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Strictly speaking, structural couple therapy (SCT) does not exist as a distinct approach for the treat- ment of couples. Structural family therapy, the “parent” model from which SCT derives, was developed (as its name indicates) as a treatment for families, not couples. As I detail here, SCT’s application of the conceptual apparatus and inter- ventive technology of structural family therapy to the treatment of couples entails some distinct strengths for the model, but at least one weakness as well.
BACkground
Structural family therapy emerged during the 1960s and 1970s out of the dissatisfaction with psychoanalysis experienced by Salvador Minuchin in his attempts to treat children. As Minuchin and his colleagues began to meet with the families of troubled children, they began to question the core psychoanalytic assumption that human behavior is driven from the inside out, by internal psycho- dynamics. Joining other early systems theorists, they began to experiment with an “outside-in” understanding of human behavior. For example, rather than viewing a child’s impulsive, acting- out behavior as a response to internal dynamics, Minuchin and his colleagues began to experiment with seeing the behavior as a child’s response to, say, a parent’s overly controlling, intrusive behav-
ior. However, the parent’s intrusive behavior could equally be viewed as a response to the child’s act- ing out. Thus Minuchin and his colleagues found themselves migrating from a psychoanalytic world of “linear causality” ( A causes B ), in which each person’s behavior is caused by his or her internal psychodynamics, to a systemic world of “circular causality” ( A causes B , which causes A , which causes B ,.. .), in which each person’s behavior, at one and the same time, is both an effect and a cause of the interactional partner’s behavior. As promising as Minuchin’s group found the new systemic perspective forged by theorists like Don Jackson and Gregory Bateson to be, they were dissatisfied with the focus on the interac- tional dynamics of dyads that had character- ized the work of these theorists up to that point. Minuchin’s group found the concepts developed by these theorists unequal to the task of compre- hensively describing the interactional dynamics in systems consisting of more than two people. With no published literature to guide them, Minuchin and his colleagues undertook to develop concepts of their own that would bring a systemic way of thinking to bear on whole families, rather than just dyads. In the theory that they developed, the family is depicted as a system that comprises “subsystems,” which arise in families as a result of differences (Minuchin, 1974). Generational differences, for example, produce parental and sibling subsystems.
C h a p t e r 1 3
structural Couple Therapy
George M. Simon
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Precisely because they are produced by differences, subsystems were conceived by Minuchin’s group as being surrounded by “boundaries,” which demar- cate subsystems one from another. The internal differences that give rise to sub- systems are potentially a good thing for the fam- ily. That this is so becomes clear when we realize that the family is itself only a subsystem— of an extended family, possibly, but certainly a subsys- tem of the broader society in which it is immersed. A family is functional to the degree that it nur- tures in its members the ability to negotiate well the demands of the world outside the family (Minuchin & Fishman, 1981). Performing this task of socialization requires that the family be able to adapt itself to changes in its social envi- ronment. However, it also requires that the family, when necessary, be able to exercise some agency in changing its environment, with an eye toward rendering the environment more supportive of the family’s functioning. The family system is better equipped to engage in this kind of complex interaction with the out- side world if it has access to as many internal resources as possible. This is why the presence of internal differences that give rise to subsystems is potentially good news for the family. A family with a significant array of complexly cross-linked subsystems should find itself richly endowed with resources to manage its dealings with the outside world. Such will be the case, however, if, and only if, the various subsystems interact with each other in a way that allows the family as a whole to benefit from the resources contained in each subsystem. To describe and to assess how adaptively fam- ily subsystems interact with each other, Minuchin (1974) proposed that we think of the boundaries that demarcate subsystems one from another as varying in permeability, from diffuse to rigid. A “diffuse” boundary between two family subsystems is one that does not adequately differentiate the functioning of the two subsystems, resulting in a deprivation of resources to the family as a whole. The presence of a diffuse boundary can be assessed when two family subsystems have no clear division of labor and/or focus between them. Subsystems separated by a diffuse boundary are said to be “enmeshed.” Equally debilitating to the family is the pres- ence of “rigid” boundaries between subsystems. Here, differentiation has been carried to the point that resources in one subsystem are unavailable to the other. Subsystems separated by a rigid bound- ary are said to be “disengaged.”
The constellation of subsystems in a family, along with the boundaries, whether diffuse, adap- tive, or rigid, that separate the various subsystems from each other, are collectively referred to as the “structure” of the family. It must be kept in mind that in devising the heuristic metaphors of family structure, subsystems, and boundaries, Minuchin and his colleagues remained anchored in the assumptive world of systems thinking. Thus cir- cular causality was seen as governing transactions both within and between subsystems.
FunCTionAl–dysFunCTionAl Couples
Most readers no doubt realize that this brief over- view of structural family therapy’s foundational concepts does not include the couple as an explicit unit of analysis. This omission was not an over- sight. To reiterate the point made at the beginning of this chapter, structural therapy is, first of all, a therapy of families, and only derivatively a therapy of couples. When structural theorists consider couple func- tioning, they do so after having first articulated a view of family functioning. Inevitably, then, struc- tural theorists’ view of couples, both functional and dysfunctional, is set against the background of the theory’s view of families. The couple is viewed as a family subsystem, no more and no less, and assessment of how well or poorly a couple is func- tioning is based on the theory’s notion of what constitutes adaptive functioning for any and all family subsystems. This conceptual arrival in the world of couple- hood, after a journey through the world of family life, entails a distinct theoretical strength and one practical weakness for SCT. I describe the deficit— and, I hope, begin to remediate it—later in the chapter. Here, I briefly describe the strength. Because SCT views the couple as a subsystem (perhaps of a family including children, perhaps of an extended kinship network, certainly of numer- ous societal-level systems), the approach does not base its understanding of the couple on a notion of romantic love. Structural theorizing about the couple recognizes that the ways people form couples and their expectations in doing so have varied dramatically from time to time and from place to place over the course of human history (Minuchin, Lee, & Simon, 2006). The notion that optimal couple relating is based on mutually expe- rienced and reciprocally expressed romantic love is of rather recent vintage. Although this notion has
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treatment: The problem lies in a structure charac- terized by boundaries, within and around the cou- ple subsystem, that are maladaptively diffuse and/ or rigid. There is no camouflaging the fact that this notion of where to look for malfunction in the couple is brought to the therapy by the therapist, not the clients. What the clients do bring, how- ever, is their own assessment that there is, in fact, something malfunctioning in their life together, expressed in their self-generated defining into existence of a “problem” that they judge merits the commencement of couple therapy. In order for these ideas to provide the buf- fer against therapeutic colonialism that they are intended to provide, the very first thing that the SCT therapist must determine when meeting a new client couple is whether their presenting problem is genuinely self-defined by the couple, or has been defined for them by some external agent, who also has the power to coerce them into therapy (e.g., a family court judge or a child pro- tective services worker). Thus, before engaging in the project of assessment, it is incumbent on the therapist to join with a client couple sufficiently to allow its real customership for therapy to be revealed (Sciarra & Simon, 2008). If it becomes clear to the SCT therapist that the couple’s presenting problem has been defined for the partners, rather than having been self-defined, he or she should not proceed into therapy-as-usual mode. In particular, the therapist should assidu- ously avoid assessing the couple, using the model’s structural notions. Instead, the therapist can offer his or her services to help the couple members remove themselves from the supervision of the outside agent who has pushed them into therapy (Sciarra & Simon, 2008). Therapy “proper,” and with it, the use of SCT’s notions of functional and dysfunctional couple structure, commences if and only if the couple members at some point volun- teer to the therapist that they do, in fact, have a self-defined problem that has been a concern to them and that they would like to make the focus of treatment.
Development of Dysfunctional Structure
So what is SCT’s explanation for the fact that whereas some couples crystallize an adaptive structure, others drift into an organization char- acterized by the dysfunctional features just listed? Structural theory has something to say about when couples are susceptible to developing a dysfunc- tional structure. Periods in a couple’s life when
partners experience a press for change, originat- ing either from a normative life cycle transition (e.g., the arrival of a first child, the leaving home of a young adult child) or from some acute stressor (e.g., the occurrence of a natural disaster, extended unemployment of one of the partners), are seen in structural theory as periods when the couple is at risk of developing a dysfunctional structure. How- ever, as regards why some couples respond to such periods adaptively, while others do not, structural theory is relatively mute. In large measure, SCT’s silence on this mat- ter reflects the model’s nondeterministic outlook on the development of human systems. Precisely because human systems are human , they are com- plex, multifaceted entities, whose development over time cannot be subjected to the kind of rigorous modeling that is required to make accu- rate predictions. The structure exhibited by any given couple subsystem at any given point in its development is the product of the complex and largely idiosyncratic interplay of numerous factors, including the family-of-origin histories of the indi- vidual partners, the partners’ respective biological endowments, the sociocultural environment in which the couple is immersed, chance events that have influenced the couple’s life, and (not least) the couple’s decisions about how to deal with all of these factors. A corollary of SCT’s nondeterministic outlook on couple development is the belief that a given couple’s structure at any point in its development could always have turned out to be something dif- ferent from what it is. A different decision made by the couple, a different response to some exigency of the couple’s life, would have resulted in the crystallization of a different structure. This belief entails a crucial implication for the way SCT is conducted. Structural therapy is thoroughly informed by what I have termed an “assumption of competence” (Simon, 1995). No matter how dys- functional the structure that a couple exhibits at the outset of treatment, it is never assumed that this structure reveals some essential, core quality of the couple. Because SCT assumes that the couple could have evolved a structure different from the dys- functional one now being displayed, it also assumes that the couple possesses in its relational repertoire adaptive resources that currently lie dormant. SCT is not, therefore, an attempt to put something new into a couple viewed as deficient; rather, it is an attempt to activate what is already there, but latent, in a couple viewed as fundamentally com- petent. I soon demonstrate what a thorough-going
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influence this assumption of competence has on the way SCT is practiced.
The prACTiCe oF sCT
As is the case with every model of psychotherapy, the process of therapy prescribed by SCT follows rigorously from the way the model conceptualizes human functioning. The mechanism of therapeu- tic change in SCT, the structure of the therapy pro- cess, the way assessment is conducted and the goals set, the role of the therapist, and the therapeutic techniques employed all flow from the model’s sys- temic conceptualization of couple functioning.
Mechanisms of Change
As noted earlier, structural therapy fully endorses the concept of circular causality. In the view of SCT, the most therapeutically relevant cause of a couple member’s behavior is not that person’s history, biology, thinking, or feeling. Rather, the most proxi- mal cause is that person’s here-and-now experience of the partner’s behavior. And, of course, the partner’s behavior is itself primarily caused by his or her here-and-now experience of the other’s behavior. In the conceptual universe of SCT, here-and- now relational experience elicits and maintains couple members’ patterned behavior. Thus it fol- lows that a therapist who wants to change behav- ior must change how couple members experience each other. The mechanism of change in SCT is the production of new relational experiences for clients. It is the experience of receiving different behav- ior from the partner that induces a couple mem- ber to behave differently toward the partner, and vice versa. In SCT, clients change each other by behaving differently toward each other. The job of the therapist is to facilitate this internal change process within the couple subsystem. It is precisely because SCT is focused entirely on the production of novel, in-session relational experiences for its clients that enactment consti- tutes the centerpiece of the therapeutic process prescribed by the model (Aponte, 1992; Simon, 1995). “Enactment” refers to those moments in therapy when couple members interact directly with each other. It is in this direct interaction with each other during sessions that clients have the new relational experiences constituting the mechanism of change in SCT. I have much more to say about enactment later, at various points in this chapter. Here, I want to
make clear that enactment is more than simply one technique among many utilized in the practice of structural therapy. Directly linked as it is to struc- tural therapy’s understanding of the mechanism of therapeutic change, enactment is better conceived as a leavening agent that is mixed into every aspect of the therapy process, from assessment to termination. Minuchin, Nichols, and Lee (2007) express this idea by asserting that enactment is more an attitude of the structural therapist than a technique that he or she utilizes. Everywhere, and at all times, the SCT therapist is oriented toward having couple members enact their relational life in the here-and-now of the therapy session, rather than talk about the relational life they live outside the session. Thus enactment organizes the therapy session as a setting in which couple members have experiences. Via enactment, couple members expe- rience the futility and dysfunctionality of their current way of relating, and the possibility of relat- ing in new, more functional ways.
Structure of the Therapy Process
SCT’s understanding of the mechanism of thera- peutic change dictates the manner in which the therapist manages the nuts-and-bolts details of how the therapy process is structured. Matters such as who should attend therapy sessions, how often sessions should occur, and whether referrals for medication evaluation should be made are all decided in light of SCT’s understanding of the nature of couple dysfunction and how such dys- function is remediated via the therapy process. As I have just described, SCT aims entirely at changing how couple members experience each other. Obviously, one couple member cannot experience the other differently if that person is not in the therapy room with him or her. Thus, in general, both couple members are expected to be present together in every session of SCT. Even when the SCT therapist succeeds in get- ting couple members to experience each other differently during sessions, he or she fully expects that during the early phase of therapy, those novel relational experiences are going to “wash out” during the period between sessions, as the couple subsystem’s structure reasserts itself and the couple members return to their usual way of relating to each other. (I have more to say about this “rela- tional inertia” later in the chapter, when I discuss goal setting and technical aspects of the therapeu- tic process.) Since the therapist wants the novel relational experiences produced in session to build
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The client couple carries its structure with it into the therapy room. The unarticulated rules and expectations that organize the couple’s rela- tional life outside the therapy room also organize how the partners behave in the therapy room. Thus all the SCT therapist need do to bring the couple subsystem structure to the fore is to invite the partners to begin interacting with each other in the therapy session. Such direct interaction between couple members is, of course, what SCT refers to as “enactment.” Just as enactment, later in the therapy process, will be the SCT therapist’s primary medium for changing the couple subsys- tem structure, so too is it the therapist’s primary tool early in the therapy process for assessing that structure. Any enactment the therapist elicits during the first session will probably provide a glimpse into the couple subsystem structure. However, because the SCT therapist is particularly interested in how the couple subsystem handles internal dif- ferentiation, and how this differentiation is circu- larly linked to the permeability of the subsystem’s external boundary, certain kinds of enactment are likely to have more assessment value than others. Specifically, enactments in which couple mem- bers air and explore differences between them are likely to provide the therapist with the clearest view of the couple subsystem structure. Therefore, relatively early in the first therapy session, the SCT therapist looks for an opportunity to elicit an enactment between the partners on some matter on which they appear to differ. Some couples cite intractable differences as pre- cisely the problem that led them to seek therapy. Eliciting an enactment focused on differences is usually easy in such cases. After allowing each partner to articulate his or her position on the controversial issues(s) in question, the therapist merely directs the clients to continue their discus- sion with each other. The situation is different when a client couple identifies symptoms in one partner as the present- ing problem for therapy. In such circumstances, the partners frequently are in substantial agree- ment about the nature of the symptoms, and even about possible causes of the symptoms. More often than not, they agree in citing the identified patient’s biology and/or developmental history as the cause of the symptoms. Because enactments focused on presenting symptoms are not likely to expose differences between the partners, the therapist needs to broaden the focus of exploration during the first
session beyond the symptoms. The therapist can do so by interrupting the client couple’s familiar narrative about the presenting symptom. By ask- ing questions about the symptom that are not addressed by the couple’s “official” narrative— questions framed in relational terms—the thera- pist can turn the presenting symptom into a portal into the couple’s relationship (Minuchin et al., 2006, 2007): for example, “When she is depressed, are you left feeling high and dry, alone on a desert island?” or “Does his preoccupation with Internet porn sites feel more to you like a camouflaged kick or an abandonment?” As the therapist moves the conversation toward relational themes, differences between the partners that were papered over by their consensus about the presenting symptom are likely to emerge. Once they have emerged, the therapist can elicit enactments focused on these differences. Wherever they occur in the therapeutic pro- cess, enactments are not so much observed by the therapist as they are experienced. There is no one- way mirror between the therapist and the clients as the latter engage in enactments. The therapist is very much present during an enactment, pre- cisely as a third party within easy reach of the clients as they interact with each other. As such, the therapist occupies the same position during enactments that salient third parties occupy in the couple’s natural ecology. Thus how the clients include or exclude the therapist during first-session enactments provides important information about the permeability of the couple subsystem’s external boundary, and about how that permeability is cir- cularly linked to the way differentiation is handled within the subsystem. For example, a couple might respond to the therapist’s repeated requests for enactment with exceedingly brief conversations, followed invari- ably by one couple member’s attempt to engage the therapist in an extended dialogue about a matter not pertaining to the couple relationship. Situated at the receiving end of this transaction, the thera- pist might find him- or herself being pulled into a focal awareness of the couple member who keeps soliciting attention, and into a forgetfulness of the other member. Several repetitions of this pattern suggest to the therapist that the members of this couple are underinvolved with each other, and that this underinvolvement is circularly linked to enmeshment between at least one of the partners and one or more parties outside of the relationship. If some kind of symptom in one or both part- ners is presented by a client couple as the reason
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for seeking treatment, first-session enactments also provide the SCT therapist with the means to assess that aspect of the symptom, apart from pos- sible threat to harm self or other, in which he or she is most interested: the manner in which the symptom “fits” into the couple subsystem struc- ture, maintaining—and, at the same time, being maintained by—the structure. For example, married partners inform a thera- pist early in their first session that they have sought therapy because of the wife’s depression. The ther- apist notes near-complete agreement between the spouses as they respond to her questions about the particulars of the wife’s symptomatology. Differ- ences, however, begin to emerge when the thera- pist asks whether they have always agreed about how best to handle the depression. The therapist highlights the differences and asks, in an offhand way, what else the spouses disagree on. “Noth- ing, really,” the wife replies. “Well, I have told you repeatedly that I think you spoil the children,” the husband says tentatively. The therapist invites the spouses to talk together about this matter. As the resulting enactment proceeds, the thera- pist notes that the husband builds gradually from a halting, tentative presentation of his ideas about parenting to a vigorous, increasingly angry presen- tation. The wife responds to each increase in her husband’s anger by becoming ever more deroga- tory of his character: “Well, I may spoil the kids, but you’re a socially inept jerk.” The cycle of escalation continues for several moments until the wife suddenly falls silent and visibly begins to withdraw. Quietly, and, at least as the therapist experiences it, quite pathetically, she begins to cry. The therapist recognizes that the wife is beginning to enact in session that particu- lar combination and sequence of behaviors that the couple has described earlier in the session as constituting her depression. The husband notices the change in his wife. He reaches out to her with a tissue in hand and gently wipes away her tears. Turning to the therapist, he says, “I think she handles the kids just fine. She’s right; I’m really something of a jerk when it comes to dealing with people.” The therapist uses her experience of this enact- ment to construct the hypothesis that this is a conflict-avoiding couple, hypothesizing that the wife’s depression functions effectively to ward off the outbreak of conflict between the spouses, and to quickly short-circuit any episode of con- flict that does manage to break the surface of the couple’s life. Because the couple subsystem struc-
ture, aided and abetted by the wife’s depression, does not permit the airing of differences, resources within the subsystem are not being utilized. The wife cannot benefit from her husband’s perspec- tive on parenting, and the husband cannot ben- efit from his wife’s insights about his social skills. Meanwhile, the assiduous avoidance of conflict has had the paradoxical effect of causing consid- erable unresolved conflict to build up within the subsystem. The more conflict builds below the surface of the couple’s life, the more necessary the wife’s depression becomes to forestall its outbreak. The longer the depression succeeds in forestall- ing the airing of conflict, the more firmly rooted within the couple subsystem structure the depres- sion becomes.
Goal Setting
A couple enters therapy with the goal of alleviat- ing whatever it is that the members have identi- fied as their presenting problem. The SCT thera- pist thoroughly accepts this goal and considers the therapy successful only if the couple members are satisfied that their presenting problem has been resolved. The SCT therapist’s intention of realizing the couple’s goal of alleviating its presenting problem encounters an immediate impediment in situa- tions where the couple members articulate very different notions of what such alleviation would look like. Such divergence in couple members’ conceptions of a solution to their presenting prob- lem occurs most frequently when the presenting problem is one of relational dissatisfaction. In cases such as this, it happens with some regularity that one partner’s notion of a solution involves a more harmonious life together, while the other partner openly expresses ambivalence about the continua- tion of the relationship, wondering aloud whether the only solution is dissolution of the relationship. The SCT therapist’s first response to this situation will be to question the latter partner as to why, given this expressed ambivalence about the future of the relationship, he or she is sitting in a couple therapist’s office. Any of my readers who have had the least experience doing couple therapy are probably already mouthing the two answers most frequently given to this question:
- “I’m here because he [or she] wants me to be.”
- “I’m here because I want to make sure that I try everything before I decide to leave the rela- tionship.”
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the partners’ overarching goal of alleviating their presenting problem. However, he or she needs also to communicate an “explanation” for the presenting problem that orients the clients away from whatever expectations about the therapeu- tic process they might have carried into therapy, toward at least an inchoate grasp of what the pro- cess will in fact look like. The provision of such an “explanation” is what SCT refers to as “reframing” (Minuchin & Fishman, 1981). The “explanation” provided by reframing is in no way conceived of in SCT as an educative inter- vention. The causal theories endorsed by most clients who enter therapy are not “incorrect” in any absolute sense. To be sure, these linear, indi- vidualistic theories do not fit with SCT’s circular, systemic worldview. However, there is nothing self-evidently true about that systemic worldview. The linear thinking that underlies clients’ causal theories is every bit as intellectually credible as the circular thinking underlying SCT. Indeed, such thinking is more representative of the mainstream of the mental health professions than is systemic thinking. Thus the SCT therapist is not trying to edu- cate clients when, late in the first session, he or she offers a reframing of their presenting problem. Rather, the therapist uses reframing as an exercise in informed consent. In the reframe, the therapist shares with the couple his or her preliminary view of the structural features implicated in the genesis and/or maintenance of the presenting problem. Perhaps more importantly, the reframe also pro- vides clients a glimpse into their therapist’s sys- temic worldview. A very small percentage of client couples respond to the therapist’s reframing of their pre- senting problem in the first session by leaving therapy. These are clients who presumably find the causal theory about their presenting problem con- veyed in the reframe—and, perhaps furthermore, the systemic worldview informing the reframe— too foreign to be entertained. The therapist who conceives of reframing as an exercise in informed consent is not disheartened by the exit of these couples from therapy. Having found the SCT therapist’s view of their situation unacceptable, these couples, in leaving therapy, are doing exactly what they should be doing: rejecting a treatment whose rationale they find spurious, and mounting a search for a treatment whose underlying world- view fits more closely with their own. Although the clients who remain in therapy following the reframing—and these comprise the
vast majority—presumably do not experience the causal theory expressed in the reframing as being toxic, as do the clients who leave, it would be incorrect to assume that they simply accept the reframe; quite the contrary, in fact. Most couples devote the bulk of their energy during the next few sessions to attempts to refute the reframe. Some do so explicitly, trying to engage the therapist in a debate about the view of the presenting problem contained in the reframe. Most do so behaviorally, continuing to act in ways that are consonant with their original, linear view of their situation. The SCT therapist not only expects this response from clients, but actually welcomes it. Clients’ “resistance,” not only to reframing but also to the therapist’s ensuing interventions, helps to shape and to particularize treatment that the SCT therapist delivers. In addition to its assumption of competence, SCT is also characterized by an “assumption of uniqueness”—an assumption that “whatever characteristics it may share with other [couples], each [couple] is fundamentally unique” (Simon, 1995, p. 20). The SCT therapist welcomes clients’ struggle against reframing and ensuing interven- tions because he or she sees this struggle as repre- senting (at least in part) clients’ assertion of their uniqueness. Seeing “resistance” in this way allows the therapist to think of interventions as tentative probes that provide feedback on a given couple’s uniqueness, rather than as specifically targeted change attempts that, because of their very speci- ficity, can only be evaluated either as having “suc- ceeded” or “failed” (Minuchin & Fishman, 1981). Because, under the influence of the assump- tion of uniqueness, the SCT therapist conceives of interventions as probes, he or she allows the particular ways a couple struggles with and against interventions to shape the next series of interventions he or she delivers. Without doubt, that next series of interventions will continue to be guided by the therapist’s overarching, generic goal of changing the couple subsystem structure. However, by struggling against interventions, cli- ent couples progressively “teach” the therapist, as they simultaneously discover for themselves, what idiosyncratic arrangement drawn from their reser- voir of unutilized resources they will crystallize as an adaptive alternative to the dysfunctional struc- ture being challenged by the therapist’s interven- tions. It is by struggling with and against the SCT therapist’s interventions that the client couple collaborates with the therapist in guiding therapy toward an outcome that, in the end, will be as
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much informed by the couple’s idiosyncratic style, outlook, values, and relational resources, as by the therapist’s therapeutic ideology. It is by struggling with and against the therapist’s interventions that the client couple participates in setting goals for the therapy.
Role of the Therapist
The fundamental task of the SCT therapist is to help the client couple replace its dysfunctional structure, which is maintaining the couple’s pre- senting problem, with a more adaptive structure. SCT’s assumptions of competence and uniqueness lead the therapist to expect that this new structure will emerge from the wellsprings of clients’ latent, idiosyncratic resources. Thus the SCT therapist does not function in the change process as a sup- plier of adaptive alternatives to the couple, but rather as an activator of relational resources that are assumed to lie latent in the client couple’s rep- ertoire as the couple enters the therapy. As highlighted earlier, SCT’s assumption of circular causality leads to the view that the most therapeutically relevant cause of human behavior is here-and-now relational experience. Thus the SCT therapist considers the mechanism of change in therapy to be the production, via enactment, of new relational experiences for clients. By provid- ing the opportunity in session for couple members to experience each other in new ways, the thera- pist acts to dislodge the self-reinforcing, circular interactional loops that maintain the couple’s pre- senting problem, and to help the couple stabilize more functional, problem-free loops. The desire to make enactment the centerpiece of the change process in therapy places stringent requirements on both the level and the kind of activity in which the SCT therapist should engage. As regards level of activity, the therapist certainly needs to be active enough to induce clients to begin using relational competencies that are cur- rently being suppressed by the couple subsystem’s dysfunctional structure. At the same time, how- ever, the therapist must avoid becoming so active as to centralize him- or herself in the therapy pro- cess, with the result that clients spend more time talking with the therapist than with each other. As regards the kind of activity in which he or she should engage, the SCT therapist is once again guided by the assumption of circular cau- sality. Because SCT assumes that here-and-now relational experience is primarily responsible for eliciting and maintaining human behavior, the
therapist uses how clients experience him or her as the chief means to activate their latent relational resources. A concrete example helps to illustrate how the SCT therapist functions to elicit change in therapy. Let us imagine a hypothetical couple subsystem whose lack of internal differentia- tion manifests itself in a rigid overfunctioning– underfunctioning role structure. This couple’s therapist notes how the complementary role struc- ture informs in-session enactments, with the over- functioning member invariably taking the lead to organize and to keep on task any conversation that the therapist elicits between the partners. The therapist also notes how the underfunction- ing member invites and reinforces this behavior on the part of the partner—by never taking the lead in conversations, and never objecting when the partner leaps in to “help” when the underfunc- tioning member pauses (even briefly) in what he has to say. In order to elicit a change-producing enactment for this couple, the therapist needs to do some- thing in session to induce the underfunctioning member of the couple to surrender the passive posture that he invariably assumes when dealing with his partner. Structural theory informs the therapist that there is little chance of succeeding in this endeavor if the underfunctioning partner experiences the therapist in the same way he expe- riences his partner. So the therapist enters into a conversation with the underfunctioning partner, working hard as he or she does so to maintain a low-key posture, always following the client’s lead rather than leading in a manner that is isomorphic with the way the partner usually behaves. After a few awkward moments, the underfunc- tioning client begins to increase his activity level in the conversation. Soon, he is leading and orga- nizing the conversation in a way he almost never does when interacting with his partner. The therapist does not consider this shift in the client’s behavior all that newsworthy. SCT’s assumption of competence predicted that the cli- ent would be able to behave in this way. What the therapist needs to do now is to produce an inter- action between the partners in which the under- functioning client behaves toward the partner as he has begun behaving toward the therapist. Thus the therapist allows the conversation with the underfunctioning client to continue only long enough for the client to develop some momen- tum in the exercise of the new relational behavior displayed toward the therapist. After a couple of
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jocular or as serious, as vulnerable or as impass- able. The SCT therapist needs, therefore, to be in possession of a complex and varied interpersonal repertoire. Moreover, the therapist, just like an actor, needs to be able (or to develop the ability) to activate, more or less on demand, that element in his or her repertoire that fits the “scene” in which he or she is acting (Minuchin et al., 2006). SCT makes one more crucial demand on the clinician who wishes to implement this model successfully— one that has more to do with the therapist’s intellectual outlook than the stylis- tic attributes just described. Like every other approach to therapy, SCT is founded upon a set of philosophical assumptions about what it means to be human (Simon, 2003). Prominent among these is SCT’s collectivist, systemic assumption that the group, rather than the individual, constitutes the fundamental unit of the human universe. This assumption is manifest in SCT’s contention that it is the structure of the couple subsystem, and not anything internal to its members as individuals, that primarily drives the way the members relate to each other. I have argued elsewhere that it is reasonable to hypothesize that a therapist’s thera- peutic effectiveness will be greatest if his or her practice is consistently guided by a model whose underlying philosophical assumptions provide a close fit with his or her own personal worldview (Simon, 2006a, 2007, 2012a, 2012b). In a related vein, a preliminary study has shown that thera- pists with a collectivist worldview adhered more closely to structural family therapy, SCT’s “parent” model, than did therapists with an individualist worldview (Ryan, Conti, & Simon, 2012, 2013). Thus it may very well be the case that in order for it to be implemented faithfully and effectively, SCT needs its practitioner to share its assumptive view of the human world, and perhaps especially its collectivist outlook. Therapists with an indi- vidualist worldview might do well to avoid SCT in favor of a model that provides a better fit with their view of the human condition.
Technical Aspects of the Therapeutic Process
Because each client couple is unique, every course of SCT is in some ways also unique. Nonetheless, there is sufficient resemblance among successful courses of SCT to allow me to make some gen- eralizations about how a “typical” course of SCT evolves over time. To make these generalizations, I return to the theatrical metaphor I have employed
in the preceding section to illuminate the role of the therapist in SCT. If a course of SCT is thought of as a play, in which the therapist functions as director and supporting actor, then it typically is a play in two acts, with a brief prologue.
Prologue: The Director and Actors Meet
The curious thing about the SCT “play” is that it is already in progress when the director comes on the scene. The script for this play has been pro- vided by the couple subsystem structure, and the couple members have been following this script for an extended period of time prior to the com- mencement of therapy. The script has given rise to a problem that has motivated the couple to seek treatment. As the couple members enter the first session, they are substantially focused on their present- ing problem, and only minimally (if at all) on the structural script that has elicited and/or is main- taining the problem. The SCT therapist, in dis- tinction, is primarily focused on the couple subsys- tem structure because it is by means of a change in that structure that the therapist undertakes to alleviate the clients’ presenting problem. Thus, in most cases, the first meeting finds the director and the actors of the therapeutic drama looking in dif- ferent directions. This state of affairs needs to be rectified quickly, if the therapeutic play is to move toward a satisfying end. The primary agenda of the first session in SCT is construction of a consensus between director and actors regarding what the therapeutic play is going to be about. Not only is the pending thera- peutic drama talked about during the first session, the session itself constitutes the opening scene of that drama, functioning as its prologue. For the first session to perform its function as prologue to the therapeutic play, the therapist must execute several tasks during the session, many of them simultaneously. The therapist opens the session by asking the couple members to inform him or her about the problem that has brought them into therapy. As the clients begin to tell the story about their presenting problem, the therapist immediately begins the process of joining, allowing him- or herself to feel the “pull” exerted by the couple members, by their pacing, their use of language, and their demeanor and car- riage. The therapist accommodates, in his or her own idiosyncratic way, to the couple’s style, hoping that the couple members quickly begin to experi-
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ence him or her as someone who “fits” who they are as a couple. After giving the clients ample time to narrate their view of the presenting problem, but long before a focus on the problem is allowed to domi- nate the session, the therapist moves the session toward an assessment of the relational structure that, in the view of SCT, is circularly linked to the couple’s presenting problem. The therapist looks for and/or creates opportunities to elicit enactments focused on the partners’ differences, using his or her experience of these enactments to begin constructing hypotheses about how internal differentiation is handled within the couple sub- system, and how this differentiation is circularly linked to the permeability of the boundary sur- rounding the couple. During this middle part of the first session, almost all client couples allow themselves to be nudged by the therapist away from a focus on their presenting problem and toward an exploration of their relational structure. However, most clients expect (and, in my view, have the right to expect) that the therapist will make clear sooner rather than later the connection between the relational structure he or she has been exploring and the pre- senting problem that the clients entered therapy to resolve. Thus the necessary finale to the first ses- sion is the provision of the therapist’s preliminary formulation as to how the client couple’s present- ing problem is being elicited and/or maintained by the couple subsystem structure. The therapist pro- vides this formulation in the reframe, as described earlier.
Act I: Destabilizing the Old Structure
The return of the client couple for the second ses- sion marks the opening of Act I of the therapeu- tic play. The fact that the actors show up for the second session indicates that they have agreed to “play” with the dramatic script proposed by the therapist-director in the reframe. This is certainly not to say, however, that the actors have accepted their director’s script lock, stock, and barrel. Many couples enter the second session with revisions to the therapist’s script in hand—revisions that render that script less discrepant with the script they have already been following: “You don’t understand. It really is all her fault that we argue so much,” or “You don’t understand. In the face of his obsessiveness, I have to act the way I do.” Even couples who enter the second session expressing
complete acceptance of the therapist’s reframe have, in all likelihood, spent the entire time since the first session living out their old structural script with little, if any, change. The SCT therapist is not in the least surprised by or chagrined at the structural inertia that the client couple almost invariably displays at the beginning of the second session. The therapist, after all, did not expect the reframe to have a substantial impact on the structure of the couple subsystem. As noted earlier, the SCT therapist conceives of reframing as an exercise in informed consent rather than as a restructuring interven- tion. The therapist begins in the second session, and in the several sessions that follow, to provide cou- ple members with opportunities to enact in ses- sion new, more adaptive structural arrangements. Inevitably, however, this experimentation with a new relational script occurs in the context of cli- ents’ long experience of having lived out their old script. As problematic as that old script might be, it is familiar and predictable to the client couple. The partners know their lines well, and the long run that their play has had has given them con- fidence that they can act their assigned parts to perfection. As a result, clients’ predominant experience during the first several sessions of SCT is the unsettling one of being asked by their therapist to leave what is relationally familiar to them. Almost invariably, clients respond to this unset- tling experience with attempts to hold on to their old relational structure. Thus a polemic of sorts develops between director and actors—a polemic that quickly comes to dominate the first act of the therapeutic play. Whereas the therapist continu- ally asks clients to experiment with new relational arrangements, the clients continually (sometimes subtly and sometimes not so subtly) try to allevi- ate their discomfort by reverting to their old rela- tional arrangement. As I demonstrate shortly, this polemic usually builds until a crisis point is reached. Enactment is the primary tool used by the SCT therapist during the first act of the therapeutic play to begin changing the structure of the couple sub- system. Depending on how it is used, enactment can target for change either the external boundary or the internal structure of the couple subsystem. Recall that an excessively rigid or diffuse exter- nal boundary is a common structural characteristic of dysfunctional couple subsystems. During enact-
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the survival of your marriage depends on your perspective becoming as visible as his. You need to get him to listen to you. Talk with him now and see whether you can get him to take you seriously.
Having endeavored to “lend” the wife some indig- nation over her one-down status in the couple sub- system, the therapist elicits an enactment, hoping to see in this enactment the beginning of an airing of the conflict that has been driving the spouses apart but has rarely emerged into the open. Unbalancing is a difficult “role” for the SCT therapist to play well (Minuchin & Fishman, 1981). To begin with, its implementation is at odds with SCT’s core assumption of circular causal- ity. In the previous vignette, for example, struc- tural theory assumes that each spouse elicits the behavior of the other. The wife is as responsible for casting her husband in the one-up position he occupies as he is for casting her in the one-down position. Yet to produce an enactment in which the currently avoided conflict is aired, the thera- pist needs to act as if the husband is the sole cul- prit. Since the therapist does not believe that such is the case, acting in this way does indeed require quite the job of “acting.” In addition, unbalancing, if it is effective, inevi- tably disrupts the therapist’s alliance with the “target” partner. To appreciate this fact, just put yourself in the shoes of the husband in the pre- vious vignette, and fantasize how you would feel about the therapist at that moment. Thus effective unbalancing requires of the therapist an exquisite balancing act: to maintain the unbalanced pos- ture long enough to produce the desired effect of eliciting or prolonging in-session conflict, but not so long as to disrupt irreversibly the alliance with the “target” partner. Indeed, to reestablish equi- librium within the therapeutic system, the SCT therapist frequently follows a period of extensive unbalancing on one partner’s behalf with a period of unbalancing on behalf of the other. Avoidance of couple conflict is a common structural characteristic of families with a child as the identified patient. Because structural therapy was devoted almost entirely to the treatment of such families during the first decades of its devel- opment, unbalancing occupied a prominent place in the structural therapy literature of that period. However, when therapists began to apply struc- tural therapy to couples presenting themselves for treatment precisely as couples rather than as par- ents of a child identified patient, they found them-
selves facing the need to supplement unbalancing with another kind of intervention. Many couples that SCT therapists encounter are characterized by conflict that is vigorously aired rather than avoided. Indeed, for many of these couples, it is precisely their chronic and intractable conflict that is the presenting prob- lem in the treatment they are seeking. Although unbalancing might be of some use in the treat- ment of these couples, genuine restructuring of these couple subsystems requires not the amplifi- cation of conflict, which is the goal of unbalanc- ing, but the replacement of conflict with more supportive modes of transaction. To elicit this relational competence, the SCT therapist needs to soften the typically harsh transactions between these partners. “Softening,” then, constitutes the second “role” that SCT therapists play with some regularity during Act I of the therapeutic drama. Examples of softening can be cited from the earlier structural therapy literature (e.g., see Minuchin & Fishman, 1981, p. 167). However, due to the limited call for the use of this intervention with the families that were the focus of structural therapy at that time, softening never developed into an explicit category of intervention in this literature. This lack of a detailed understanding of softening as an intervention in structural therapy is what I have mentioned early in this chapter as the model’s practical weakness when it is applied to the treatment of couples. Although softening is not discussed themati- cally in the literature of structural therapy, it is the centerpiece of another approach to couple therapy, emotionally focused therapy (EFT; see Chapter 4, this volume). Despite some similarity between the two interventions, significant differ- ences in underlying worldview between structural therapy and EFT render softening in SCT a sub- stantially different intervention from softening in EFT (Simon, 2004, 2006b). Softening in SCT begins with the thera- pist’s assuming a soft posture to induce—almost hypnotically— one or both couple members to begin acting softly. Just as the SCT therapist “lends” indignation during unbalancing, he or she “lends” vulnerability during softening. As the SCT therapist engages in a soft exchange with one or both couple members, he or she looks for the first opportunity to move offstage and to cede the therapeutic drama back to its stars. The therapist maintains the dialogue with one or both clients during softening just long enough to pro- duce the kind of soft, affiliative atmosphere that
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he or she would like to see stabilized within the couple subsystem. Once that atmosphere has been established, the therapist elicits an enact- ment between the partners, asking them to main- tain the softened mood in their interaction with each other. The therapist then retreats offstage to observe the scene. The following vignette illustrates the use of softening in SCT. A young married couple requested therapy to address the problem of epi- sodes of intense conflict, followed by extended periods of disengagement from each other. The couple entered the fourth session of the therapy in the midst of one of these conflictual episodes. The therapist elicited an enactment, so that the episode could play itself out in the therapy room. During the enactment, the wife kept talking about how “concerned” she was about her hus- band’s drinking. Her manner as she used this word bespoke fury rather than worry. The therapist interrupted the enactment after it had proceeded for about 5 minutes.
theraPiSt: ( Softly, rolling his chair closer to the couple ) Trish, you’ve been telling Kevin how concerned you are about his drinking. Tell me what scares you about his drinking.
WiFe: ( After a brief pause, looking a bit nonplussed ) It concerns me that he needs to drink to have a good time.
theraPiSt: Do you think he knows how much seeing him drink frightens you? Do you think he knows how scared you get?
WiFe: ( Appearing to struggle to hold back some emo- tion ) No.
theraPiSt: He certainly knows how angry his drinking makes you, but I don’t think he has a clue how much it terrifies you. Do you know why it scares you so much?
WiFe: ( Wrapping her jacket tightly around her as she begins to cry softly ) My father was an alcoholic.
theraPiSt: Ah, now I see why his drinking scares you so. Can you tell him now about the fear that you feel when you see him drinking?
The wife stared speechlessly at her husband for about 30 seconds, while she continued to cry softly. Finally she began to tell him how frightened she felt when she saw him drinking, even though she never really had seen him drink to intoxica- tion. As she spoke with him in this vein, he tenta- tively reached out and took her hand in his.
Whether they occur in the context of unbal- ancing, softening, or some other “role” played by the therapist as supporting actor in the thera- peutic drama, enactments during Act I of this drama inevitably have the effect of introducing a wedge between the partners and the familiar structure that informed their transactions when they entered therapy. This is so, despite the fact that the couple subsystem usually reverts to its old structure— sometimes during the enactments themselves, and almost invariably between ses- sions. However, even when the partners revert in this way, they generally find that they simply can- not play out their old structural script in the same un-self-conscious way they did prior to the onset of therapy, due to the fact that they are now playing it out in the context of having enacted alterna- tives to the old script. Their experience during the first act of therapy is thus one of living in a kind of limbo. A new structure has not yet stabilized within the couple subsystem, and the old structure has begun to feel a bit alien. Living in this limbo is a disorienting experience for clients. In most cases, somewhere around the fourth or fifth session, this experience of disori- entation exceeds clients’ capacity to bear it com- fortably. Most couples at this point seek to relieve their discomfort by making a last-ditch attempt to retrieve their old relational structure. This attempt at retrieval is usually enabled by a crisis, marked by the resurgence (perhaps beyond baseline levels) of the presenting problem that served as the occasion for the commencement of treatment. Recall that in the systemic universe of SCT, a loop of circular causality exists between the presenting problem and the couple subsystem structure, each elicit- ing and maintaining the other. Precisely because their presenting problem was intimately linked to their old relational structure, a resurgence of the problem provides clients with an opportunity to retrieve the “gusto” in playing out their old struc- tural script of which the therapy has deprived them. A crisis occurring around the fourth or fifth session of therapy is generally a sign of a course of SCT that is on its way to succeeding. Interest- ingly, in their research project designed to test the efficacy of structural therapy in the treatment of young adult heroin addicts, Stanton, Todd, and Associates (1982) found that a characteristic shared by most failed cases was the therapy’s fail- ure to generate such a crisis. Although the occurrence of a therapeutic crisis during Act I of the therapeutic drama enhances
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ment is reached that the next session should be the last.
Common Technical Errors
As is probably the case in every model of couple therapy, a therapist can make a large number of errors in the implementation of SCT. A couple of common threads run through many of these errors, however. Given the significant differences I have just described between Act I and Act II of SCT, it should come as little surprise that the thread that runs through the errors commonly made during Act I differs appreciably from the thread running through the errors common to Act II. Recall that the leitmotiv of Act I of SCT is the tension between the therapist’s agenda of eliciting a new structure for the couple subsystem, and the couple members’ preference to continue relating to each other according to the script provided by the subsystem’s old structure. The sessions that consti- tute Act I will only achieve their overarching goal of restructuring the couple subsystem if the ther- apist prevails in the inevitable struggle with the couple’s structural inertia that dominates these sessions. In order to prevail in this way, the thera- pist’s interventions during these sessions need to be characterized by what in SCT parlance is termed “intensity” (Minuchin & Fishman, 1981), which refers to the therapist’s resolute mainte- nance of behaviors designed to elicit enactments in which the couple members relate to each other differently. The common thread running through most errors made by SCT therapists during Act I of therapy is a lack of this intensity. Due to widespread misunderstanding of inten- sity in SCT, it is necessary at this point to detail some things that intensity is not. It is not, for example, loudness, or even less, irascibility. Nor is it simply the repetition of the same failed inter- vention over and over again. As described ear- lier, SCT’s assumption of uniqueness leads the therapist to view “resistance,” at least in part, as a couple’s way of asserting its unique identity as a couple. “Resistance,” therefore, provides the therapist with an opportunity to learn more about what makes a given couple unique, and to respond to this learning by modifying his or her interven- tive strategy accordingly. What the SCT therapist should never modify during Act I, however, is the overarching goal of restructuring the couple subsystem. Intensity, then, refers to the thera- pist’s single-minded focus on and commitment to achieving this goal.
Why do therapists sometimes fail to generate sufficient intensity during Act I of the therapeutic drama? Several factors might come into play, but one in particular is worth mentioning here. Inten- sity is founded upon SCT’s assumption of compe- tence. It would be neither therapeutic nor ethical for a therapist to resolutely undermine a couple subsystem’s existing structure if he or she did not dogmatically believe that the couple members were fully competent to crystallize an adaptive structure in its place. SCT therapists who fail now and then to generate sufficient intensity during Act I may be therapists who are induced by the particulars of certain cases to temporarily “forget” the model’s assumption of competence. Losing sight of the fact that the clients in these cases are fully capable of generating a new, adaptive structure, the thera- pists lose nerve in maintaining their challenge to the old, dysfunctional structure. Such occasional lapses in the generation of intensity can usually be redressed by good supervision. Intensity is the sine qua non of therapeutic suc- cess in Act I of SCT. It is, however, the enemy of such success in Act II. As noted earlier, the thera- pist goes from being a challenger of entrenched, dysfunctional structure in Act I to being a nur- turer of fragile, emerging, functional structure in Act II. Such nurturing does not require a therapist with the single-minded purposiveness that char- acterizes intensity. Rather, it requires a therapist who is observant and curious, providing ample space for the client couple to experiment with novel structural arrangements. Thus the thread that runs through the errors most commonly made by therapists during Act II of SCT is an inappro- priately high level of therapeutic activity. Such a level of activity during this portion of the thera- peutic drama tends to direct the couple members’ attention away from each other and toward the therapist. Precisely at the point where their con- fidence in their ability to generate and maintain functional ways of relating to each other should be steadily increasing, the couple members instead become increasingly dependent on their overac- tive therapist to guide them in the crystallization of a new structure. Rather than quickly tending toward termination, Act II begins to drag on, with no clear end in sight. Once again, it is usually a failure in regard to SCT’s assumption of competence that is impli- cated in the generation of this common therapeu- tic error. The therapist who loses touch with this assumption may well find it difficult to make the transition from the more therapist-driven action
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of Act I to the more client-driven action of Act II. Failing to believe that the clients can stabilize an adaptive structure on their own, the therapist “helps” in a way that ultimately is unhelpful.
AppliCABiliTy And empiriCAl supporT
SCT, like all psychotherapeutic approaches, is not effective in all cases. It would be convenient if the cases in which the model is not helpful shared some easily discernible demographic or clini- cal characteristics. Then, referral to some other, more applicable form of treatment could be made before clients and therapist had devoted effort and resources to a failed course of therapy. Unfortu- nately, at this time, no research identifies readily observable characteristics shared by failed cases of SCT. It is certain that the nature of a couple’s present- ing complaint is not correlated with the outcome of SCT. Couples in which one or both partners describe discrete symptoms as their presenting complaint are no less likely to benefit from SCT than couples who define their presenting problem in relational terms. Likewise, demographic vari- ables are not correlated with outcome. Structural therapy developed out of Minuchin and colleagues’ work with urban, poor families. However, over the years the model has proven helpful in work with clients at all socioeconomic levels, with families and couples representing numerous ethnic groups, with both homosexual and heterosexual couples, and in numerous countries (Greenan & Tunnell, 2003; Minuchin et al., 2006, 2007). SCT is also not limited in applicability to cou- ples whose members define themselves as having a shared future. Because the goal of SCT is to produce an adaptive structure for the client sys- tem, the model can be applied to divorcing and divorced couples as well as it can to engaged and married couples, and to unmarried couples whose members’ mutual commitment is not in question. To be sure, an adaptive structure for a divorced couple little resembles that of a married couple, with the result that the therapy of a divorced cou- ple is likely to have a very different feel from that of a married couple. However, one of the strengths of SCT’s single-minded focus on systemic structure is that it renders the model applicable to couples at every stage of coming together, staying together, or coming apart. The claims that I have made for the broad applicability of SCT find indirect empirical sup-
port in the extant outcome research literature about structural therapy. This literature provides only indirect support because, like the model itself, research on structural therapy’s efficacy has tended to focus more on the model’s application to family treatment, in which a child, adolescent, or young adult is presented as the identified patient, than on its application to couple therapy. This limitation having been noted, however, the results of outcome research on structural ther- apy still deserve to be characterized as impressive. Research to date suggests that structural therapy is effective with widely varying populations in the treatment of a host of widely varying presenting symptoms, including psychosomatic symptoms in children (Minuchin et al., 1975); anorexia nervosa in children and adolescents (Eisler, Simic, Rus- sell, & Dare, 2007; Minuchin, Rosman, & Baker, 1978); heroin addiction in young adults (Stanton et al., 1982); school adjustment, anxiety, depres- sion, and withdrawal in adolescents diagnosed with attention-deficit/hyperactivity disorder (Bar- kley, Guevremont, Anastopoulos, & Fletcher, 1992); conduct-disordered behavior in adolescents (Chamberlain & Rosicky, 1995; Santisteban et al., 2003; Szapocznik et al., 1989); and drug use in adolescents (Santisteban et al., 2003). The treatment administered in all of these stud- ies was based on the same theoretical assumptions and constructs, utilizing to a large degree the same interventions, described in this chapter. More- over, in the treatment of two-parent families, the therapy almost invariably attempted to restructure the parental subsystem in ways very similar to the ways that SCT attempts to restructure the couple subsystem. Thus it is reasonable to conclude that these studies provide indirect evidence of the effi- cacy of SCT intervention principles across a broad range of presenting problems and client popula- tions. However, indirect evidence is hardly suffi- cient in the face of the current quest for empiri- cally supported psychotherapeutic practice. The field of couple and family therapy stands in need of well-constructed research studies that provide a direct test of structural therapy’s efficacy when applied to the treatment of couples.
CAse illusTrATion
Session 1: The Prologue
“I still can’t believe that he would do that to me!” Kayla was frenzied as she said this to me, 5 min- utes into my first session with her and Peter, her
