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Appendices
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 in Basic Clinical Skills Common to Many Behavioral Interventions
Level one training is the kind of training that teaches counselors basic
clinical skills common to many kinds of behavioral interventions, such as:
- Interviewing skills
- Active listening - reflecting back or repeating to the client the
content and feelings the client has expressed
- 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 needs
Level Two: Training in Basic Family Systems Theory
Level two training is the kind of training that is often provided in
clinically oriented, master's level programs in social work, marriage
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: Brief Strategic Family Therapy Specific Training
Counselors who have basic clinical skills and family systems training
can be trained in BSFT concepts and techniques. However, counselors
who lack basic skills training are required to take extensive pre-
requisite 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
- 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,
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.
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.
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 Therapeutic System
When the counselor first arrived at the Guerrero home, he began to
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.
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.
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
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 Based on Diagnosis
Understanding the dimensions that describe family interactions goes
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.
- 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.
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 Therapeutic System
The counselor began to join with Ms. Hernandez by listening to
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.
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
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.
- 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 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
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.
Index
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Therapy Manuals for Drug Abuse:
Manual 5
Contents
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