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” ), 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, 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 parent-child 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.

Brief Strategic Family Therapy	Juvenile Justice Bulletin • April 2000