school

or with peers and the nature of the neighborhood may serve as powerful risk or protective factors. In addition, one’s parents,

extended family, friends, or career may

serve as sources of strength or stress that

may or may not contribute to the problems

experienced by the youth.

Restructuring

As therapists identify what a family’s patterns of interaction are and how these fit

with individual and social factors, they

make judgments about the relationship between the family’s pattern of interactions

and the youth’s problem behaviors. Based

on these judgments, therapists develop

specific plans for changing the family interactions and individual and social factors

that are directly related to the child’s problem behavior. The ultimate goal of treatment plans in BSFT is to change family

interactions that maintain the problems

to more effective and adaptive interactions that eliminate the problems. BSFT

therapists use a range of techniques that

fall within three broad categories:

◆ Working in the present.

◆ Reframing.

◆ Working with boundaries and alliances.

Working in the present. While some types

of counseling focus on the past, BSFT focuses primarily on the present interactions

that occur between family members and

are observable to the therapist. For example, enactments are a critical feature of

BSFT. Enactments encourage, help, and/or

allow family members to behave or interact

as they would if the therapist were not

present. Very frequently, family members

will spontaneously behave in their typical

way when they fight, interrupt, or criticize

one another. Therefore, when families become rigidly focused on speaking to the

therapist, the therapist should systematically redirect communication to encourage

interactions between session participants.

There are two reasons for encouraging enactments. The first is to permit the therapist to observe problematic interactions

directly rather than relying on stories

about what happens when the therapist

is not present. Clinical experience shows

that families’ stories about how they interact are often very different from their actual interactions.

The second reason for enactments, and

a central tenet of BSFT, is that the therapist is responsible for restructuring (or

transforming) interactions. Frequently,
5

interactions are transformed when the

therapist allows family members to interact and then intervenes in the midst of

these interactions to facilitate the occurrence or emergence of a different, more

positive set of interactions. It is important

to remember that in BSFT, therapists are

not interested in having the family simply

“talk about” behaving differently. Rather,

they are interested in having the family

behave differently during and following

the intervention sessions.

Reframing. Perhaps one of the most interesting, useful, subtle, and powerful techniques in BSFT is reframing. Reframing

creates a different sense of reality; it gives

family members the opportunity to perceive their interactions or situation from

a different perspective. Reframing is a restructuring technique that typically does

not cause the therapist to lose his or her

rapport with the family. For this reason,

reframing should be used liberally throughout the treatment process, especially at the

beginning of treatment when the therapist

needs to bring about changes but is still in

the process of building a working relationship with the family. Reframing serves two

extremely important functions. First, it is a

tool for changing negative and apparently

“uncaring” emotions into positive and caring interactions. This is achieved, for example, by redefining anger and frustration

as the bonds that tie a family together; the

therapist may help a parent recognize that

his or her anger toward a child is based

on love. The other important function is

to shift from a blaming or castigating approach to developing a team spirit that allows family members to acknowledge that

they are in therapy because they care about

one another. One major goal of all restructuring interventions is to create the opportunity for the family to behave in constructive new ways. That is, when the family is

unable to break out of its maladaptive interactions, the therapist’s job is to help the

family interact in a new, more positive, way.

Working with boundaries and alliances.

The lives of youth who use drugs are likely

to include a complex set of alliances that

require intervention. The alliances between

the drug user and other users and sellers

need to be severed, and alliances with individuals who can encourage prosocial behaviors need to be established.

Boundaries are the social “walls” that exist

around groups of people who are allied with

one another and that stand between individuals and groups that are not allied with

one another. Shifting boundaries refers to

changing the patterns of alliance. A common

situation of drug-using youth is a strong alliance with only one parent. The resulting

alliance may cross generational lines and

work against the traditional parental hierarchy. For example, there may be a strong

bond between a youth and her or his

mother (or mother figure). Whenever the

youth is punished by the father (or father

figure) for inappropriate behavior, the

youth may solicit sympathy and support

from the “mother” to undermine the

“father’s” authority and remove the sanction. In a single-parent family, it may be the

grandmother who overprotects the youth

and undermines the parent’s attempts at

discipline. Shifting of boundaries involves:

◆ Creating a more solid bond between

the parents so they will make executive decisions together.

◆ Removing the inappropriate parentchild alliance and replacing it with an

appropriate alliance between both parents or parent figures and the youth

that meets the youth’s needs for support and nurturance.

Implementation

Philosophy

BSFT is based on the assumption that the

family—one of the most important and influential systems in the lives of children and

adolescents—provides the foundation for

child development. As a result, BSFT conceptualizes and intervenes to change youth

behavior problems at the family level. Although BSFT also uses unique interventions

to work with individual family members (see

“One-Person Family Therapy” on page 7), it

attempts to include the entire family in

treatment. In fact, therapists are very active

in trying to engage reluctant family members, particularly during the early phase of

therapy. The basic philosophy is that therapists will be able to understand family problems and treat youth behavior problems

more effectively if they view the family’s

patterns of interaction directly.

Although BSFT therapists are active and

directive, they never do what the family

members can do for themselves. The

therapist’s goal is to move in and out of

family interactions, creating opportunities

in the session that will propel the family’s

interactions in a new, more positive direction. Even in these circumstances, the

therapist moves briefly into a centralized

role and quickly moves out of it. Ideally,

when the therapist leaves the system, the

family will be able to respond positively to

internal and external challenges. Exceptions are allowed when crises occur or

when situations arise that require expert

intervention (e.g., suicidal thoughts or behaviors, family violence/abuse).

A fundamental assumption of BSFT is that

families enter treatment with their own,

naturally occurring, informal networks,

including friends, extended family members,

schools, and work. BSFT therapists examine

these networks to identify potential problems or areas of strength on which to capitalize in therapy. Thus, rather than attempting to hook family members into formal

systems, like social services, that tend to be

transient in nature, BSFT tries to improve

naturally occurring relationships so the

family is more likely to maintain positive

changes when the therapist (or social
6

services agency) is no longer involved

with the family.

Length of Treatment

BSFT is a short-term, problem-focused intervention. The average treatment includes

approximately 12–15 sessions and lasts

about 3 months. For more severe cases,

such as substance-abusing adolescents, the

average number of sessions and length of

treatment may be doubled. It is important

to note, however, that BSFT is not a fixed

“package.” Treatment continues until the

family achieves changes in key behavioral

criteria rather than until it completes a

predetermined number of sessions.

Location of Treatment

Most BSFT work with children with behavior problems occurs in the office. However, some treatment of substance-abusing

adolescents and their families is conducted in the home or community. The

movement to “home-based” treatment results from many factors; therapists must

deal with families that are highly disorganized and/or unmotivated to attend treatments and families that lack the necessary

resources (e.g., transportation, money) to

make it to the office. BSFT does not believe

that home- or community-based treatment

is required for all youth with behavior

problems, but finds that it may be required for more severe cases. Therapists

should never allow the location of treatment (e.g., home, office, schoolyard) to

become an obstacle to treatment.

Development of a

Culturally Specific

Family Approach

Applying BSFT to Hispanic families revealed

how profoundly the process of immigration

and acculturation could affect the family

and each member. To meet this challenge,

an intervention was specifically designed to

address the special stressors and clinical

problems faced by this population.

Bicultural Effectiveness

Training

The Center for Family Studies developed the

bicultural effectiveness training intervention

to enhance bicultural skills in all family members. Bicultural effectiveness training is

specifically designed to ameliorate the

acculturation-related stresses confronted

by two-generation immigrant families

(Szapocznik et al., 1984).

A clinical trial1

 investigated the relative effectiveness of bicultural effectiveness training

in comparison with BSFT (Szapocznik,

Santisteban, et al., 1986b) in improving behavior problems in early adolescence and

family functioning. (Drug-abusing adolescents were excluded from this study because

they were considered beyond the reach of

the intervention.) The results of this study

indicated that bicultural effectiveness training was as effective as structural family

therapy in improving adolescent and family

functioning. These findings suggested that

bicultural effectiveness training could accomplish the goals of family therapy while

focusing on the cultural content that made

the therapy attractive to Hispanic families.

Family Effectiveness Training

Subsequently, BSFT and bicultural effectiveness training were combined into a

Dimensions of Family Functioning* Addressed in Brief Strategic Family Therapy

Hierarchy/Leadership

One parent is more active than the

other.

Child is more powerful than the parents.

Behavior Control

Parents are not engaging in behavior

control when needed or are engaging

in ineffective behavior control (e.g.,

inappropriate consequences, lack of

followthrough, unclear expectations,

inconsistency, or excess emotion).

Guidance/Nurturance

Parents do not nurture children.

Parents are poor role models (e.g.,

engaged in illegal activity, substance

abuse, or violence).

Spousal Alliance

Marital relationship is poor (e.g., high

conflict or disengagement).

Enmeshment

Emotional, psychological, or physical

boundaries between family members

are excessively close.

Disengagement

Emotional, psychological, or physical

boundaries between family members

are excessively distant.

Structure Resonance

Executive Subsystem

Decisionmaking subsystem is absent.

Sibling Subsystem

Relationship between siblings is poor

(e.g., high conflict or disengagement).

Triangulation

Child is stuck in the middle of a

conflict between adults.

Communication

Family lacks direct verbal communication or uses ineffective communication

(e.g., vagueness, sermonizing, or

excess emotion).

One family member serves as a

switchboard operator or gatekeeper.

* Examples of problems in family interaction are listed under each of the five dimensions.

1 This study was funded by National Institute of Mental

Health (NIMH) grant #MN31226.
7

Parenting

Parent is immature.

Children

Child is treated as/acts too young (e.g.,

overly restricted, low requirement/

opportunity for responsible behavior,

or no negotiation allowed).

Child is treated as/acts too old (e.g.,

overloaded with adult tasks or exhibits

parentlike behavior).

Extended Family

Extended family usurps parental power

or treats the parent like a child.

Negativity

Family members are critical about and

negative toward the identified patient.

Centrality

Identified patient is almost always the

central topic of conversation.

Family members are organized around

the identified patient and her/his

problem behaviors.

Support

Family members protect or support

identified patient.

Denial/Avoidance

Family members deny or avoid

conflict.

Diffusion

Family members jump from conflict to

conflict without achieving any depth

regarding one particular issue.

Emergence Without Resolution

Family engages in an indepth discussion about a particular conflict but is

not able to resolve the problem.

Negativity/Conflict

Family interactions are openly critical

or hostile.

Developmental Stage Identified Patient Conflict Resolution

package called family effectiveness training

(Szapocznik, Santisteban, et al., 1986a). A

study2

 investigated the value of family

effectiveness training as a prevention/

intervention strategy for Hispanic families

of children ages 6–11 who presented emotional and behavioral problems (Szapocznik,

Santisteban, et al., 1989). The results of this

study indicated that families in the family

effectiveness training treatment group

showed significantly greater improvement

than did control families on measures

of family functioning, problem behaviors,

and child self-concept. Thus, the intervention was able to improve both child

and family functioning. The improvements

were still in effect at 6-month followup.

Multicultural Effectiveness

Training

Recently, the cultural context in Miami has

become more complex. When bicultural

effectiveness training and family effectiveness training were developed in the 1970’s,

the targeted Cuban-born families lived in a

cultural context that was dominated by

Cuban immigrants and Caucasian Americans. However, by the 1990’s, Miami included Cuban Americans, Cuban immigrants, Caucasian Americans, Latin

Americans from nearly all countries in

the Western Hemisphere, African Americans, and Haitian immigrants. In response

to these changes, the bicultural effectiveness training intervention was redesigned into the multicultural effectiveness training (Mancilla and Szapocznik,

1994) program that helps non-Cuban

Hispanic parents understand the complex cultural context in which they live.

In multicultural effectiveness training, the

challenges faced by non-Cuban Hispanic

families who find themselves in a culture

that is heavily influenced by Cuban Americans are considered for the first time.

One-Person Family

Therapy

Engaging the whole family in treatment is

one of the most challenging aspects of

working with youth with behavior problems

and their families. Thus, developing a procedure that can achieve the goals of family

therapy without having the whole family

present was an important challenge.

To meet this challenge, it was necessary to

question some basic theoretical assumptions of conventional family systems practice. Family systems theory postulates that

the youth’s behavior problems are a symptom of flawed patterns of family interaction.

As such, interventions must change family

interactions that produce problem behaviors in the child. Conventional family systems theorists assume that to change these

interactions, the entire family must be

present in therapy. Thus, the challenge involved developing an approach, One-Person

Family Therapy, that seeks to change family

interactions while working with only one

person (Szapocznik, Kurtines, et al.,

1990; Szapocznik and Kurtines, 1989).

One-person family therapy applies the principle of complementarity, which suggests

that a change in the behavior of one family

member will lead to corresponding changes

in the behavior of other family members.

One-person family therapy uses this principle deliberately and strategically to direct

the identified patient to change his or

her behavior in ways that will lead to 2 This study was funded by National Institute on Drug

Abuse (NIDA) grant #1E0702694.
8

adjustments in the behavior of other family

members toward him or her.

A clinical trial3 examined the effectiveness

of one-person family therapy, comparing

the entire family format with the one-person

format of BSFT (Szapocznik, Kurtines, et

al., 1983, 1986). Both conditions were designed to use the BSFT framework so that

only the number of people would differ.

Results indicated that one-person family

therapy was as effective as the group format not only in improving behavior and

reducing drug abuse in the youth, but

also in improving and maintaining significant improvements in family functioning.

The results of this study demonstrated

that it is possible to change family interactions even when the whole family is not

present at most sessions. It is important

to note, however, that one-person family

therapy was most effective when it was

implemented by expert BSFT therapists.

To implement one-person family therapy,

therapists must be proficient with family

and individual BSFT techniques. Oneperson techniques are very complex and

sophisticated and thus require a therapist

with extensive training and experience in

changing family interactions.

Engaging Hard-ToReach Families

Although it is possible to conduct family

therapy through one person, getting individuals to begin treatment continues to be a

problem. For example, in the clinical trial

discussed above, only 250 of approximately

650 families who met intake criteria on the

basis of a telephone screening began the

intake process. Of this number, 145 completed the intake procedure and only 72

completed treatment. Clearly, a very large

proportion of families who initially seek

treatment never participate in therapy.

Strategic Structural Systems

Engagement

Strategic structural systems engagement

was developed to more effectively engage

drug abusers and their families in treatment

(Szapocznik, Perez-Vidal, et al., 1990;

Szapocznik and Kurtines, 1989). It is based

on the premise that resistance to change

within the family results from two systems

properties. First, the family is a selfregulatory system—that is, the family will

attempt to maintain structural equilibrium

(status quo) which, in the case of drugabusing youth with behavior problems, can

be accomplished by avoiding therapy. Second, while the presenting symptom may be

drug abuse, the initial obstacle to change is

resistance to treatment. The same structural principles that apply to family

functioning and treatment also apply to

understanding and handling the family’s

resistance to treatment (Szapocznik,

Perez-Vidal, et al., 1990). The solution to

overcoming the undesirable “symptom” of

resistance is to restructure the family’s patterns of interaction that permit the symptom of resistance to continue to exist. It is

here that one-person family therapy techniques become useful because the person

requesting help becomes the person

through whom therapy can work to improve the family’s pattern of interaction.

Having accomplished the first phase of

the therapeutic process in which resistance has been overcome and the family,

including the drug-abusing youth, have

agreed to participate in therapy, the

therapist may shift the focus of the intervention toward the removal of behavior

problems and drug abuse.

Clinical work suggests that the patterns

of interaction that permitted the symptoms to exist may be the same patterns

of interaction that keep the families from

entering treatment. Hence, to have the

opportunity to intervene in these hard-toreach families, the therapist using strategic structural systems engagement must

begin the intervention with the first phone

call rather than the first office session.

To test the effectiveness of strategic structural systems engagement in engaging and

retaining Hispanic families with drugabusing youth in treatment, a major clinical trial4

 was conducted (Szapocznik,

Perez-Vidal, et al., 1988). In this study,

strategic structural systems engagement

was compared to an engagement-as-usual

control condition. Clients in the control

condition were approached in a way that

resembled as closely as possible the kind

of engagement that usually takes place in

outpatient centers. There were two basic

findings from the study (Szapocznik, PerezVidal, et al., 1988). First, as figure 1 shows,

the effects of the experimental condition

were dramatic. More than 57 percent of

the families in the engagement-as-usual

condition failed to participate in treatment. In contrast, only 7.15 percent (four

families) in the strategic structural systems engagement condition failed to participate in treatment. The differences in

the retention rates were also dramatic. In

the engagement-as-usual condition, 41

percent of cases did not complete treatment; whereas, in the treatment condition,

17 percent of cases did not complete

treatment. Thus, of all cases assigned to

therapy, 25 percent in the engagementas-usual condition and 77 percent in the

strategic structural systems engagement

condition were successfully completed.

For families that completed treatment in

both conditions, behavioral improvements

4 This study was funded by NIDA grant #DA2059.

Percentage of Families

0

20

40

60

80

100

Engagement

Engagement-as-Usual Control Group

Strategic Structural Systems Engagement Experimental Group

Retention

Figure 1: Differential Engagement and Retention Rates for Strategic

Structural Systems Engagement Experimental Group and

Engagement-as-Usual Control Group

3 This study was funded by NIDA grant #DA0322.
9

by adolescents were highly significant and

these improvements were not significantly

different across the engagement conditions.

The critical distinction between the conditions was in the rates of participation

and completion.

A second major finding of the project

(Szapocznik et al., 1988) was the identification of a number of resistant family

types and the development of intervention strategies for engaging these families

(Szapocznik and Kurtines, 1989).

Replication Study

An additional study5 was designed to replicate these findings and to further explore

the elements of effective interventions

(Santisteban et al., 1996). This study, which

included a large multicultural sample, demonstrated the overall effectiveness of the

specialized engagement interventions discussed above. Significant differences in

rates of engagement were found between

the treatment group and the control group.

In the treatment group, 81 percent of the

families were successfully brought into

treatment. In contrast, 60 percent of the

families assigned to the two control groups

were successfully brought into treatment.

In addition to investigating the overall effectiveness of the specialized engagement

intervention, the study also investigated

the influence of culture/ethnicity on the

multicultural Hispanic sample. The data

suggested varying rates of engagement

across Hispanic groups. Among the nonCuban Hispanics (primarily Nicaraguan, but

also including Colombian, Puerto Rican,

Peruvian, and Mexican) assigned to the

treatment group, the rate of intervention

failure was extremely low (3 percent). Fully

97 percent of the non-Cuban Hispanic families were successfully treated. In contrast,

among the Cuban Hispanic sample assigned

to the treatment group, the rate of intervention failure was relatively high at 36 percent,

with 64 percent of the Cuban Hispanic

families successfully treated.

Comparing Structural

Family Therapy With

Other Types of Therapy

Earlier research concentrated on the development, refinement, and testing of

BSFT theory and strategies. The next

challenge was to compare the relative

effectiveness of BSFT with that of other

widely used clinical interventions. Two

such studies are described below.

BSFT Versus Individual

Psychodynamic Child

Therapy

The first study6 compared the effectiveness of a structural family therapy group

(Minuchin, 1974; Minuchin and Fishman,

1981) with an individual child therapy

group and a recreational activity control

group for children with behavior problems. In addition, this study investigated

the mechanisms for change used by each

type of therapy. Both theoretical approaches assume underlying causes of

symptoms and try to eliminate or reduce

symptoms. However, each form of therapy

uses a different approach to reducing

symptoms. The individual child approach

postulates that the child’s internal (i.e.,

emotional, cognitive) functioning needs to

be modified to eliminate the symptoms.

BSFT, on the other hand, postulates that

family interactions need to be modified

to eliminate the symptoms. Because of

these important theoretical differences,

this study explored the impact of each

form of therapy on child psychodynamic

functioning and family interactions.

The analysis revealed several important

findings. First, members of the recreational

activity (control) group were significantly

more likely to drop out than members of

the two treatment conditions, with more

than two-thirds of dropouts belonging to

the control group. Second, the two forms

of therapy were equally effective in reducing behavior and emotional problems.

A third finding demonstrated the greater

effectiveness of BSFT over child therapy in

protecting family integrity in the long term

(see figure 2). In this study, psychodynamic

therapy was found to be effective in reducing symptoms and improving child psychodynamic functioning, but it was also found

to result in undesirable deterioration of

family interactions. The findings supported

the BSFT assumption that treating the

whole family is important because it reduces the symptoms and protects the family, versus treating just the child, which may

cause family interactions to deteriorate.

Structural Family Therapy

Versus Group Counseling

A second clinical trial compared the effectiveness of BSFT with that of a control

condition delivered in a group format

(Santisteban et al., 1996). This study also

investigated whether changes in family

functioning were responsible for the

changes observed in youth behavior.

Youth who received BSFT showed significantly greater improvement in behavior

(p<.05) than youth assigned to group counseling. In fact, youth in BSFT showed significant improvements in conduct disorder

and socialized aggression, while youth in

group counseling did not.

Figure 2: Comparison of Family Functioning at Pretest, Posttest, and

1-Year Followup for Youth Assigned to Brief Strategic Family

Therapy, Individual Child Therapy, and Recreational Control

Group

Note: The three points on each line designate the following events: pretest, posttest,

and 1-year followup, in that order.

5 This study was funded by NIDA grant #DAO5334.

6 This study was funded by NIMH grant #DA34821. Level of Family Functioning*

15

16

17

18

Timepoint

Brief Strategic 

Family Therapy

Control Group

Individual Child 

Therapy

14

*Numbers on this axis reflect the family’s functioning on five dimensions of family interaction.

Higher numbers represent healthier, more adaptive family functioning.
10

A Structural Approach

to Changing the Social

Context of Families

As the needs of families change, the

theoretical and clinical work of the Center for Family Studies continues to

evolve. The Center has expanded and

adjusted its interventions in response to

declining inner-city social conditions, the

multiple problems faced by minority

families, and the complex contextual factors that affect behavior problems. The

Center is developing a structural approach for changing the social context of

families that works more effectively with

minority youth with behavior problems

and their families.

Theoretical Background

The Center for Family Studies uses

the theoretical work of Bronfenbrenner

(1977, 1979, 1986) and the multisystemic,

service-oriented approach of Henggeler and

colleagues (Henggeler and Borduin, 1990;

Henggeler, Melton, and Smith, 1992).

Bronfenbrenner examined the complexity

of contexts, especially the relationships

between various systems that affect an

individual. In doing so, he identified and

defined “microsystems” as those systems

that have direct contact with the individual.

For a child, microsystems include the family,

school, and peers. He defined “mesosystems” as those systems that occur when

microsystems interact. One example of a

mesosystem occurs when the parents and

school collaborate on a child’s education.

Another example of a mesosystem occurs

when parents and peers interact (e.g., when

parents organize and supervise peer activities). “Exosystems” are defined as those

systems that affect family members and,

through their impact on family members,

affect the child. Examples of exosystems

are a mother’s workplace or her natural

support network.

Bronfenbrenner’s theory highlights the

pivotal role of context in the life of a

child and her or his family members.

Moreover, this theory helps to explain

how culture influences all other social

contexts and provides a framework for

developing culturally sensitive interventions that take into account the complex

influence that cultural factors have on

minority families.

Most of the current work at the Center

for Family Studies reflects an increasing

understanding of ecosystemic influences

on youth behavior problems. In fact,

several ongoing ecosystemic prevention

and intervention projects are being

implemented in schools and neighborhoods to address children’s behavior

problems. In place of a review of each of

these programs, one program that exemplifies the ecosystemic philosophy is described below.

The Family Alliance Project.7 The Family Alliance Project study is investigating the effectiveness of ecosystemic

family therapy compared with traditional family therapy and a community

control group. The experimental intervention, structural ecosystems therapy,

organizes the life context of the drugabusing youth using Bronfenbrenner’s

social ecology framework and the theoretical principles of BSFT—that is, patterns of interaction are examined within

and outside the family. Structural ecosystems therapy includes a full dose of

BSFT (e.g., alliance, hierarchy, communication flow, personal and subsystem

boundaries, developmental stage, identified patient, conflict resolution style,

and abilities). However, interventions go

beyond the family to target other critical youth interactions. In particular, the

youth’s relationships with school authorities and prosocial versus antisocial

peers are examined. At the mesosystem

levels, the relationships between parents and school, parents and their

children’s peers, and parents and the

juvenile justice system are considered.

At this mesosystem level, the extent to

which the different systems support one

another, or are in conflict with one another, is critical. For example, in the

parents-peers mesosystem, parents may

know the peers, organize supervised

peer activities, and know the parents of

their child’s peers. Parents may participate in community organizations that

provide organized, supervised peer

activities.

Results of the interventions suggest that

it is possible to affect youth conduct

problems at home and school by correcting patterns of interaction in the family

and school microsystems and the familyschool mesosystem; reducing youth drug

abuse also requires improving interactions in the peer microsystem and

family-peer mesosystem.

Conclusion

In the evolution of BSFT, the Center for Family Studies has sought to integrate theory,

application, and research. The Center’s work

began in the 1970’s to address an issue of

growing concern: promoting culturally

competent therapists and therapies to address behavior and drug abuse problems

among Miami’s Hispanic youth. Since then,

the Center has achieved important breakthroughs in assessment, engagement, treatment, and prevention, which have provided

a solid foundation from which to pursue new

advances in the field. Refinement of structural family theory strategies and goals in

BSFT, in turn, enabled the Center to modify

these strategies to achieve the same goals

without having the entire family in therapy,

thus making one-person family therapy possible. Changing family interactions by working primarily with one person led to a breakthrough in engaging hard-to-reach families

in treatment.

The work of the Center for Family Studies

will help therapists develop new strategies to support minority families. As the

needs of families change, work in the field

needs to continue to evolve to address

the multiple problems minority families

will continue to confront. The Center operates under the assumption that “it takes a

village to raise a child.” It is necessary

both to create a “village,” or community,

that can support healthy child development and to modify policies and systems

that provide services to the community.

Bronfenbrenner (1979) wrote, “Seldom is

attention paid to the person’s behavior in

more than one setting or to the way in

which relations between settings can affect what happens within them” (p. 18).

He suggested that an individual’s environment is composed of a complex set of

nested structures. Scientists involved in

intervention must consider the social and

cultural context in which treated families

live. The Center for Family Studies’ development of theory, research, and services

within the complex community is based

on this priority.

References

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7 This study was originally funded as a treatment development project by Center for Substance Abuse

Treatment grant #1 HD7 TI00417; it is currently funded

by NIDA grant #1 RO1 DA10574.
11

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Acknowledgments

This Bulletin was written by Michael S. Robbins, Ph.D., Research Assistant

Professor, and José Szapocznik, Ph.D., Professor and Director, Center for Family

Studies, Affiliation University of Miami School of Medicine, Department of

Psychiatry and Behavioral Sciences.

Photograph page 2 copyright © 1999 Artville; photograph page 5 copyright © 1999

PhotoDisc, Inc.

Points of view or opinions expressed in this

document are those of the authors and do not

necessarily represent the official position or

policies of OJJDP or the U.S. Department of

Justice.

The Office of Juvenile Justice and Delinquency Prevention is a component of the Office of Justice Programs, which also includes

the Bureau of Justice Assistance, the Bureau

of Justice Statistics, the National Institute of

Justice, and the Office for Victims of Crime.
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