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

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 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).

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 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 Influences

Family influences may be experienced as an "invisible force." Family 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.

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 of Complementarity

The idea that family members are interdependent, influencing and 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.

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 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.

The Three Ps of Effective Strategy

As its second word suggests, a fundamental concept of Brief Strategic 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.

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.

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.

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