Brief Strategic Family Therapy

The fifth manual in the Therapy Manuals for Drug Addiction series, produced by the National Institute on Drug Abuse, called "Brief Strategic Family Therapy for Adolescent Drug Abuse" has an introduction for counselors to concepts that are needed for understanding the family as "a vital context within which adolescent drug abuse occurs."  Strategies are described for creating a relationship with families that is therapeutic, for assessment and diagnosis of patterns of family interaction that are maladaptive, and changing patterns of family interaction from maladaptive to adaptive.  "This manual assumes that therapists who adopt these BSFT techniques will be able to engage and retain families in drug abuse treatment and ultimately cause them to behave more effectively."  The following is directly from the manual and is in the public domain.

An Overview

Brief Strategic Family Therapy (BSFT) is a brief intervention used to treat adolescent drug use that occurs with other problem behaviors.  These co-occurring problem behaviors include conduct problems at home and at school, oppositional behavior, delinquency, associating with antisocial peers, aggressive and violent behavior, and risky sexual behavior.

BSFT is based on three basic principles.  The first is that BSFT is a family system approach.  Family systems means that family members are interdependent:  What affects one family member affects other family members.  According to family systems theory, the drug-using adolescent is a family member who displays symptoms, including drug use and related co-occurring problem behaviors.  These symptoms are indicative, at least in part, of what else is going on in the family system.  Just as important, research shows that families are the strongest and most enduring force in the development of children and adolescents.  For this reason, family-based interventions have been studied as treatments for drug-abusing adolescents and have been found to be efficacious in treating both the drug abuse and related co-occurring problem behaviors.

The second BSFT principle is that the patterns of interaction in the family influence behavior of each family memberPatterns of interaction are defined as the sequential behaviors among family members that become habitual and repeat over time.  An example of this is an adolescent who attracts attention to herself when her two caregivers (e.g., her mother and grandmother) are fighting as a way to disrupt the fight.  In extreme cases, the adolescent may suffer a drug overdose or get arrested to attract attention to herself when her mother and grandmother are having a very serious fight. 

The role of the BSFT counselor is to identify the patterns of family interaction that are associated with the adolescent's behaviour problems.  For example, a mother and grandmother who are arguing about establishing rules and consequences for a problem adolescent never reach an agreement because the adolescent disrupts their arguments with self-destructive attempts to get attention.

Therefore, the third principle of BSFT is to plan interventions that carefully target and provide practical ways to change those patterns of interaction (e.g., the way in which mother and grandmother attempt but fail to establish rules and consequences) that are directly linked to the adolescent's drug use and other problem behaviors.

 

Why Brief Strategic Family Therapy?

The scientific literature describes various treatment approaches for adolescents with drug addictions, including behavioral therapy, multi-systemic therapy, and several family therapy approaches.  Each of these approaches has strengths.

  • BSFT's strengths include the following:
  • BSFT   is an intervention that targets self-sustaining changes in the family environment of the adolescent.  That means that the treatment environment is built into the adolescent's daily family life. BSFT can be implemented in approximately 8 to 24 sessions.  The number of sessions needed depends on the severity of the problem.

  • BSFT has been extensively evaluated for more than 25 years and has been found to be efficacious in treating adolescent drug abuse, conduct problems, associations with antisocial peers, and impaired family functioning.
  • BSFT is "manualized," and training programs are available to certify BSFT counselors.
  • BSFT is a flexible approach that can be adapted to a broad range of family situations in a variety of service settings (e.g., mental health clinics, drug abuse treatment programs, and other social service settings) and in a variety of treatment modalities (e.g., as a primary outpatient intervention, in combination with residential or day treatment, and as an aftercare/continuing care service to residential treatment). 
  • BSFT appeals to cultural groups that emphasize family and interpersonal relationships

     

    What Are the Goals of Brief Strategic Family Therapy?

    In BSFT, whenever possible, preserving the family is desirable.  While family preservation is important, two goals must be set: to eliminate or reduce the adolescent's use of drugs and associated problem behaviors, known as "symptom focus," and to change the family interactions that are associated with the adolescent's drug abuse, know as "system focus."  An example of the latter occurs when families direct their negative feelings toward the drug-abusing youth.  The parents' negativity toward the adolescent directly affects his or her drug abuse, and the adolescent's drug abuse increases the parents' negativity.  At the family systems level, the counselor intervenes to change the way family members act toward each other (i.e., patterns of interaction).  This will prompt family members to speak and act in ways that promote more positive family interaction, which, in turn, will make it possible for the adolescent to reduce his or her drug abuse and other problematic behaviors.

     

    What Are the Most Common Problems Facing the Family of a Drug-Abusing Adolescent?

    The makeup and dynamics of the family are discussed in terms of the adolescent's symptoms and the family's problems. 

    The Family Profile of a Drug-Abusing Adolescent

    Research shows that many adolescent behavior problems have common causes and that families, in particular, play a large role in those problems in many cases.  Some of the family problems that have been identified as linked to adolescent problem behaviors include:

    Some adolescents may have families who had these problems before they began using drugs.  Other families may have developed problems in response to the adolescent's problem behaviors.

    Because family problems are an integral part of the profile of drug-abusing adolescents and have been linked to the initiation and maintenance of adolescent drug use, it is necessary to improve conditions in the youth's most lasting and influential environment: the family.  BSFT targets all of the family problems listed above.

    The Behavioral Profile of a Drug-Abusing Adolescent

    Adolescents who need drug abuse treatment usually exhibit a variety of externalizing behavior problems.  These may include:

    ·         School truancy

    ·         Delinquency

    ·         Associating with antisocial peers

    ·         Conduct problems at home and/or school

    ·         Violent or aggressive behavior

    ·         Oppositional behaviors

    ·         Risky sexual behavior

    Negativity in the Family

    Families of drug-abusing adolescents exhibit high degrees of negativity.  Very often, this negativity takes the form of family members blaming each other for both the adolescent's and the family's problems.  Examples might include a parent who refers to her drug-abusing son "no good" or "a lost cause."  Parents or parent figures may blame each other for what they perceive as a failure in raising the child.  For example, one parent may accuse the other of having been a "bad example," or for not "being there" when the youngster needed him or her.  The adolescent, in turn, may speak about the parent accused of setting a bad example with disrespect and resentment.  The communication among family members is contaminated with anger, bitterness, and animosity.  To the BSFT counselor, these signs of emotional or affective distress indicate that the work of changing dysfunctional behaviors must start wit changing the negative tone of the family members' emotions and the negative content of their interactions.  Research shows that when family negativity is reduced early in treatment, families are more likely to remain in therapy.

    What Is Not the Focus of Brief Strategic Family Therapy?

    BSFT has not been tested with adult addicts.  For this reason, BSFT is not considered a treatment for adult addiction.  Instead, when a parent is found to be using drugs, a counselor needs to decide the severity of the parent's drug problem.  A parent who is moderately involved with drugs can be helped as part of his or her adolescent's BSFT treatment.  However, if a parent is drug dependent, the BSFT counselor should work to protect and disengage the adolescent from the drug dependent parent.  This is done by creating an interpersonal wall or boundary that separates the adolescent and non-drug-using family members from the drug dependent parent(s). 

     

    Basic Concepts

     Context

    The social influences an individual encounters have an important impact on his or her behavior.  Such influences are particularly powerful during the critical years of childhood and adolescence.  The BSFT approach asserts that the counselor will not be able to understand the adolescent's drug-abusing behavior without understanding what is going on in the various contexts in which he or she lives.  Drug-abusing behavior does not happen in a vacuum; it exists within an environment that includes family, peers, neighborhood, and the cultures that define the rules, values, and behaviors of the adolescent.

    Family as Context

    Context, as defined by Urie Bronfenbrenner, 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.

    Peers as Context

    Considerable research has demonstrated the influences that friends' attitudes, norms, and behaviors have on adolescent drug abuse.  Moreover, drug-using adolescents often introduce their peers to and supply them with drugs.  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 drug-using or delinquent 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 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.  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. 

    Counseling as Context

    The counseling situation itself is a context that is associated with a set of rules, expectations, and experiences.  The cultures of the client (i.e., the family), the counselor, the agency, and the funding source can all affect the nature of counseling as can the client's feelings about how responsive the "system" is to his or her needs.

    Systems

    Systems are a special case of context.  A system is made up of parts that are interdependent and interrelated.  Families are systems that are made up of individuals (parts) who are responsive (interrelated to each other's behaviors. 

    A whole Organism

    "Systems" implies that the family must be viewed as a whole organism.  In other words, it is much more than merely the sum of the individuals or groups that it comprises.  During the many years that a family is together, family members develop habitual patterns of behaviour 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.  Their 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 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--perfect, predictable fit.

    Family Systemic Influences

    Family influences may be experienced as an "invisible force."  Family members' behavior can vary considerable.  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 there mutual influences as family members both serving as stimuli for and eliciting responses from one another.  The theoretical approach underlying existential family treatments might describe this influence as family members either supporting or constraining the growth of other family members.  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.  Only when parents change their behavior and stop reinforcing or "complementing" negative behavior will the child change.

     Structure: Patterns of Family Interaction

    An exchange among family members, either through actions or conversations, is called an interaction.  In time, interactions become habitual and repetitive, and thus are referred to as patterns of interaction.  Patterns of family interaction are 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 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 performs their particular actions.  The family's structure is the script for the family to play.

    Families of drug-abusing adolescents tend to have problems precisely because they continue to interact in ways that allow the youths to misbehave.  BSFT counselors see the interactions between family members as maintaining or failing to correct problems, and so they make these interactions the targets of change in therapy.  The adaptiveness of an interaction is defined in terms of the degree to which it permits the family to respond effectively to changing circumstances

     

    Strategy

    The Three Ps of Effective Strategy

    As its second word suggests, a fundamental concept of Brief Strategic Family Therapy is strategy.  BSFT interventions are strategic 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 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 the 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 there cases, it is important for the counselor to carefully observe the distinction between "content" and "process".  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 families 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 this 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.

     Content Versus Process: A Critical Distinction

    In BSFT, the "content" of therapy refers to what family members talk about, including their explanations for family problems, beliefs about how problems should be managed, perspectives about who or what causes the problems, and other topics.  In contrast, the "process" of therapy refers to how family members interact, including the degree to which family members listen to, support, interrupt, undermine, and express emotion to one another, as well as other ways of interacting.  The distinction between content and process is absolutely critical to BSFT.  To be able to identify repetitive patterns of interaction, it is essential that the BSFT counselor focus on the process rather than the content of therapy.

    Process is identified by the behaviors that are involved in a family interaction.  Nonverbal behavior is usually indicative of process as is the manner in which family members speak to one another. 

    Process and content can send contradictory messages.  For example, while an adolescent may say, "Sure Mom, I'll come home early," her sarcastic gesture and intonation may indicate that she has no intention of following her mother's request that she be home early.  Generally, the process is more reliable that 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 processes rather than just hear the content when Mom tells the therapist can observe therapist what her son did.  Observations like these will help the therapist characterize the problematic interactions in the family. 


    Source:  NIH Pub. No. 03-4751, Printed September 2003

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