Structural Versus Strategic Family Therapies

n a 2- to 3-page paper, address the following:

• Summarize the key points of both structural family therapy and strategic family therapy.
• Compare structural family therapy to strategic family therapy, noting the strengths and weaknesses of each.
• Provide an example of a family in your practicum using a structural family map. Note: Be sure to maintain HIPAA regulations.
• Recommend a specific therapy for the family, and justify your choice

International Journal of

Environmental Research

and Public Health

Article

Effectiveness of Structural–Strategic Family Therapy
in the Treatment of Adolescents with Mental Health
Problems and Their Families

Lucía Jiménez 1 , Victoria Hidalgo 1,* , Sofía Baena 1 , Antonio León 2,† and Bárbara Lorence 1

1 Faculty of Psychology, University of Seville, Camilo José Cela s/n, 41018 Seville, Spain;
luciajimenez@us.es (L.J.); mbaena3@us.es (S.B.); bll@us.es (B.L.)

2 Child and Adolescent Mental Health Unit, Virgen Macarena Hospital, C/ Dr. Fedriani, 3, 41009 Seville, Spain
* Correspondence: victoria@us.es; Tel.: +34-954554332
† Deceased 13 September 2017.

Received: 8 March 2019; Accepted: 4 April 2019; Published: 8 April 2019
����������
�������

Abstract: Mental health problems during adolescence constitute a major public health concern today
for both families and stakeholders. Accordingly, different family-based interventions have emerged
as an effective treatment for adolescents with certain disorders. Specifically, there is evidence of the
effectiveness of concrete approaches of systemic family therapy on the symptoms of adolescents and
family functioning in general. However, few studies have examined the effectiveness of other relevant
approaches, such as structural and strategic family therapy, incorporating parent–child or parental
dyadic measurement. The purpose of this study was to test the effectiveness of a structural–strategic
family therapy with adolescents involved in mental health services and their families. For this purpose,
41 parents and adolescents who participated in this treatment were interviewed at pre-test and post-test,
providing information on adolescent behavior problems, parental sense of competence, parental
practices, parenting alliance, and family functioning. Regardless of participants’ gender, adolescents
exhibited fewer internalizing and externalizing problems after the treatment. Parents reported higher
family cohesion, higher satisfaction and perceived efficacy as a parent, and healthier parental practices
(less authoritarian and permissive practices, as well as more authoritative ones). An interaction
effect between parenting alliance and gender was found, with more favorable results for the mothers.
In conclusion, this paper provides evidence of the usefulness of structural–strategic family therapy
for improving family, dyadic, and individual facets in families with adolescents exhibiting mental
health problems.

Keywords: family therapy; effectiveness; strategic therapy; structural therapy; family functioning;
parental competence; parenting alliance; behavior problems; mental health

1. Introduction

Mental health problems during adolescence constitute a major public health concern today for
both families and stakeholders [1,2]. Epidemiological studies show that mental health issues are the
first nonfatal cause of illness [3], are in the top five causes of death among adolescents [4], and represent
16% of the global health-related burden in young people [4,5]. In addition, mental health problems
during adolescence are an important predictor of socialization difficulties and absenteeism at this
developmental stage, as well as one of the most significant predictors of adjustment problems and
mental disorders in adulthood [6–8]. In order to address these pressing issues, it is essential to have
effective intervention and prevention strategies that meet the specific needs of adolescents with mental
health problems.

Int. J. Environ. Res. Public Health 2019, 16, 1255; doi:10.3390/ijerph16071255 www.mdpi.com/journal/ijerph

http://www.mdpi.com/journal/ijerph

http://www.mdpi.com

https://orcid.org/0000-0003-2223-7263

https://orcid.org/0000-0002-9179-2722

https://orcid.org/0000-0003-4736-9318

https://orcid.org/0000-0001-6154-8852

http://dx.doi.org/10.3390/ijerph16071255

http://www.mdpi.com/journal/ijerph

https://www.mdpi.com/1660-4601/16/7/1255?type=check_update&version=2

Int. J. Environ. Res. Public Health 2019, 16, 1255 2 of 14

Adolescence is a challenging transitional period for both children and families. It is a developmental
stage characterized by normative physical, social, and psychological changes [9], some of which may be
identified as potentially stressful among this population [10]. Psychosocial stress in adolescents can be
accentuated by the presence of stressful or adverse life events (as maltreatment and violence, loss events,
intrafamilial problems, school and interpersonal problems) that are associated with severe negative
outcomes [11]. Although there are important inter-individual differences, the current homogenization
of adolescents’ daily experiences has contributed to the observation of fewer cross-cultural and gender
differences during this stage [12]. Some of the normative developmental tasks that adolescents need
to undertake for a healthy development are the search for autonomy, identity, and independence [9].
For families, this is a period characterized by the readjustment of family roles and norms, along with
an increase in family conflicts [9,13,14]. Families face the challenge of adjusting to these new demands
and needs while trying to conserve family unity [9,13,14]. The inability to adjust to these new demands,
together with inflexibility within the family over the negotiation of new norms and different solutions,
are often related to mental health problems. Families with an adolescent with mental health problems
have additional needs, demands, and difficulties stemming from the mental disorder [15]. Parents often
face challenging behaviors and conflictive situations, having to manage symptoms and coordinate and
engage with different service systems [16,17]. As they struggle to deal with these additional demands,
parents often find their skills coming into question, and this can be accompanied by feelings of low
competence, frustration, and powerlessness, together with increased isolation and contraction in their
social network [15,18].

There has been a proliferation of family-oriented and family-based interventions with adolescents
with mental health difficulties; some of these are considered as evidence-based practices in the
treatment of children and adolescents with certain disorders [19,20]. Previous research indicates that
the incorporation of family members or family elements in therapy is either directly or indirectly an
effective component of interventions that target adolescents with mental health problems [21–23].
On one hand, direct approaches (e.g., family-centered behavioral management or family therapy)
involve a more immediate engagement with the family and usually include specific objectives that target
families or family members. On the other hand, indirect approaches (e.g., psychodynamic therapy
or cognitive–behavioral therapy) incorporate the family context through reviews or reports, using
them as informants at some point and by keeping the family elements in mind while intervening [22].
In sum, under the “family-based interventions” umbrella term, there are a wide range of qualitatively
different interventions and approaches. The most widely used family-based interventions include
psychoeducational approaches [24], behavioral interventions, and systemic family therapy [25].
The goal of the present study was to evaluate the efficacy of specific systemic family therapy approaches
in families with an adolescent presenting a mental health problem.

From a systemic perspective, family is defined as a transactional system, where difficulties in
any member have an influence on every other member and on the whole family as a unit. In turn,
family processes have an impact on every individual member, as well as on the different relationships
embedded within the family context [26]. This perspective shifts away from a linear consideration
of family processes by recognizing the multiple recursive influences that shape family relationships
and family functioning, perceiving it as an ongoing process throughout the life cycle [27]. Systemic
family therapy has been shown to be an efficacious intervention for families and adolescents with
a wide range of mental health problems, such as drug use [19,28–32]), eating disorders [29,30] and
both internalizing and externalizing disorders [19,29–31,33–36]. Despite these advances, most of the
literature has focused on either systemic family therapy as a whole, without taking into account the
different approaches embedded within this framework, or on the effectiveness of more manualized
approaches, such as multisystemic family therapy (e.g., [37]) or functional family therapy (e.g., [34,38]).
Few studies have examined the effectiveness of more classical and widely used approaches, such as
structural and strategic family therapy [39]. Hence, more research is needed to be able to draw more
definite conclusions regarding the use of these types of family therapy approaches.

Int. J. Environ. Res. Public Health 2019, 16, 1255 3 of 14

Structural family therapy is one of the dominant approaches in systemic family intervention,
originally created by Minuchin [40]. The focus of this approach is on achieving a healthy hierarchical
family organization, where there are different subsystems with their limits and boundaries [27,41].
According to this approach, the difficulties expressed by the adolescent are a reflection of: (1) A family
structural imbalance; (2) a dysfunctional hierarchy within the family system, often characterized
by difficulties in establishing boundaries between the parental and the child subsystem; and (3) a
maladaptive reaction to changing demands [27]. Therefore, the intervention focuses on reinforcing
the parental subsystem, highlighting the need to present a “united front”, and clearly differentiating
it from the parent–child subsystem [25,27,41,42]. It also emphasizes the need to adjust the rigidity
of the limits and the relationship between subsystems according to the moment of the life cycle [42].
During adolescence, while authority still relies on the parental subsystem, the way it is exerted cannot
be the same as in previous developmental stages, and the limits between the subsystems, while
remaining clear, have to be more flexible [25,27,42]. Although the core elements of this approach are
well established and widely used among the clinical community [30,43], few studies have addressed
the effectiveness of this approach for adolescents with mental health problems [39,44].

Strategic family therapy is purely embedded within the systemic model and has a more directive
impression [25,45]. From this approach, the symptom is considered as serving a function to the family,
as well as reflecting a difficulty of the family to solve a problem [25,27,45]. According to the strategic
approach, when faced with a problem, families adopt solutions that have been useful to them in the past.
However, symptoms such as behavioral or emotional difficulties or an increase in conflicts emerge for
which those solutions are no longer valid, and the family is unable to find and effectively use alternative
ones; thus, they become stuck in a symptom-maintaining sequence [27]. The objective of this therapy is
for the family to initiate actions and solutions that are different to the ones previously attempted [27,45].
There is extensive evidence about the effectiveness of the brief–strategic family therapy approach, which
is a manualized and specific variant of the strategic approach, with different populations [46], including
adolescents with mental health problems (e.g., [32,47,48]). Though structural and strategic family
therapy are conceptually two different approaches within the systemic framework, they share certain
core elements, and it is not rare to use them conjointly. Some illustrative examples are brief–strategic
family therapy and multisystemic therapy, both of which incorporate representative elements from
both approaches.

In general, literature has shown that systemic family therapy has a significant impact by
reducing internalizing and externalizing symptoms of adolescents, as well as improving overall family
functioning [35,36]. However, in spite of the evidence indicating gender differences in adjustment
problems, especially in internalizing symptoms, most available studies have not taken into account the
adolescent’s gender when examining the impact of these interventions [49]. In addition, most studies
have focused on individual outcomes or on family functioning as a whole, rather than incorporating
parent–child dyadic measures or parental dyadic measures. Research has shown that some of these
dyadic dimensions play an important role in families with adolescents with mental health problems;
they should therefore be incorporated in effectiveness evaluations. More specifically, coercive and
permissive parenting practices [50–52] have generally been considered as two of the most important
predictors of internalizing and externalizing problems. Other parenting dimensions linked to child
psychopathology include: Low sense of parental competence, defined as the perception parents have
of their own performance as parents [52–54], and high levels of interparental conflict [55]. As a result,
parental practices, sense of parental competence, and parenting alliance constitute intervention targets
and should be included in effectiveness evaluations.

For some of these dimensions, the studies available highlight the need to control gender differences.
Specifically, there is evidence of important differences in parenting practices between mothers and
fathers, with mothers scoring higher in communication and control dimensions [56–58]. In addition,
there is evidence of gender differences in the perception of parenting alliance and co-parenting; more
specifically, in parental support and involvement dimensions. Thus, mothers are more likely to be

Int. J. Environ. Res. Public Health 2019, 16, 1255 4 of 14

involved in parental decision-making processes than fathers but also feel less supported in their
parental role [59].

In this framework, the goal of this study was to evaluate the effectiveness of structural–strategic
family therapy on different individual, dyadic, and family dimensions in families with an adolescent
with a mental health problem; to do so, we conducted a comprehensive analysis and incorporated
a gender perspective. According to previous evidence on systemic family therapy, we expected a
reduction of internalizing and externalizing symptoms of adolescents, as well as an improvement in
family functioning. Due to their role in child psychopathology, a reduction of coercive and permissive
parenting practices as well as an increase in sense of parental competence and parenting alliance were
hypothesized. Because of an absence of previous studies, we did not have expectations regarding
the adolescent’s gender, although higher improvements in mothers were expected in comparison
to fathers.

2. Materials and Methods

2.1. Study Design

This study was part of a wider research project assessing the effectiveness of a structural–strategic
family therapy (SSFT) initiative run by mental health services in Southern Spain (Andalusia) for families
with an adolescent with a mental health problem. This initiative combined the theoretical principles
and techniques of structural and strategic family therapy in order to reduce the adolescent’s mental
behavior problems and improve family relationships. The family therapy sessions initially focused
on establishing a therapeutic alliance with all members of the family, providing them with a safe,
nonjudging space where all of them felt understood. Afterwards, the objectives of the sessions were
to set clear boundaries between the subsystems, to strengthen the parental subsystem encouraging
joint decision-making and teamwork, to highlight and balance parental authority with the increasing
need for autonomy from the adolescent, and to reframe the relationships within the family system.
Both the referred adolescent with a mental health diagnosis and his/her parents participated in SSFT;
any other significant family members were also asked to attend. The intervention was led by two
therapists trained in structural and strategic family therapy (a clinical psychologist and a psychiatrist).
On average, the treatment consisted of a one-hour session each month over a period of approximately
10 months [60].

For the purpose of the evaluation, a quasi-experimental design was followed, including a pre-test
versus post-test evaluation of the participants of an experimental group (EG). This EG consisted of the
population of families receiving the SSFT intervention during the study (i.e., between 2009 and 2012).

2.2. Participants

The sample consisted of 41 participants (51.22% mothers, 48.78% fathers), whose adolescent
children had been referred to mental health services in the South of Spain. The children’s ages ranged
between 10 and 17 (M = 14.12, SD = 1.79), and there was a higher percentage of girls (73.17% girls and
26.83% boys). Most families were two-parent (90.24%), with nearly all of them having four members
(M = 3.82, SD = 0.85) and an average of two children (M = 1.80, SD = 0.51).

Following ICD-10 criteria, behavioral disorders were the most common diagnoses (31.71%),
followed by anxiety (29.27%), mood (17.07%), and eating disorders (17.07%). Other less frequent
diagnoses included personality disorders (9.76%), psychotic disorders (9.76%), and pervasive
developmental disorders (4.88%). Approximately 20% of adolescents with one type of disorder
met the criteria for another class of disorder (19.51%), with half of the comorbidities between behavioral
and anxiety disorders (9.76%) and the other half between anxiety and mood disorders (9.75%).

Int. J. Environ. Res. Public Health 2019, 16, 1255 5 of 14

2.3. Measures

The study followed a multi-informant approach, collecting information from practitioners,
caregivers, and target adolescents. In this paper, information provided by practitioners and caregivers
is included. Practitioners provided information about adolescent and family sociodemographic
profiles. Caregivers informed about the target adolescent behavior, as well as about their parental sense
of competence, parental practices, perceived parenting alliance, and perceived family functioning.
These measures are described below.

Sociodemographic profile: We compiled an ad-hoc questionnaire to collect sociodemographic
information about the target adolescent’s age and gender (by measuring sex) and the family structure
(one/two-parent structure) and composition (number of family members and children at home).

Child behavior checklist for ages 6–18 [61]: This inventory provides information on child and
adolescent behaviors from the perspective of caregivers. It measures both positive competences and
problem behaviors (internalizing and externalizing). A compilation of 113 items (ranging from 0 = not
true to 2 = very true or often true) measures internalizing (withdrawn/depressed, somatic complaints, and
anxiety/depression) and externalizing problems (rule-breaking and aggressive behavior). Cronbach’s
alpha coefficients were α = 0.85 for internalizing problems and α = 0.89 for externalizing problems.
Higher scores indicate greater behavior problems. Mean scores were computed.

Parental sense of competence [62]: This scale explores perceived competence as a parent. It consists
of 16 items with responses on a six-point scale. Two subscales can be computed, measuring efficacy
and satisfaction in parenting. Cronbach’s alpha coefficients were α = 0.75 for efficacy and α = 0.73 for
satisfaction. For both subscales, mean scores were computed, with higher scores indicating greater
parental sense of competence.

Parenting styles and dimensions questionnaire [63]: This 32-item instrument consists of three scales
measuring authoritarian, authoritative, and permissive parenting. The authoritative items reflect
reasoning/induction, warmth and support, and democratic participation; the authoritarian items reflect
verbal hostility, physical coercion, and nonreasoning/punitive strategies; and the permissive items
reflect indulgence and failure to follow through. All items are answered on a five-point scale, with
higher scores showing higher authoritative/authoritarian/permissive practices. Internal consistency in
this study was α = 0.81 for authoritative practices, α = 0.79 for authoritarian practices, and α = 0.64 for
permissive practices. Mean scores were computed.

Parenting alliance inventory [64]: This 20-item scale assesses the degree of commitment and
cooperation between husband and wife in child rearing. For each item, parents respond on a 5-point
scale. The total score revealed α = 0.94 in this study. We used the mean score, with higher scores
indicating stronger support between partners as parents.

Family cohesion and adaptability scale [65]. We used the FACES-III, which evaluates emotional
bonding between family members, as well as the adaptability of the family system. It is ranked on
a 5-point scale. Unlike other versions, the scores assessed with FACES-III are interpreted in a linear
manner, so the higher the score, the greater the level of family cohesion and adaptability. Internal
consistency in this research was α = 0.74 for cohesion and α = 0.56 for adaptability. Mean scores
were computed.

2.4. Procedure

Mental health practitioners referred the families for SSFT intervention. SSFT practitioners enrolled
the families in SSFT if they met the following criteria: (1) A child under 18 was being treated by the
mental health service; (2) the referred child met ICD-10 criteria for: Pervasive developmental disorders;
behavioral and emotional disorders with an onset usually occurring in childhood and adolescence;
neurotic, stress-related, and somatoform disorders; and if the previous criteria were not met, the
child had to meet the requisites for an eating disorder process or severe mental illness; and (3) SSFT
practitioners, based on their professional criteria through the observation and interviews with both
the adolescent and the parents, considered that the child’s symptomatology could be related with a

Int. J. Environ. Res. Public Health 2019, 16, 1255 6 of 14

family dysfunction (e.g., the symptomatology was limited to the family context, parental disagreement
or dysfunctional communication patterns) or that the family dynamic was either being impacted by
the symptomatology or maintaining it (e.g., difficulties in adjusting to changes due to adolescence
or parental practices not coherent with the adolescent period, frequent or persistent family conflicts).
If the intervention criteria were met, SSFT practitioners enrolled the family in the trial if they had an
adolescent member (10 years or older).

Two trained researchers, external to the SSFT, interviewed the caregivers and practitioners of each
family and assessed the adolescents at the mental health service facilities. The pre-test was completed
before the first SSFT session, and the post-test in the last session (for those families that had attended at
least three intervention sessions). The average length of time between pre- and post-test assessment
was 10 months, which corresponded approximately to the school year. Every informant participated
in the study voluntarily, after signing an informed consent form in accordance with the Declaration
of Helsinki. The aims of the research project were explained, and all participants were assured that
their anonymity would be protected. Ethics approval was obtained from the ethics committee of the
Andalusian Health Services (code 22/0509). No monetary incentives were offered.

The flow of cases through the trial is shown in Figure 1. Patients were classified as dropouts if
they did not complete Time 2 assessment protocols, despite being contacted at least three times by the
research team. The dropout rate at Time 2 was 42.25%.

Figure 1. Flowchart of participants through the study.

Int. J. Environ. Res. Public Health 2019, 16, 1255 7 of 14

Dropouts and completers were compared in all pretreatment variables using one-way ANOVAs
for quantitative variables and Chi-square tests for qualitative ones. Partial eta squared and Cramer ’s V
were computed as effect-size indices. Partial eta squared was considered small if <0.01, medium if ≥0.06 and <0.14, or large if >0.14; Cramer’s V was considered small if <0.30, medium if >0.30 and
<0.50, or high if >0.50 [66]. Significant differences were not found in any variables, except for parenting
alliance (see Table 1).

Table 1. Baseline characteristics for completers and dropouts.

Completers %/M Dropouts %/M Differences χ2/F

Target adolescent
Girls 73.17% 56.67% 2.11
Age 14.12 14.14 0.01

Family
No. of family members 3.82 4.04 0.83
No. of children 1.80 1.60 1.86
Two-parent structure 90.24% 81.48% 1.09

Behavior problems
Internalizing 0.50 0.52 0.04
Externalizing 0.55 0.56 0.01

Parental competence
Efficacy 3.10 3.22 0.26
Satisfaction 3.77 3.88 0.32

Parental practices
Authoritative 3.65 3.67 0.02
Authoritarian 1.84 1.83 0.02
Permissive 2.35 2.54 1.09

Parenting alliance 4.03 3.59 5.21* η2partial = 0.08

Family functioning
Cohesion 3.65 3.44 2.00
Adaptability 2.64 2.76 1.16

* p < 0.05.

2.5. Data Analyses

Statistical analyses were performed with SPSS v-18 (SPSS Inc., Chicago, IL, USA) [67]. Missing
data at item level were extrapolated using the missing value analysis. When more than 10% of the
items from a questionnaire were missing, the case was excluded from the corresponding analysis.
If this were not the case, we then applied the SEM procedure to impute the data, having previously
checked that the data were missing at random using Little’s MCAR test. We found less than 5% of
missing data with an MCAR distribution.

We examined univariate and multivariate outliers using box plots and Mahalanobis’ distance,
respectively [68], finding two multivariate outliers which we excluded from subsequent analyses.
Other statistical assumptions for parametric tests were checked and confirmed following Hair, Anderson,
Tatham, and Black’s [69] recommendations (i.e., linearity, normality, homogeneity, and absence of
multicollinearity and singularity). As an exception, high kurtosis for parental alliance required a
reflected and logarithmic transformation.

We based statistical conclusions on effect-size indices when statistical significance did not reach
significance due to small sample size. We examined main and interaction effects from mixed factorial
ANOVAs for the analyses of effectiveness, considering the pre-post measures as within the subjects’
factor (change) and informant’s gender as between the subjects’ factor. We used partial eta squared as
an effect-size index, with the conventional limits of 0.01, 0.06, and 0.14 for the small, medium, and
large levels of effect size, respectively [66].

Int. J. Environ. Res. Public Health 2019, 16, 1255 8 of 14

3. Results

First of all, we examined the main effect of gender and found neither a significant effect nor a
medium or large effect size. As Table 2 shows, after controlling for gender, the change between pre-
and post-measures was significant for several dependent variables. Thus, the adolescents exhibited
fewer internalizing and externalizing problems in the post-test with a high effect size. In turn, parents
reported higher satisfaction, as well as fewer authoritarian and permissive practices, also with a high
effect size. Moreover, higher efficacy as a parent and more authoritative practices were reported with
a medium effect size. Finally, the interaction between change and gender was significant for the
parenting alliance variable, with a high effect size.

Table 2. Descriptives and inferential statistics for change and change * gender interaction of the mixed
factorial ANOVAs for each dependent variable.

Descriptives M
(SD) Change

F (η2partial)
Change × Gender

F (η2partial)
Pre-Test Post-Test

Behavior problems
Internalizing 0.48 (0.21) 0.33 (0.19) 14.74*** (0.38) 0.02 (<0.01) Externalizing 0.55 (0.26) 0.35 (0.21) 20.72*** (0.46) 0.47 (0.02)

Parental competence
Efficacy 3.14 (0.68) 3.32 (0.64) 4.04* (0.10) 0.88 (0.02)
Satisfaction 3.76 (0.70) 3.98 (0.81) 5.19* (0.14) 0.12 (<0.01)

Parental practices
Authoritative 3.61 (0.50) 3.75 (0.53) 4.25* (0.11) 0.21 (0.01)
Authoritarian 1.84 (0.46) 1.65 (0.40) 11.30** (0.25) 0.23 (0.01)
Permissive 2.31 (0.77) 2.05 (0.56) 5.44* (0.14) 2.08 (0.05)

Parenting alliance 4.03 (054) 4.11 (0.63) 0.89 (0.02) 2.94 (0.08)

Family functioning
Cohesion 3.62 (0.44) 3.73 (0.45) 3.26 (0.08) 0.13 (<0.01) Adaptability 2.65 (0.42) 2.73 (0.44) 0.91 (0.03) 0.39 (0.01)

Note. Boldfaced contrasts indicate medium or high effect sizes. * p < 0.05, ** p < 0.005, *** p < 0.001.

The change * gender interaction is plotted in Figure 2, and it shows that mothers improved
their parenting alliance after intervention, while the opposite occurred with fathers. To investigate
further into the interaction effect, we performed a simple repeated measures ANOVA for each gender.
The results showed that mothers significantly improved their parenting alliance after treatment with a
high effect size, F(1,18) = 4.54, p = 0.047, η2partial = 0.20, but no statistical difference was observed for
fathers, F(1,18) = 0.24, p = 0.628, η2partial = 0.01.

Figure 2. Interaction effect of gender on parenting alliance.

Int. J. Environ. Res. Public Health 2019, 16, 1255 9 of 14

4. Discussion

The results of this study have shown a positive impact of a structural–strategic oriented family
therapy on both the parents and adolescents in the family, dyadic, and individual-level dimensions.
The improvement observed after the intervention was independent of the gender of both parents and
adolescents, barring the parenting alliance variable.

The systemic approach understands the family as a whole, not as a simple sum of individual
members. According to this approach, a common objective in structural family therapy, regardless
of clients’ needs, consists of empowering and strengthening the family as a system, favoring the
persistence of these changes over time [38]. In consonance with previous empirical evidence [35,36], this
study shows the impact of this approach in the family sphere, particularly in terms of improving family
cohesion. This result is particularly relevant with vulnerable families facing difficulties associated
with the readjustment of family roles and norms, response to new demands and needs of family
members [9,13,14]. This is the case of families with adolescents suffering from mental health problems,
due to the existence of additional needs, demands, and difficulties linked to the presence of the
mental disorders [15]. Nevertheless, despite the importance of the abovementioned results, no
improvement was observed in family adaptability. Families in this situation tend to behave inflexibly
when negotiating and learning new ways of resolving parent–adolescent conflict [42]. An improvement
in family adaptability in this population would have been remarkable; the absence of changes in this
dimension may be due to reliability problems when assessing with FACES [70].

At a dyadic level, authoritative parental practices increased after the treatment, and both
authoritarian and permissive practices decreased. Only a handful of studies had previously assessed
the effectiveness of a systemic family approach on families whose adolescents presented mental health
problems in dyadic dimensions [44]. Parenting training in childrearing practices constitutes a core
component of most family interventions, particularly when child behavior problems exist [38]. Parental
practices based on affect, dialogue, and reasoning are related to better family functioning [71] and
adolescent adjustment [6,72,73].

The structural–strategic therapy tested in this study has also shown other dyadic effects. Participant
mothers reported feeling more support from fathers in childrearing, although the opposite was not
found (fathers feeling more supported by mothers). This result is not surprising considering that
mothers are usually involved more in childrearing than fathers and also feel less supported in their
parenting role [59]. This difference in gender may also be explained because mothers reported a lower
level of parenting alliance before the intervention, and therefore had greater scope for subsequent
improvement compared to fathers.

At an individual level, participating parents reported better parental sense of competence after
the therapy. Thus, both fathers and mothers reported higher perceived efficacy and satisfaction as
a parent. Again, this result is particularly relevant as parents from these families presented high
levels of difficulty in exerting their parental role [15]. For example, there is evidence of the existence
of additional parental stress on parents with adolescents presenting mental health problems, and
the relationship between parental stress and less perceived efficacy and satisfaction as a parent [74].
Consequently, the increase observed in parental sense of competence could be mirrored by a decrease
in parenting stress. In any event, the improvement in parental sense of competence is positive not just
for parents at an individual level, but also for the adolescents and the family as a whole [53,75,76].

Finally, this study has shown positive results in adolescent behavior, regardless of gender [19,33,34].
The reduction in adolescent problematic behavior both at external and internal level confirms the
usefulness of structural–strategic therapy. This result can be explained as a direct effect of the intervention
or as an indirect effect of improvements in family functioning [35,36], parental practices [50–52], parental
sense of competence [52,54], and parenting alliance [55]. As pointed out in the introduction, the absence
of differences between boys and girls can be explained by the homogenization of adolescents’ daily
experiences in today’s society [12].

Int. J. Environ. Res. Public Health 2019, 16, 1255 10 of 14

This study has several limitations. First, a main shortcoming is the small sample of families
recruited in the study. The high specialization and costs associated with SSFT together with the
high-risk profile of these families help to understand this limitation. The latter, due to mental health
problems and family dysfunction, can also explain the high dropout rate reported in this study.
Whatever the reason is, the statistical strength of the study could be improved with a higher sample
size, particularly if considering the statistical conditions of the longitudinal analyses [77]. Second,
we would have liked to have been able to conduct a long-term analysis to examine the persistence of
treatment effects in the mid to long term. Third, the most important limitation of this study was the
absence of a comparison group to enable us to corroborate that changes between pre-test and post-test
were due to the therapy and not to other circumstances [78].

5. Conclusions

Despite the abovementioned limitations, this study has made some contributions. We drew
on previous findings about the effectiveness of family-oriented and family-based interventions with
adolescents with mental health difficulties [19,20] from family systemic therapy approach [19,27–31].
While reaching the gold standard for effectiveness remains a distant goal for structural–strategic family
therapy, this paper offers some evidences about its usefulness for improving individual, dyadic, and
family adjustment in families with adolescents with mental health difficulties [39].

In sum, this study has practical implications concerning the way specialized services for children
and adolescents with mental health problems have been traditionally organized, and regarding the core
elements that need to be specifically targeted when working with these families. In general, specialized
mental health services for children and adolescents have traditionally focused on symptom reduction
and “parental training”, which have proven to be useful and essential interventions. However, our
results support the importance of incorporating complementary approaches targeting families as a
whole in their regular services as to adequately address the complex needs and difficulties of families of
adolescents with mental health issues [23]. In addition, this study highlights the need to directly target
certain core elements related to the dyadic parental relationship and the parent–child relationship
when intervening with families of adolescents with mental health problems. Finally, gender-related
results support the idea of differentiated approaches when working at a dyadic parental level, such as
co-parenting. Mothers and fathers seem to not only experience co-parenting differently but also respond
differently to interventions that directly target this core element [59]. Therefore, this study highlights
the relevance of taking into account and incorporating gender-based strategies in interventions.

Author Contributions: Project administration, supervision and methodology: L.J., A.L., and V.H. Data curation:
S.B., L.J., and B.L. Resources: A.L. Conceptualization, formal analysis, and writing: L.J., V.H., B.L., and S.B.
All authors have read and approved the final manuscript.

Funding: This study has been supported by the Research Project “Effectiveness of the family therapy treatment
developed in mental health services. Analysis of effectiveness moderators”. This work was also supported by the
Spanish Government (MINECO, Ministry of Economics and Competitiveness). Project reference: EDU2013-41441-P.
In addition, the Ministry of Education, Culture and Sports has funded the author S.B. with a predoctoral grant
(FPU 014/6751).

Acknowledgments: To M.J. Blanco, coordinator in charge of the Child and Adolescent Mental Health Unit, Virgen
Macarena Hospital (Seville, Spain), for her technical support in data collection.

Conflicts of Interest: The authors declare no conflict of interest.

References

1. Lawrence, D.; Hakefost, J.; Johnson, S.E.; Saw, S.; Buckingham, W.J.; Sawyer, M.G.; Ainley, J.; Zubrick, S.R.
Key findings from the second Australian child and adolescent survey of mental health and wellbeing. Aust. N.
Z. J. Psychiatry 2016, 50, 876–886. [CrossRef] [PubMed]

2. Mehra, S.; Daral, S.; Sharma, S. Investing in our adolescents: Assertions of the 11th World Congress on
Adolescent Health. J. Adolesc. Health 2018, 63, 9–11. [CrossRef] [PubMed]

http://dx.doi.org/10.1177/0004867415617836

http://www.ncbi.nlm.nih.gov/pubmed/26644606

http://dx.doi.org/10.1016/jadohealth.2018.05.005

http://www.ncbi.nlm.nih.gov/pubmed/30060863

Int. J. Environ. Res. Public Health 2019, 16, 1255 11 of 14

3. Whiteford, H.A.; Degenhardt, L.; Rehm, J.; Baxter, A.J.; Ferrari, A.J.; Erskine, H.E.; Charlson, F.J.; Norman, R.E.;
Flaxman, A.D.; Johns, N.; et al. Global burden of disease attributable to mental and substance use disorders:
Findings from the Global Burden of Disease Study 2010. Lancet 2013, 382, 1575–1586. [CrossRef]

4. World Health Organization Home Page. Available online: http://www.who.int/news-room/fact-sheets/detail/
adolescent-mental-health (accessed on 22 September 2018).

5. Kieling, C.; Baker-Henningham, H.; Belfer, M.; Conti, G.; Ertem, I.; Omigbodun, O.; Rohde, L.A.; Srinath, S.;
Ulkuer, N.; Rahman, A. Child and adolescent mental health worldwide: Evidence for action. Lancet 2011,
378, 1515–1525. [CrossRef]

6. Carr, A. The Handbook of Child and Adolescent Clinical Psychology: A Contextual Approach, 3rd ed.; Routledge:
Abingdon, UK, 2016; ISBN 978-1-138-806009.

7. Hofstra, M.B.; van der Ende, J.; Verhulst, F.C. Child and adolescent problems predict DSM-IV disorders in
adulthood: A 14-year follow up of a Dutch epidemiological sample. J. Am. Acad. Child Adolesc. Psychiatry
2002, 41, 182–189. [CrossRef] [PubMed]

8. Trentacosta, C.J.; Hyde, L.W.; Goodlett, B.D.; Shaw, D.S. Longitudinal prediction of disruptive behavior
disorders in adolescent males from multiple risk domains. Child Psychiatry Hum. Dev. 2013, 44, 561–572.
[CrossRef]

9. Goossens, L. Adolescent development: Putting Europe on the map. In Handbook of Adolescent Development;
Jackson, S., Goossens, L., Eds.; Psychology Press: New York, NY, USA, 2006; pp. 1–10, ISBN 978-1-84169-200-5.

10. Grant, K.E.; Compas, B.E.; Stuhlmacher, A.F.; Thurm, A.E.; McMahon, S.D.; Halpert, J.A. Stressors and child
and adolescent psychopathology: Moving from markers to mechanisms of risk. Psychol. Bull. 2003, 129,
447–466. [CrossRef]

11. Serafini, G.; Muzio, C.; Piccinini, G.; Flouri, E.; Ferrigno, G.; Pompili, M.; Girardi, P.; Amore, M. Life
adversities and suicidal behavior in young individuals: A systematic review. Eur. Child Adolesc. Psychiatry
2015, 24, 1423–1446. [CrossRef]

12. Lannengrand-Willems, L.; Barbot, B. Challenges of adolescent psychology in the European identity context.
In The Global Context for New Directions for Child and Adolescent Development; Grigorenko, E.L., Ed.; Wiley
Periodicals: Hoboken, NJ, USA, 2015; pp. 69–76, ISBN 1520-3247.

13. Lubenko, J.; Sebre, S. Longitudinal associations between adolescent behaviour problems and perceived
family relationship. Procedia Soc. Behav. Sci. 2010, 5, 785–790. [CrossRef]

14. Jaworska, N.; MacQueen, G. Adolescence as a unique developmental period. J. Psychiatry Neurosci. 2015, 40,
291–293. [CrossRef]

15. Rodríguez-Meirinhos, A.; Antolín-Suárez, L.; Oliva, A. Support needs of families of adolescents with mental
illness: A systematic mixed studies review. Arch. Psychiatr. Nurs. 2018, 32, 152–163. [CrossRef]

16. Doornbos, M.M. The 24-7-52 job: Family caregiver for young adults with serious and persistent mental
illness. J. Fam. Nurs. 2001, 7, 328–344. [CrossRef]

17. Huang, L.; Stroul, B.; Friedman, R.; Mrazek-Rochester, P.; Friesen, B.; Pires, S.; Mayberg, S. Transforming
mental health care for children and their families. Am. Psychol. 2005, 60, 615–627. [CrossRef] [PubMed]

18. Lila, M.; van Aken, M.; Musitu, G.; Buelga, S. Families and adolescents. In Handbook of Adolescent Development;
Jackson, S., Goossens, L., Eds.; Psychology Press: New York, NY, USA, 2006; pp. 154–174, ISBN 978-1-84169-200-5.

19. Goorden, M.; Schawo, S.J.; Bouwmans-Frijters, C.A.M.; van der Schee, E.; Hendriks, V.M.;
Hakkaart-van Roijen, L. The cost-effectiveness of family/family-based therapy for treatment of externalizing
disorders, substance use disorders and delinquency: A systematic review. BMC Psychiatry 2016, 16, 237.
[CrossRef] [PubMed]

20. Larner, G. Family therapy with children and adolescents (Editorial). Aust. N. Z. J. Fam. Ther. 2016, 37,
439–442. [CrossRef]

21. Johnson, M.H.; George, P.; Armstrong, M.I.; Lyman, D.R.; Dougherty, R.H.; Daniels, A.S.; Ghose, S.S.;
Delphin-Rittmon, M.E. Behavioral management for children and adolescents: Assessing the evidence.
Psychiatr. Serv. 2014, 65, 580–590. [CrossRef] [PubMed]

22. Karamat, R. The parental couple relationship in child and adolescent mental health. Clin. Child Psychol. Psychiatry
2015, 20, 169–172. [CrossRef]

23. Oruche, U.M.; Draucker, C.; Alkhattab, H.; Knopf, A.; Mazurcyk, J. Interventions for family members of
adolescents with disruptive behavior disorders. J. Child Adolesc. Pyschiatr. Nurs. 2014, 27, 99–108. [CrossRef]

http://dx.doi.org/10.1016/S0140-6736(13)61611-6

http://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health

http://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health

http://dx.doi.org/10.1016/S0140-6736(11)60827-1

http://dx.doi.org/10.1097/00004583-200202000-00012

http://www.ncbi.nlm.nih.gov/pubmed/11837408

http://dx.doi.org/10.1007/s10578-012-0349-3

http://dx.doi.org/10.1037/0033-2909.129.3.447

http://dx.doi.org/10.1007/s00787-015-0760-y

http://dx.doi.org/10.1016/j.sbspro.2010.07.185

http://dx.doi.org/10.1503/jpn.150268

http://dx.doi.org/10.1016/j.apnu.2017.09.004

http://dx.doi.org/10.1177/107484070100700402

http://dx.doi.org/10.1037/0003-066X.60.6.615

http://www.ncbi.nlm.nih.gov/pubmed/16173894

http://dx.doi.org/10.1186/s12888-016-0949-8

http://www.ncbi.nlm.nih.gov/pubmed/27412612

http://dx.doi.org/10.1002/anzf.1194

http://dx.doi.org/10.1176/appi.ps.201300253

http://www.ncbi.nlm.nih.gov/pubmed/24343339

http://dx.doi.org/10.1177/1359104515571818

http://dx.doi.org/10.1111/jcap.12078

Int. J. Environ. Res. Public Health 2019, 16, 1255 12 of 14

24. Fossum, S.; Handegård, B.H.; Martinussen, M.; Mørch, W.T. Psychosocial interventions for disruptive and
aggressive behaviour in children and adolescents: A meta-analysis. Eur. Child Adolesc. Psychiatry 2008, 17,
438–451. [CrossRef]

25. Lebow, J.L.; Stroud, C.B. Family therapy. In APA Handbook of Clinical Psychology: Applications and Methods;
Norcross, J.C., VandenBos, G.R., Freedheim, D.K., Krishnamurthy, R., Eds.; American Psychological
Association: New York, NY, USA, 2016; Volume 3, pp. 327–349, ISBN 978-1-4338-2129-5.

26. Von Bertalanffy, L. General System Theory: Foundations, Developments, Applications; Brazille: New York, NY,
USA, 1968; ISBN 978-0807604533.

27. Walsh, F. Clinical views of family normality, health and dysfunction: From a deficit to a strengths perspective.
In Normal Family Processes: Growing Diversity and Complexity; Walsh, F., Ed.; The Guilford Press: New York,
NY, USA, 2016; pp. 28–56, ISBN 978-1-4625-2548-5.

28. Baldwin, S.A.; Christian, S.; Berkeljon, A.; Shadish, W.R. The effects of family therapies for adolescent
delinquency and substance abuse: A meta-analysis. J. Marital Fam. Ther. 2012, 38, 281–304. [CrossRef]

29. Carr, A. The effectiveness of family therapy and systemic interventions for child-focused problems. J. Fam. Ther.
2009, 31, 3–45. [CrossRef]

30. Cottrell, D.; Boston, P. Practitioner review: The effectiveness of systemic family therapy for children and
adolescents. J. Child Psychol. Psychiatry 2002, 43, 573–586. [CrossRef] [PubMed]

31. Riedinger, V.; Pinquart, M.; Teubert, D. Effects of systemic therapy on mental health of children and
adolescents: A meta-analysis. J. Clin. Child Adolesc. Psychol. 2017, 46, 880–894. [CrossRef]

32. Robbins, M.S.; Feaster, D.J.; Horigian, V.E.; Rohrbaugh, M.; Shoham, V.; Bachrach, K.; Miller, M.; Burlew, K.A.;
Hodgkins, C.; Carrion, I.; et al. Brief Strategic Family Therapy versus treatment as usual:

Results

of a
multisite randomized trial for substance using adolescents. J. Consult. Clin. Psychol. 2011, 79, 713–727.
[CrossRef] [PubMed]

33. Cassells, C.; Carr, A.; Forrest, M.; Fry, J.; Beirne, F.; Casey, T.; Rooney, B. Positive systemic practice: A controlled
trial of family therapy for adolescent emotional and behavioural problems in Ireland. J. Fam. Ther. 2015, 37,
429–449. [CrossRef]

34. Hartnett, D.; Carr, A.; Sexton, T. The effectiveness of Functional Family Therapy in reducing adolescent
mental health risk and family adjustment difficulties in an Irish context. Fam. Process 2016, 55, 287–304.
[CrossRef] [PubMed]

35. Retzlaff, R.; von Sydow, K.; Haun, M.W.; Schweitzer, J. The efficacy of systemic therapy for internalizing and
other disorders of childhood and adolescence: A systematic review of 38 randomized trials. Fam. Process
2013, 52, 619–652. [CrossRef]

36. Von Sydow, K.; Retzlaff, R.; Beher, S.; Haun, M.W.; Schweitzer, J. The efficacy of systemic therapy for
childhood and adolescent externalizing disorders: A systematic review of 47 RCT. Fam. Process 2013, 52,
576–618. [CrossRef]

37. Van der Stouwe, T.; Asscher, J.J.; Stams, G.J.; Dekovic, M.; van der Laan, P.H. The effectiveness of Multisystemic
Therapy (MST): A meta-analysis. Clin. Psychol. Rev. 2014, 34, 468–481. [CrossRef]

38. Sexton, T. Functional Family Therapy in Clinical Practice: An Evidence-Based Treatment Model for Working with
Troubled Adolescents; Routledge: New York, NY, USA, 2011; ISBN 978-0-415-99691-4.

39. Weaver, A.; Greeno, C.G.; Marcus, S.C.; Marcus, S.C.; Fusco, R.A.; Zimmerman, T.; Anderson, C. Effects of
structural family therapy on child and maternal mental health symptomatology. Res. Soc. Work Pract. 2013,
23, 294–303. [CrossRef]

40. Minuchin, S. Families & Family Therapy; Harvard University Press: Cambridge, MA, USA, 1974; ISBN 0_674-29236_7.
41. Colapinto, J. Structural family therapy. In Family Counseling and Therapy, 3rd ed.; Horne, A., Ohlsen, M., Eds.;

Peacock: Itasca, IL, USA, 1982; ISBN 978-0875812762.
42. Martínez, M.P. Terapia estructural. In Manual de Terapia Sistémica: Principios y Herramientas de Intervención;

Moreno, A., Ed.; Editorial Desclée de Brouwer: Bilbao, Spain, 2014; pp. 263–296, ISBN 978-84-330-2737-5.
43. Szapocznik, J.; Rio, A.; Murray, E.; Cohen, R.; Scopetta, M.; Rivas-Vazquez, A.; Hervis, O.; Posada, V.;

Kurtines, W. Structural family versus psychodynamic child therapy for problematic Hispanic boys. J. Consult.
Clin. Psychol. 1989, 57, 571–578. [CrossRef]

44. Barkley, R.A.; Guevremont, D.C.; Anastopoulos, A.D.; Fletcher, K.E. A comparison of three family therapy
programs for treating family conflicts in adolescents with attention-deficit hyperactivity disorder. J. Consult.
Clin. Psychol. 1992, 60, 450–462. [CrossRef]

http://dx.doi.org/10.1007/s00787-008-0686-8

http://dx.doi.org/10.1111/j.1752-0606.2011.00248.x

http://dx.doi.org/10.1111/j.1467-6427.2008.00451.x

http://dx.doi.org/10.1111/1469-7610.00047

http://www.ncbi.nlm.nih.gov/pubmed/12120854

http://dx.doi.org/10.1080/15374416.2015.1063427

http://dx.doi.org/10.1037/a0025477

http://www.ncbi.nlm.nih.gov/pubmed/21967492

http://dx.doi.org/10.1111/1467-6427.12038

http://dx.doi.org/10.1111/famp.12195

http://www.ncbi.nlm.nih.gov/pubmed/26542420

http://dx.doi.org/10.1111/famp.12041

http://dx.doi.org/10.1111/famp.12047

http://dx.doi.org/10.1016/j.cpr.2014.06.006

http://dx.doi.org/10.1177/1049731512470492

http://dx.doi.org/10.1037/0022-006X.57.5.571

http://dx.doi.org/10.1037/0022-006X.60.3.450

Int. J. Environ. Res. Public Health 2019, 16, 1255 13 of 14

45. Styczynski, L.E.; Greenberg, L.D. Terapia estratégica. In Manual de Terapia Sistémica: Principios y Herramientas
de Intervención; Moreno, A., Ed.; Editorial Desclée de Brouwer: Bilbao, Spain, 2014; pp. 377–412,
ISBN 978-84-330-2737-5.

46. Szapocznik, J.; Schwartz, S.J.; Muir, J.A.; Brown, C.H. Brief Strategic Family Therapy: An intervention to
reduce adolescent risk behavior. Couple Fam. Psychol. 2012, 1, 134–145. [CrossRef] [PubMed]

47. Robbins, M.S.; Horigian, V.E.; Szapocnik, J. Brief Strategic Family Therapy: An empirically-validated
intervention for reducing adolescent behavior problems. Praxis der Kinderpsychologie und Kinderpsychiatrie
2008, 57, 381–400. [CrossRef]

48. Santisteban, D.A.; Perez-Vidal, A.; Coatsworth, J.D.; Kurtines, W.M.; Schwartz, S.J.; LaPerriere, A.;
Szapocznik, J. Efficacy of Brief Strategic Family Therapy in modifying Hispanic adolescent behavior
problems and substance use. J. Fam. Psychol. 2003, 17, 121–133. [CrossRef]

49. Hoffmann, M.L.; Powlishta, K.K.; White, K.J. An examination of gender differences in adolescent adjustment:
The effect of competence on gender role differences in symptoms of psychopathology. Sex Roles 2004, 50,
795–810. [CrossRef]

50. Enten, R.S.; Golan, M. Parenting styles and eating disorder pathology. Appetite 2009, 52, 784–787. [CrossRef]
51. Kerig, P.; Ludlow, A.; Wenar, C. Developmental Psychopathology: From Infancy through Adolescence, 6th ed.;

McGraw Hill: New York, NY, USA, 2012; ISBN 978-007713121-0.
52. Sanders, M.R.; Woolley, M.L. The relationship between maternal self-efficacy and parenting practices:

Implications for parent training. Child Care Health Dev. 2005, 31, 65–73. [CrossRef]
53. Coleman, P.K.; Karraker, K.H. Parenting self-efficacy among mothers of school-age children: Conceptualization,

measurement, and correlates. Fam. Relat. 2000, 49, 13–24. [CrossRef]
54. Jones, T.L.; Prinz, R.J. Potential roles of parental self-efficacy in parent and adjustment: A review. Clin. Psychol.

Rev. 2005, 25, 341–363. [CrossRef]
55. Pinheiro, C.; Mena, P. Parental relationships, self-esteem and depressive symptoms in young adults.

Implications of interparental conflicts, coalition and triangulation. Univ. Psychol. 2014, 13, 907–922. [CrossRef]
56. Darling, N.; Steinberg, L. Parenting style as context: An integrative model. In Interpersonal Development;

Zukauskiene, R., Ed.; Routledge: London, UK, 2017; pp. 225–235, ISBN 9781351153676.
57. Laursen, B.; Collings, W.A. Parent-child relationships during adolescence. In Handbook of Adolescent Psychology.

Contextual Influences on Adolescent Development; Lerner, R.M., Steinbergm, L.D., Eds.; John Wiley: Hoboken,
NJ, USA, 2009; Volume 2, pp. 3–42, ISBN 978-0-470-14922-5.

58. MicKinney, C.; Renk, K. Differential parenting between mothers and fathers: Implications for late adolescents.
J. Fam. Issues 2008, 29, 806–827. [CrossRef]

59. Murphy, S.E.; Gallegos, M.I.; Jacobvitz, D.B.; Hazen, N.L. Coparenting dynamics: Mothers’ and fathers’
differential support and involvement. Pers. Relatsh. 2017, 24, 917–932. [CrossRef]

60. León, A.; Hidalgo, V.; Jiménez, L.; Lorence, B. Estilos relacionales en terapia familiar. Necesidades de apoyo
para el proceso de intervención. Mosaico 2015, 60, 16–30.

61. Achenbach, T.M.; Rescorla, L.A. The Manual for the ASEBA School-Age Forms & Profiles; Research Center for
Children, Youth, and Families: Burlington, VT, USA, 2001; ISBN 0938565737.

62. Johnston, C.; Mash, E.J. A measure of parenting satisfaction and efficacy. J. Clin. Child Psychol. 1989, 18,
167–175. [CrossRef]

63. Robinson, C.C.; Mandleco, B.; Olsen, S.F.; Hart, C.H. The Parenting Styles and Dimensions Questionnaire
(PSDQ). In Handbook of Family Measurement Techniques: Instruments and Index; Perlmutter, B.F., Touliatos, J.,
Holden, G.W., Eds.; Sage: Thousands Oaks, CA, USA, 2001; Volume 3, pp. 319–321, ISBN 978-0803972506.

64. Abidin, R.R.; Bruner, J.F. Development of a Parenting Alliance Inventory. J. Clin. Child Psychol. 1995, 24,
31–40. [CrossRef]

65. Olson, D.H.; Portner, J.; Lavee, Y. FACES III; University of Minnesota: St. Paul, MN, USA, 1985.
66. Cohen, J. Statistical Power Analysis for the Behavioral Sciences, 2nd ed.; Erlbaum: Mahwah, NJ, USA, 1988;

ISBN 978-0805802832.
67. IBM SPSS. IBM SPSS Statistics Base 18; SPSS: Chicago, IL, USA, 2010.
68. Tabachnik, B.G.; Fidell, L.S. Using Multivariate Statistics, 5th ed.; Pearson Education: Boston, MA, USA, 2007;

ISBN 978-0205849574.
69. Hair, J.F.; Anderson, R.E.; Tatham, R.L.; Black, W.C. Multivariate Analysis, 5th ed.; Pearson Prentice Hall:

Upper Saddle River, NJ, USA, 2008; ISBN 978-0138132637.

http://dx.doi.org/10.1037/a0029002

http://www.ncbi.nlm.nih.gov/pubmed/23936750

http://dx.doi.org/10.13109/prkk.2008.57.5.381

http://dx.doi.org/10.1037/0893-3200.17.1.121

http://dx.doi.org/10.1023/B:SERS.0000029098.38706.b1

http://dx.doi.org/10.1016/j.appet.2009.02.013

http://dx.doi.org/10.1111/j.1365-2214.2005.00487.x

http://dx.doi.org/10.1111/j.1741-3729.2000.00013.x

http://dx.doi.org/10.1016/j.cpr.2004.12.004

http://dx.doi.org/10.11144/Javeriana.UPSY13\T1\textquoteright 3.rpas

http://dx.doi.org/10.1177/0192513X07311222

http://dx.doi.org/10.1111/pere.12221

http://dx.doi.org/10.1207/s15374424jccp1802_8

http://dx.doi.org/10.1207/s15374424jccp2401_4

Int. J. Environ. Res. Public Health 2019, 16, 1255 14 of 14

70. Jiménez, L.; Lorence, B.; Hidalgo, V.; Menéndez, S. Factor analysis of FACES (Family Adaptability and
Cohesion Evaluation Scales) with families at psychosocial risk. Universitas Psychologica 2017, 16, 140–151.
[CrossRef]

71. Matejevic, M.; Jovanovic, D.; Lazarevic, V. Functionality of family relationships and parenting style in families
of adolescents with substance abuse problems. Procedia Soc. Behav. Sci. 2014, 128, 281–287. [CrossRef]

72. Hawk, S.T.; Hale, W.W.; Raaijmakers, Q.A.W.; Meeus, W. Adolescents’ perceptions of privacy invasion in
reaction to parental solicitation and control. J. Early Adolesc. 2008, 28, 583–608. [CrossRef]

73. Ying, L.; Ma, F.; Huang, H.; Guo, X.; Chen, C.; Xu, F. Parental monitoring, parent-adolescent communication,
and adolescents’ trust in their parents in China. PLoS ONE 2015, 10, e134730. [CrossRef]

74. Bloomfield, L.; Kendall, S. Parenting self-efficacy, parenting stress and child behavior before and after a
parenting programme. Prim. Health Care Res. Dev. 2012, 13, 364–372. [CrossRef] [PubMed]

75. Ardelt, M.; Eccles, J.S. Effects of mothers’ parental efficacy beliefs and promotive parenting strategies on
innercity youth. J. Fam. Issues 2001, 22, 944–972. [CrossRef]

76. Hill, N.E.; Bush, K.R. Relationships between parenting environment and children’s mental health among
African American and European American mothers and children. J. Marriage Fam. 2001, 63, 954–966.
[CrossRef]

77. Bhaumik, D.K.; Roy, A.; Aryal, S.; Hur, K.; Duan, N.; Normand, S.L.; Brown, C.H.; Gibbons, R.D. Sample size
determination for studies with repeated continuous outcomes. Psychiatr. Ann. 2008, 38, 765–771. [CrossRef]

78. Hunter, J.E.; Jensen, J.L.; Rodgers, R. The control group and meta-analysis. J. Methods Meas. Soc. Sci. 2014, 5,
3–21. [CrossRef]

© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

http://dx.doi.org/10.11144/Javeriana.upsy16-2.afef

http://dx.doi.org/10.1016/j.sbspro.2014.03.157

http://dx.doi.org/10.1177/0272431608317611

http://dx.doi.org/10.1371/journal.pone.0134730

http://dx.doi.org/10.1017/S1463423612000060

http://www.ncbi.nlm.nih.gov/pubmed/22464178

http://dx.doi.org/10.1177/019251301022008001

http://dx.doi.org/10.1111/j.1741-3737.2001.00954.x

http://dx.doi.org/10.3928/00485713-20081201-01

http://dx.doi.org/10.2458/v5i1.18302

Homepage

http://creativecommons.org/licenses/by/4.0/.

Copyright of International Journal of Environmental Research & Public Health is the property
of MDPI Publishing and its content may not be copied or emailed to multiple sites or posted
to a listserv without the copyright holder’s express written permission. However, users may
print, download, or email articles for individual use.

• Introduction
• Materials and Methods

Study Design
Participants
Measures
Procedure
Data Analyses
Results

• Discussion
• Conclusions

References

EMPIRICAL PAPER

Brief Strategic Family Therapy: Implementing evidence-based models
in community settings

JOSÉ SZAPOCZNIK1, JOAN A. MUIR1, JOHNATHAN H. DUFF2, SETH J. SCHWARTZ1, &
C. HENDRICKS BROWN3

1Public Health Sciences, University of Miami, Miami, FL, USA; 2Educational and Psychological Studies, University of
Miami, Miami, FL, USA & 3Psychiatry and Behavioral Sciences, Northwestern University, Chicago, IL, USA

(Received 8 April 2013; revised 13 September 2013; accepted 10 October 2013)

Abstract

Objective: To review a 40-year collaborative partnership between clinical researchers and clinicians, in developing,
investigating and implementing Brief Strategic Family Therapy (BSFT). Method: First, to review theory, practice and
studies related to this evidenced-based therapy intervention targeting adolescent drug abuse and delinquency. Second, to
present the BSFT Implementation Model created for the BSFT intervention—a model that parallels many of the
recommendations from the implementation science literature. Results: Specific challenges encountered during the BSFT
implementation process are reviewed, along with ways of conceptualizing and addressing these challenges from a systemic
perspective. Conclusion: The BSFT implementation uses the same systemic principles and intervention techniques as
those that underlie the BSFT clinical model. Building on our on-the-ground experiences, recommendations are proposed
for advancing the field of implementation science.

Keywords: implementation; family therapy; intervention research

An increasing number of preventive and treatment
interventions have been found to be efficacious in
tightly controlled trials, and many of these have been
found to be effective in randomized controlled trials
in real world settings (Faggiano et al., 2010; Watkins
et al., 2011). However, current community practice
in medicine and behavioral health does not fully
incorporate evidence-based interventions (Institute
of Medicine, 2007). The present article grew out of
our experience with one behavioral intervention,
Brief Strategic Family Therapy® (BSFT®), which
has undergone nearly 40 years of clinical develop-
ment and research, and the challenges we encoun-
tered in bringing this evidence-based intervention to
practice settings. The current article is organized
into two major sections: (i) Brief Strategic Family
Therapy: Theory, Research and Practice; and (ii)
Transporting and Implementing the BSFT Model
in Community Based Settings: Challenge and

Solutions. Put together, these two sections trace the
evolution of the BSFT approach from initial model
development through efficacy, effectiveness, process
research, and the recent development of the BSFT
Implementation Model.

Brief Strategic Family Therapy®: Theory,
Research and Practice

The Brief Strategic Family Therapy® (BSFT®)
approach is a short-term family treatment model de-
veloped for youth with behavior problems. Developed
by a team of clinicians and clinician-scientists over
nearly 40 years of research at the University of
Miami’s Center for Family Studies, the BSFT
approach is based on the premise that families are
the strongest and most enduring force in the devel-
opment of children and adolescents (Gorman-
Smith, Tolan, & Henry, 2000; Steinberg, 2001;

Correspondence concerning this article should be directed to José Szapocznik, Department of Public Health Sciences, Leonard M. Miller
School of Medicine, University of Miami, 1120 N.W. 14th Street, 10th Floor, Miami, FL 33136, USA. Email: JSzapocz@med.miami.edu

Psychotherapy Research, 2015
Vol. 25, No. 1, 121–133, http://dx.doi.org/10.1080/10503307.2013.856044

© 2013 Society for Psychotherapy Research

mailto:JSzapocz@med.miami.edu

http://dx.doi.org/10.1080/10503307.2013.856044

Szapocznik & Coatsworth, 1999). Families of youth
with behavior problems such as drug and alcohol
use, delinquency, affiliation with antisocial peers,
and unsafe sexual activity tend to interact in ways
that permit or promote these problems (Vérroneau &
Dishion, 2010). The goal of the BSFT approach,
therefore, is to change the patterns of family inter-
actions that allow or encourage problematic adoles-
cent behavior. By working with families, the BSFT
intervention not only decreases youth problems, but
also creates better functioning families (Santisteban
et al., 2003). Because therapists bring about changes
in family patterns of interactions, these changes
in family functioning are more likely to last after
treatment has ended because multiple family mem-
bers have changed the way they behave with each
other.

The BSFT approach is based on an integration
of structural (Minuchin & Fishman, 1981) and
strategic (Haley, 1976; Madanes, 1981) approaches
to family therapy. We proposed such an integration
of structural and strategic principles given our early
clinical experiences, where (i) adolescent behavior
problems were clearly linked to structural problems
(i.e., maladaptive patterns of interactions) within the
family and (ii) a time-limited, strategic approach,
targeting only those family processes that are directly
associated with the adolescent’s symptoms, appeared
to be the most efficacious way to engage and retain
families in treatment. Indeed, our own clinical
experiences have continued to guide the refinement
of the BSFT model. We have used a collaborative,
bidirectional approach between clinicians and clini-
cian-scientists in developing the BSFT model and its
various modules (e.g., BSFT Engagement).

Based on our early experience with Cuban famil-
ies, within the BSFT approach, the family is con-
ceptualized as a system that is “greater than the sum
of its parts” (Bowen, 1978)—that is, a system in
which the behavior and development of each family
member are interdependent with the behavior and
development of other family members. Changing the
adolescent’s behavior, then, requires changing the
family system as a whole. Specifically, the BSFT
approach aims to modify the repetitive patterns of
family interactions that support the adolescent’s
drug use and associated negative behavior, and to
strengthen adaptive family interactional patterns that
promote healthy development.

Specific Techniques Used in the BSFT Model

The BSFT intervention employs four specific theor-
etically and empirically supported techniques deliv-
ered in phases to achieve specific goals at different
times during treatment. These techniques were built

from the work of master clinicians such as Minuchin,
Haley, and Madanes, and from the clinical experi-
ence of our clinicians and clinician-scientists in
working with our minority families. As will be noted,
this work is intended to make the family fully
participatory—a full partner—in the change process.
Early sessions are characterized by joining interven-
tions that aim to establish a therapeutic alliance with
each family member as well as with the family as a
whole. The therapist here demonstrates acceptance
of and respect toward each individual family member
as well as the way in which the family operates as a
whole. Early sessions within treatment also include
tracking and diagnostic enactment interventions
designed to systematically identify family strengths
and weaknesses and develop an overall treatment
plan. A core feature of tracking and diagnostic
enactment interventions includes strategies that
encourage the family to behave as they would usually
behave if the therapist were not present. Family
members are encouraged to speak with each other
about the concerns that bring them to therapy, rather
than have them direct comments to the therapist.
From these observations, the therapist is able to
diagnose both family strengths and problematic
relations. Reframing techniques are then used to
reduce family conflict and create a motivational
context (i.e., hope) for change.

Throughout the entirety of treatment, therapists are
expected to maintain an effective working relationship
with family members (joining), facilitate within-fam-
ily interactions (tracking and diagnostic enactment),
and directly address negative affect/beliefs and family
interactions. The focus of treatment, however, shifts
to implementing restructuring strategies to transform
family relations from problematic to mutually sup-
portive and effective. These interventions include
(i) directing, redirecting, or blocking communication;
(ii) shifting family alliances; (iii) helping families
develop conflict resolution skills; (iv) developing
effective behavior management skills; and (v) foster-
ing parenting and parental leadership skills.

BSFT Engagement. Often, the same interac-
tional problems that are linked with the adolescent’s
symptoms are also associated with the family’s
inability to come to treatment. Within the BSFT
model, specialized engagement techniques have
been developed in collaboration with our senior ther-
apists and evaluated by a team of clinical researchers
(Coatsworth, Santisteban, McBride, & Szapocznik,
2001; Santisteban et al., 1996; Szapocznik et al.,
1988). In this context, engagement refers to a set of
strategies designed to bring all the relevant family
members into treatment. The same intervention
domains used in BSFT treatment—joining, tracking

122 J. Szapocznik et al.

and diagnostic enactment, and reframing—are also
used to engage families into therapy. The therapist
begins to explore the family interactions in a first call
by giving the caller a task such as bringing all the
members of the family into the first session. Through
the caller’s response (e.g., “my husband won’t come
to treatment”) the BSFT therapist can begin dia-
gnosing family interactions. In these cases, and with
the caller’s approval, the therapist will insert herself
into the family’s process by reaching out directly to
the family member who either does not want to
come to treatment or whom the caller is not eager to
bring to treatment, as a way of getting around the
interactional patterns that interfere with bringing all
family members into treatment.

BSFT Research

BSFT research has occurred in four primary domains:
(i) studies evaluating BSFT efficacy in reducing
adolescent behavior problems and drug use and in
improving family functioning; (ii) studies evaluating
the efficacy of BSFT Engagement procedures in
bringing and retaining families in treatment; (i)
studies evaluating the effectiveness of the BSFT
intervention in community settings; and (iv) studies
examining the effects of BSFT therapist prescribed
behaviors on adolescent and family outcomes. These
studies have led the US Department of Health and
Human Services to label the BSFT approach as one
of its “model programs” and to be included in the
National Registry of Evidence-based Programs and
Practices (NREPP; http://nrepp.samhsa.gov/ViewIn
tervention.aspx?id=151). We discuss research in
each of these four areas in this section.

Led by a team of clinical researchers, the majority
of the earlier studies on the BSFT intervention
were conducted with Hispanic families in Miami
(Coatsworth et al., 2001; Santisteban et al., 1996,
2003; Szapocznik et al., 1988, 1989). The model was
originally developed to address acculturation discre-
pancies between Cuban adolescents and their par-
ents (Szapocznik, Scopetta, & King, 1978a, 1978b).
At the time when the BSFT model was developed,
Szapocznik et al. (1978a, 1978b) observed that the
vast majority of the drug-abusing and delinquent
adolescents referred for treatment evidenced cul-
tural, as well as normative developmental, conflicts
with their parents. The researchers drew upon their
own clinical experience, as well as on the experiences
and observations of the therapists working with these
adolescents and their families, in developing a model
that would decrease the culturally related conflicts
within client families. However, in addition to the
efficacy research on the BSFT model with Hispa-
nics, effectiveness research has suggested that the

model is equally applicable to African American and
White American families as well (Robbins, Feaster,
Horigian, Rohrbaugh, et al., 2011). The model is
currently being used broadly with a variety of
populations in the United States and Europe.

BSFT Efficacy. The efficacy of the BSFT model
in reducing behavior problems and drug abuse has
been tested in two randomized, controlled clinical
trials. In the first trial, Szapocznik and colleagues
(1989), including several very experienced clinicians,
randomized behavior-problem and emotional-problem
6–11-year-old Cuban boys to BSFT, individual psy-
chodynamic child therapy, or a recreational placebo
control condition. The two treatment conditions,
implemented by highly experienced therapists, were
found to be equally efficacious, and more efficacious
than recreational control, in reducing children’s
behavioral and emotional problems and in maintain-
ing these reductions at 1-year post-termination.
However, at 1-year follow-up, the BSFT condition
was associated with a significant improvement in
independently rated family functioning, whereas
individual psychodynamic child therapy was asso-
ciated with a significant deterioration in family
functioning. To reflect the participation of the thera-
pists in the design and conduct of the study, all four
therapists were authors on the major outcome paper
(Szapocznik et al., 1989).

In a second study, Santisteban and colleagues
(2003) randomly assigned Hispanic (half Cuban
and half from other Hispanic countries) behavior-
problem and drug-abusing adolescents to receive
either the BSFT intervention or adolescent group
counseling modeled after a widely used program in
the community. Three therapists delivered the BSFT
condition. One was a highly experienced clinician
who was proficient as a BSFT therapist. Reflecting
his broad and thoughtful contribution to the inter-
vention delivery as well as to other aspects of the
study, he was an author on the outcome article. The
other two, more junior therapists were supervised by
the experienced BSFT therapist. Within the control
condition, group counseling, a very experienced
school counselor conducted the sessions in line
with the way group counseling was being conducted
in the community, without receiving any guidance or
interference from the study team.

The BSFT condition was significantly more effi-
cacious than group counseling in reducing conduct
problems, associations with antisocial peers, and
marijuana use, and in improving independent ratings
of family functioning (Szapocznik et al., 1991).
Interestingly, baseline family functioning emerged
as a moderator of treatment effects. For families
entering the study with comparatively good family

Brief Strategic Family Therapy 123

http://nrepp.samhsa.gov/ViewIntervention.aspx?id=151

http://nrepp.samhsa.gov/ViewIntervention.aspx?id=151

functioning, family functioning remained high in
the BSFT condition, whereas it deteriorated in the
families of adolescents in group therapy. For families
entering the study with comparatively poor family
functioning, the BSFT condition significantly
improved family functioning, whereas family func-
tioning did not improve in families assigned to
adolescent group therapy.

The BSFT model has also been tested with African
American as well as Hispanic adolescents with
behavior problems. In fact, Santisteban and collea-
gues (1997) found that BSFT treatment significantly
reduced associations with antisocial peers and
improved family functioning for both Hispanics and
African Americans. However, BSFT treatment was
significantly more efficacious in reducing association
with antisocial peers among African Americans than
among Hispanics, whereas it was significantly more
efficacious in improving family functioning among
Hispanics than among African Americans.

BSFT Engagement. The efficacy of BSFT
Engagement was tested in three separate studies
with Hispanic adolescents with behavior problems
and their families. Clinicians played key roles on
the research teams for all three of these studies. In
the first study (Szapocznik et al., 1988), Hispanic
(mostly Cuban) families with drug-abusing adoles-
cents were randomly assigned to BSFT + Engage-
ment as Usual or to BSFT + BSFT Engagement.
Results indicated that 93% of the families in the
BSFT Engagement condition, compared with only
42% of the families in the Engagement as Usual
condition, engaged in treatment. Further, 75% of
families in the BSFT Engagement condition com-
pleted treatment, compared with 25% of families in
the Engagement as Usual group. Two clinicians were
authors on the major outcome paper (Szapocznik
et al., 1988).

A second study (Santisteban et al., 1996), which
included the senior clinician in the study as an
author, found similar results, with 81% of families
randomly assigned to BSFT Engagement success-
fully engaging in treatment compared to 60% of the
families in an Engagement Control condition. A
third study (Coatsworth et al., 2001) tested the ability
of BSFT + BSFT Engagement to engage and retain
adolescents and their families in comparison to a
community control condition implemented by a com-
munity treatment agency. Findings in this study indi-
cated that BSFT Engagement successfully engaged
81% of families in treatment—significantly higher
than the 61% rate in the community control condi-
tion. Likewise, among families who were successfully
engaged, 71% of BSFT cases, compared to 42% in

the community control condition, were retained to
treatment completion.

BSFT Effectiveness. A BSFT effectiveness
study was conducted within NIDA’s National Drug
Abuse Treatment Clinical Trials Network (Tai et al.,
2010). The Network is composed of 13 nodes, each
led by a university research team (the lead author is
PI of one of these nodes) in collaboration with
community providers, community-based substance
abuse treatment centers, and medical programs. The
Network was established to increase the rate at
which evidence-based practices were being trans-
lated into the frontlines of practice. Providers had
argued that many research studies had not been
designed with provider settings in mind, making it
challenging to translate evidence-based practices
tested under laboratory conditions into clinical
practice. To achieve increased translation, it was
essential to involve both researchers and practi-
tioners in designing the effectiveness studies that
would be implemented in the Network’s community
settings (Tai, Sparenborg, Liu, & Straus, 2011). The
concept was to conduct rigorous randomized clinical
trials of evidence-based practices in real-world,
community-based settings. To help ensure that studies
were designed to maximize adoption by providers,
interventions would be delivered by real-world
providers. To achieve this kind of synergy between
researchers and practitioners, teams of providers and
researchers selected the studies to be conducted and
were intimately involved in their design. In this
spirit, the BSFT study design, implementation, and
manuscript writing team included clinician-scientists
and provider-investigators, the latter from particip-
ating study sites. For example, denoting this kind of
collaboration, the major outcome paper (Robbins,
Feaster, Horigian, Rohrbaugh, et al., 2011) was
authored by seven clinicians in leadership roles in
community-based adolescent drug abuse treatment
programs, six university-based clinician-scientists,
and one biostatistician. In the BSFT effectiveness
trial, we recruited 480 families of adolescents (213
Hispanic, 148 White, 110 Black and 9 Other; 377
male, 103 female) who had been referred to drug
abuse treatment at eight community treatment agen-
cies located around the United States. Adolescents
and their families were randomized to either BSFT
or Treatment as Usual (TAU, which was allowed to
vary based on whatever treatment the agency typic-
ally provided for drug-using adolescents). Particip-
ating therapists were employees of the participating
community agencies. They had a broad range of
educational backgrounds (ranging from bachelor’s
to doctoral degrees) and prior experience (from

124 J. Szapocznik et al.

minimal to extensive; from having worked with teens
and families to never having done so).

Both families and therapists were randomized
within each agency to either the BSFT or TAU
modalities. Regarding engagement and retention,
families in TAU were 2.33 times (11.4% BSFT;
26.8% TAU) more likely to fail to engage and 1.41
times (40.0% BSFT; 56.6% TAU) more likely to fail
to retain compared to families in the BSFT condi-
tion. These significant differences were consistent
across racial/ethnic groups.

Median drug use at 12 months, the final follow-
up, was significantly lower in the BSFT condition
(Mdn = 2 days) than TAU (Mdn = 3.5 days),
although the actual number of drug use days
remained low from baseline through follow-up in
both conditions. These low levels of drug use may
have been, at least in part, a function of the majority
of adolescents having come from residential treat-
ment or having been referred (and monitored) by the
juvenile justice system.

Family functioning in this study differed between
adolescent and parent reports, with the BSFT condi-
tion producing significantly greater improvements in
parent-reported family functioning compared to the
treatment as usual condition. Adolescents in both
conditions, however, reported significant improve-
ments in family functioning, with no statistically
significant differences by treatment condition. Post-
hoc analyses also demonstrated that the BSFT
intervention was more effective than Treatment as
Usual in improving parental functioning, and that
this effect was mediated by parental reports of family
functioning.

BSFT Therapist Behaviors, Therapy Process,
and their Relationship to Outcomes

Research has demonstrated that negativity in family
interactions in the first session leads to failure to
retain families in treatment past the first session
(Fernandez & Eyberg, 2009); that families are more
likely to engage in treatment if negativity is reduced
(Robbins, Alexander, & Turner, 2000); that refram-
ing is an effective method of reducing negativity
(Moran, Diamond, & Diamond, 2005); and that
reframing is the technique that is least likely to dam-
age therapists’ rapport (alliance, bond) with family
members (Robbins et al., 2006). Research on BSFT
engagement has indicated that if, in the first session,
the therapist does not develop a balanced set of
bonds with the parent and the youth, this imbalance
leads to early dropout from treatment (Robbins et al.,
2000). The empirical evidence derived from the
work of these clinicians has brought about findings

that have been incorporated into BSFT treatment as
conducted today.

Therapist collaboration in delivering evidence-
based interventions is essential to achieve high
adherence rates and, consequently, better outcomes.
Using data from the effectiveness study, Robbins,
Feaster, Horigian, Puccinelli, et al. (2011) examined
the extent to which BSFT therapists implemented
the treatment protocol properly. Adherence (pre-
scribed) items were rated in terms of the four theor-
etically and clinically relevant expected/prescribed
therapist behaviors: joining, tracking and eliciting
enactments, reframing, and restructuring. Therapist
adherence to the BSFT model was associated with:

(1) Engagement: Higher levels of restructuring and
reframing (creating a motivational context for
change) significantly increased the likelihood of
families being engaged in treatment. Because
joining, tracking, and diagnosis were high
across most cases, what distinguished cases
that came to a second session from those that
did not were reframing and restructuring, the
technique domains that therapists found most
challenging.

(2) Retention: The impact of adherence on reten-
tion was evaluated using adherence ratings for
sessions 2–7, with retention defined as a family
attending at least eight sessions. Higher levels
of all four technique domains—therapist join-
ing, tracking and enactment, reframing, and
restructuring—predicted significantly higher
rates of retention. A one standard-deviation
increase in reframing predicted a 19% increase
in the likelihood of retention; a one standard-
deviation increase in joining predicted a 22%
increase in the likelihood of retention; a one
standard-deviation increase in restructuring
predicted a 59% increase in the likelihood of
retention; and a one standard-deviation increase
in tracking and eliciting enactment predicted
a 62% increase in the likelihood of retention.

(3) Family functioning: Overall joining levels pre-
dicted improvements in observer-reported
family functioning.

(4) Adolescent drug use: Therapists who were high
in joining in early sessions and remained so
throughout treatment were associated with
“better” adolescent drug use outcomes. Thera-
pists whose attempts to restructure maladap-
tive family interactions increased most during
the course of treatment were also associated
with “better” adolescent drug use outcomes.
Thus, therapists who failed to implement suf-
ficient numbers of restructuring interventions
were less able to affect the youths’ drug use.

Brief Strategic Family Therapy 125

These results indicate that, within a sample of thera-
pists from community agencies, therapists’ clinical
interventions follow a pattern that is consistent with
the theory behind the BSFT model. Indeed, the
specific therapist behaviors prescribed by the BSFT
approach are needed to engage families in treatment,
retain them, improve family functioning, and reduce
adolescent drug use. However, when therapists did
not engage sufficiently in these behaviors, adolescent
outcomes tended to suffer. On the basis of consid-
erable input from the participating therapists as well
as the authors’ own observations, the authors con-
cluded that adherence ratings were affected by a
number of systemic factors, including over-burdened
therapists and therapists’ lack of embeddedness
within dedicated BSFT units. That an effectiveness
study, conducted with community providers as
therapists, revealed such impactful effects of therap-
ist adherence suggests strongly that implementing
the model with fidelity in community agencies is
necessary for adolescents and families to achieve the
maximum benefits from the BSFT treatment model.

Transporting and Implementing the BSFT
Model in Community Settings: Challenges and

Solutions

What is involved in transporting an evidence-based
intervention into community agencies? The literat-
ure suggests that the combination of a detailed treat-
ment manual, well-developed training programs,
and an organization (sometimes called a purveyor)
that promotes the intervention and provides therapists
with training and ongoing monitoring, coaching,
and feedback is needed (Fixsen, Blase, Naoom, &
Wallace, 2009). These resources were all available for
the BSFT model a decade ago. However, implementa-
tion brings a number of challenges in terms of
transforming agency practices to ensure that the
model is implemented with fidelity (Fixsen, Blase, &
Van Dyke, 2011) and sustained (Henggeler, 2011).
Community agencies and clinicians may not be
accustomed to the rigors of evidence-based treat-
ments, and there are a number of important chal-
lenges that arise during the process of working with an
agency that has expressed interest in delivering an
evidence-based treatment.

Our experiences in implementing the BSFT
model within community agencies have been con-
sistent with the challenges reported in the emerging
literature on implementation (Fixsen, Blase, et al.,
2011). The solutions that we have utilized were not
directly informed by the implementation literature—
but our solutions have dovetailed with recommenda-
tions from leaders in the implementation science
field (Addiction Technology Transfer Center Network

Technology Transfer Workgroup, 2011). Similar to the
implementation science literature (see Fixsen et al.,
2009; Fixsen, Blase, et al., 2011), we view successful
implementation in terms of adoption, fidelity, and
sustainability. Adoption refers to an agency’s decision
to deliver an evidence-based treatment model and to
reconfigure itself so that the model can be delivered
as intended; fidelity represents delivery of the model
in accordance with the treatment manual; and
sustainability represents a lasting commitment and
ability to continue delivering the model on a long-
term basis. Broadly, we have developed a systems
approach to working with agencies, where some of
the same principles that we use with families around
the presenting symptom of “adolescent problem
behaviors” are utilized with funders, agency leaders,
supervisors, and therapists around the challenges of
implementation. We describe these challenges and
approaches in more detail in this section.

Our early implementation experience. Our
first attempts to disseminate the BSFT clinical inter-
vention into the community involved simply training
therapists from community agencies in the BSFT
approach and supervising them to achieve a specified
level of fidelity in their delivery of the BSFT approach.
These therapists would attend our training sessions,
and would then apply the BSFT model, receiving
monitoring, coaching, and feedback for fidelity.
Many therapists would reach fidelity levels for
“BSFT Therapist Certification.” In most cases,
however, these therapists encountered a number of
obstacles to using the BSFT approach, and initial
attempts to infuse the BSFT model into practical
settings were largely unsuccessful in terms of attain-
ing enduring fidelity and sustainability. We received
considerable input from therapists that helped us to
identify the challenges they were encountering.
Agency supervisors, for instance, often place addi-
tional demands on therapists’ time, such as addi-
tional caseloads using other therapy models that
distracted therapists from their BSFT caseloads.
For example, the BSFT approach mandates that
families be seen wherever and whenever necessary—
meaning that therapists must be available during
evening and weekend hours. However, when thera-
pists have large additional daytime caseloads, they
may not be available when families are available—
evenings and weekends. Indeed, we experienced these
challenges in our effectiveness study when therapists
who were assigned to deliver the BSFT model almost
always had large caseloads using various treatment
approaches. A dedicated BSFT team is necessary
to deliver the model, given all of the requirements
involved, and given the need for therapists to
maintain conceptual focus on the model.

126 J. Szapocznik et al.

In our early implementation experience, although
the agency had expressed interest in delivering the
BSFT model, the agency leadership did not under-
stand all that this entailed. When we followed up
with therapists and agencies after training, we found
that many therapists had not been able to continue
to conduct the BSFT model without agency support,
and had consequently reverted to previous, less
demanding treatment models. Moreover, without
ongoing monitoring, coaching, and feedback, thera-
pists were unable to maintain acceptable levels of
adherence or fidelity.

As our experience attempting to solely train (with
monitoring, coaching, and feedback throughout
training) therapists using the BSFT model demon-
strates, an evidence-based model cannot simply be
“picked up” from the research setting and “put
down” into a community agency. The members of
the BSFT research team, most of whom are clinic-
ally trained, recognized that a second layer of
intervention at the organizational level was needed
to facilitate successful implementation. From a fam-
ily systems theory perspective, we understand that it
is difficult to change one family member’s behavior
without changing the family system. Similarly, we
learned that the same principles applied to agencies
and their therapists: It is difficult to implement an
evidence-based intervention in a community agency
without creating a participatory process with agency
and therapist personnel that establishes the context
that will support the adoption, fidelity, and sustain-
ability of the model. Based on this experience, and
on our unsuccessful attempts to train therapists
without working directly with the agency leadership,
we developed a BSFT Implementation model,
based on the systemic principles in which BSFT is
grounded.

The feedback that we received from therapists and
their local supervisors helped to shape the kind of
implementation intervention that was needed. For
example, it was clear that therapists were being
pulled in many directions and did not have the
time to dedicate to providing services to each family
with the persistence required by the BSFT model.
Therapists felt pulled in many directions not only by
their heavy caseloads, but also because of the need to
provide services using other approaches that are
incompatible with the theoretical perspective under-
lying the BSFT approach. As a consequence, it
became clear that a dedicated BSFT team with an
agency advocate was needed to deliver the model,
given all of the requirements involved, and given
the need for the therapist to maintain conceptual
focus on the model. This made sense because the
efficacy of the BSFT model (and other family-based
models) had always been tested with dedicated

teams. Moreover, when we looked at other family-
based models with successful sustainability, such as
Functional Family Therapy (Breuk et al., 2006) and
Multisystemic Therapy (Henggeler, 2011), we
observed that these models had dedicated imple-
mentation teams.

How the BSFT model informs “adoption” in
our implementation model. The BSFT Imple-
mentation model now extends the concept of sys-
tems to apply to therapists, the agencies with which
they work, and these agencies’ social ecology. Sim-
ilar to our work in BSFT intervention, our experi-
ence in BSFT Implementation has taught us that a
participatory approach to organizational work—at all
levels of the agency—is essential to establish the
context for adoption, fidelity, and sustainability.

Just as families require support from their social
ecologies—such as adequate financial resources and
freedom from excessive stress on the parent figures—
treatment agencies must become partners in the
implementation process to ensure that they, for
example, seek and receive sufficient support from
their funders, referral sources, and other stake-
holders. Such support is essential to ensure that
agencies have the flexibility to adopt (e.g., funding
by case rather than by session), reach acceptable
levels of fidelity (e.g., have time set aside for therapists
and supervisors to train, be supervised, and review
their own work), and achieve sustainability (e.g.,
long-term funding based on clinical outcomes rather
than hours of services delivered; demonstrated cost
savings to the funder and/or society; trained and
certified BSFT on-site supervisor to ensure ongoing
supervision to fidelity over time who can also func-
tion as an advocate for the model within the agency).
Therefore, successful BSFT implementation requires
full collaboration between the BSFT Institute, the
agency (e.g., BSFT therapists and supervisors,
agency middle and upper management), and its
context (e.g., funders and other stakeholders such
as judges who are often a major referral source). Such
collaborations help to create a broadly participatory
process in which all of the levels of the organization
and its context, from therapists to agency middle-
management, agency leadership, and funders, are
actively involved in the implementation process.

To provide a BSFT Implementation intervention,
we created the BSFT Institute, an example of an
implementation “purveyor” whose goal is to facilitate
adoption of, fidelity to, and sustainability of the
evidence-based treatment model (Fixsen et al., 2009).
The BSFT Institute is run by clinicians who are
highly experienced and proficient in the BSFT ther-
apy and/or implementation models. The BSFT
Implementation approach borrows from the BSFT

Brief Strategic Family Therapy 127

clinical intervention by engaging all members of an
organization to create a participatory process. For
example, the BSFT consultant joins with each of the
individuals, inside and outside the agency, who has,
or will have, a critical impact on the functioning of the
BSFT unit. This joining requires identifying the
“key” members of the system—therapists, adminis-
trative supervisors, agency director, clinical director,
community referral sources, funders, and other
stakeholders. Joining also often includes identifying
the goals of agency personnel at all levels and
ensuring that the BSFT model can help to achieve
these goals. For example, an agency director may cite
pressure from funders to treat as many adolescents as
possible, for the least possible cost, within a given
period of time. We would then present evidence
indicating that the BSFT approach is more effective
in reducing adolescent drug use and behavior pro-
blems compared to other approaches commonly used
by community agencies (Robbins, Feaster, Horigian,
Puccinelli, et al., 2011; Santisteban et al., 2003), and
present evidence from Florida’s Redirection program
demonstrating reduced cost to the state (http://www.
evidencebasedassociates.com/featured_projects/flori
da.html). Presenting such evidence helps promote
buy-in on every level, making it more likely that the
BSFT model will be adopted and supported by
funders. Similarly, therapists are interested in out-
comes in the sense that they want to help their client
families. When therapists see their ability to engage
and retain families increase, they quickly become
supporters of the BSFT approach.

Fidelity. Research on the BSFT clinical interven-
tion (Robbins, Feaster, Horigian, Puccinelli, et al.,
2011) and other family-based models (e.g., multi-
systemic therapy; Schoenwald, Sheidow, & Letorneau,
2004) has demonstrated that fidelity is essential to
achieve desired outcomes. Our research has demon-
strated that independently rated adherence to pre-
scribed BSFT behaviors predicts engaging and
retaining families in treatment, improving family
functioning, and reducing adolescent drug use. As
a result, ensuring fidelity to the model is a core
principle of moving intervention research into prac-
tice. As with other similar models (e.g., Functional
Family Therapy, Multisystemic Family Therapy),
BSFT Implementation experience indicated that, to
attain and maintain fidelity over time, administrative
units need to be established and dedicated to the
BSFT model. These units have therapists devoted
solely to delivering the evidence-based intervention.
In the BSFT model, typically four or five therapists
are selected to form a BSFT team within the agency,
and weekly supervision occurs after initial training to
ensure the therapists are adherent to the model.

Additionally, an agency person outside the BSFT
therapy team is appointed by the agency as the
BSFT program administrative coordinator to man-
age the BSFT program within the organization and
the community, and to serve as a liaison between the
BSFT Institute and the agency. The organizational
component of the BSFT Implementation model is
consistent with our BSFT intervention theory, in
which agency-supported leaders are identified who
can motivate and support therapists in such a way that
the agency’s desired outcomes of adoption, fidelity,
and sustainability can be achieved—that is, that will
better adolescent outcomes and sustained funding
for the program.

Interfacing with therapists. In addition to
addressing relevant organizational factors important
for successful implementation, it is also essential to
listen carefully to therapists’ objections and feedback
regarding their experiences with the BSFT model. In
our experiences, along with those reported by others
in the field of family therapy research (e.g., Henggeler,
2011), therapists, like professionals in other service
fields, often understand the importance of fidelity to
the evidence-based model, but they dislike the
scrutiny that accompanies intensive supervision and
regularly scheduled feedback sessions (Fixsen, Scott,
Blase, Naoom, & Wagar, 2011). Some of the thera-
pists in the agencies with whom we have worked
have commented that the intensive supervision
involved in delivering the BSFT approach “feels
like graduate school all over again.”

BSFT Implementation maintains an essential
commitment to the clinicians who, at the front line
of practice, make or break successful implementa-
tion. Although joining with agency clinicians and
selecting and training the BSFT team of therapists
enhances successful adoption and faithful utilization
of the BSFT approach, obstacles nonetheless arise.
Many therapists, for example, are often reluctant to
adopt a manualized treatment (Henggeler, 2011),
with the most experienced therapists often expres-
sing the greatest doubts. Often therapists earlier in
the careers are more willing to explore new clinical
models, particularly when they feel that they are
struggling with their current caseloads. Another
challenge arises out of the BSFT supervision
approach, which involves monitoring through video-
taping all sessions. Therapists are often initially
uncomfortable with the perceived scrutiny involved
in this process. Given the systemic approach under-
lying the BSFT clinical and intervention models, the
BSFT model manager views her/himself as main-
taining a systemic relationship with each therapist,
and as such the model manager shares responsibility
for therapists’ behavior in therapy sessions. Thus,

128 J. Szapocznik et al.

http://www.evidencebasedassociates.com/featured_projects/florida.html

http://www.evidencebasedassociates.com/featured_projects/florida.html

http://www.evidencebasedassociates.com/featured_projects/florida.html

the BSFT model manager assumes a leadership role
in helping therapists develop comfort with the
manualized intervention and behaving with families
in ways that are consistent with the model. BSFT
clinical techniques such as reframing, which are
useful in creating a motivational context for change
with families, are also useful in creating a motiva-
tional context for change for therapists: “I can see
that you struggle with videotaping. Yet your com-
mitment to providing the best treatment for your
clients is exemplary. Even when videotaping feels so
awkward, you are willing to do it for the benefit of
your clients.”

Selecting therapists. One way to maximize the
likelihood that therapists will deliver the BSFT
model properly is to select therapists who are best
matched with the model’s assumptions and require-
ments. The BSFT approach requires a strong com-
mitment to systemic work, conceptual ability, the
ability and willingness to take on challenging cases,
and the willingness to work in rough neighborhoods.
Moreover, bringing whole families to treatment is
often quite difficult—and many therapists are wary
of the work and potential frustration involved.
Indeed, specialized BSFT engagement strategies
would not be necessary if drug-abusing or delin-
quent adolescents’ families were able to come to
treatment together easily. When considering whether
to accept therapists, the BSFT Institute uses these
and other criteria, as assessed through interviews. In
addition, a therapist’s family therapy audition tape is
used in the selection process. We do not expect
therapists to know the BSFT model or to have
experience in family therapy. However, because we
work with all family members, candidates must be
able to support all family members and not to take
sides for personal reasons. An example of an unsuit-
able therapist candidate would be someone who is
unable to be supportive of male or female parents,
who is likely to staunchly support one parent to the
detriment of her/his relationship with another parent,
or who takes generational sides (e.g., youth vs.
parent). Although some of these abilities can be
taught such as having balanced alliances, others such
as the ability to relate to all family members may be
more difficult to teach. The therapist must be the
leader who will help the parent and the child change
their behaviors—which the therapist cannot achieve
if she/he is unable to establish a strong bond with all
of the people who need to change. Thus, therapists
must be able to adopt a nonjudgmental stance
toward family members who behave in ways that
appear maladaptive. Therapists must also possess the
maturity to “own” their negative reactions to family
members, to set aside their own views of family

members whom they dislike, and to avoid permitting
their frustration concerning a family’s lack of pro-
gress to derail the course of therapy. We all may have
negative reactions to particular people, but, when
conducting therapy, we must be aware of these
feelings so that we can manage them effectively.
Accordingly, during the therapist selection phase,
therapists are rated on a number of systems-based
criteria, including the ability to communicate with all
family members without judgment, the ability to
recognize family strengths and to validate family
members, and speaking to each family member in
ways with which that family member can resonate.

Further, as noted by Phares, Lopez, Fields,
Kamboukos, and Duhig (2005), fathers are seldom
involved in family-based treatment, even if they are
present in the home and/or in the child’s life. In our
experiences with BSFT therapist trainees, indivi-
duals in fathering roles—those who play responsible
roles in their children’s lives—are left out of treat-
ment because therapists may not fully understand
the critical role that every family member (especially
father figures) plays in the family system. Fathers
who have mental health, substance abuse, or crim-
inal problems, and/or who appear not to be involved
in their children’s lives, are often left out of treat-
ment because of the difficulties involved in engaging
them in therapy. For example, a frequent family
pattern of interaction has mothers and behavior-
problem sons in a close relationship, whereas fathers
are alienated from both mother and son. This
pattern of interactions often gives rise to triangula-
tions that can only be addressed when all members
of the triangle are present. Hence, restructuring the
father’s (and the mother’s) relationship with other
family members—including the target adolescent—is
vital to improving family functioning and to ameli-
orating the adolescent’s symptoms. Fathers, like
mothers, are essential members of the family and
must be included in the treatment process. In our
experience, when a critical family member is missing
from the therapy session, it is impossible for the
therapist to observe the family’s repetitive patterns of
interactions as they would occur at home (i.e., to
diagnose the repetitive patterns of interactions that
may be linked to the adolescent’s problem beha-
viors) because a critical individual is missing who,
when present, changes the family’s patterns of
interactions dramatically. What is essential in the
selection process is to identify therapists who have
the ability to relate to all family members, including
fathers. Many people may be intimidated by father
figures, more so than by mother figures.

Involving fathers may require conducting sessions
at times when both parents are available; interfacing
with substance-abuse, mental health, or criminal

Brief Strategic Family Therapy 129

justice systems for fathers involved with these sys-
tems; or reaching out to a father who has remarried
or lives with a new family. Therapists may initially be
reluctant to take on the additional work that is
required to include fathers in treatment. Just as
joining with a family member requires convincing
that person that she or he has something to gain from
coming to therapy, overcoming a therapist’s objec-
tion to working with whole families (including
fathers) may require presenting research evidence
demonstrating the importance of fathers (and all
relevant family members) in adolescents’ lives—and
in their success in helping the target adolescent. The
parental system must always participate in BSFT
treatment, and fathers are very often part of the
parental system.

A broad organizational perspective. As we
suggested earlier, consistent with the systemic
approach on which the BSFT intervention is based,
challenges in implementing the BSFT model and
working with clinicians are also viewed from a
broader, organizational perspective. Examples of
such obstacles include cases where BSFT therapists
are located in administrative units that are not
dedicated to delivering the BSFT model. In such
situations, therapists may be given a caseload of 30–
60 patients. Such caseloads can be managed through
individual and group interventions, but are not
possible to manage when whole families need to be
engaged in treatment, when sessions often must be
conducted in families’ homes during evening and
weekend hours, and when retaining family members
requires frequent out-of-session contacts. The usual
caseload for BSFT therapy is 10 families. For
another example, if a community agency is not fully
involved in the delivery of the BSFT model, thera-
pists will often fail to submit videotapes required for
supervision. Without these videotapes, we are unable
to provide adequate monitoring, coaching, and
feedback on BSFT adherence. Hence, supervisors
cannot be successful unless the agency leadership is
actively involved in ensuring that therapists have a
caseload that allows them to deliver the BSFT
intervention properly, are provided with adequate
time to review their own videotapes, and are
required to submit videotapes for supervision.

Rather than faulting therapists or other agency
members for implementation challenges, such as
clinicians’ reluctance to quickly adopt the BSFT
model, BSFT Implementation focuses on exploring
the interactional patterns that support and maintain
these obstacles. Using this systemic thinking, the
BSFT Implementation team focuses on transform-
ing interactional patterns that represent obstacles
to change toward BSFT adoption and fidelity. BSFT

Implementation applies BSFT intervention techniques
such as joining, tracking and eliciting, diagnosing,
reframing, and restructuring to transform organiza-
tional interactional patterns that are obstacles to
implementation. Because the BSFT intervention is
a problem focused model, BSFT Implementation
focuses only on those interactional patterns within
the agency that must be reconfigured for the BSFT
model to be delivered successfully. This principle is
parallel to the focus of the BSFT clinical interven-
tion—only those family interactions that are directly
associated with the adolescent’s symptoms are tar-
geted in therapy. Other organizational issues are
unlikely to be addressed if they are peripheral to
BSFT Implementation.

Sustainability. Much of the work already men-
tioned has found that engaging multiple levels of an
agency is essential to sustainability. In addition, we
collaborate with agency leadership to facilitate sup-
port from funders and referral agents, often giving
presentations on the BSFT model to educate these
stakeholders on evidence-based practices generally
and the BSFT approach specifically. In terms of
promoting sustainability, nothing is more important
than an engaged funder. In addition, to ensure
sustainable fidelity to the BSFT manual within the
agency, as part of the training, monitoring, coaching,
and feedback related to the BSFT approach, an “on-
site” supervisor is selected in collaboration with
agency leadership. The on-site supervisor is one of
the therapists in training who distinguishes him/
herself in their BSFT abilities, demonstrates leader-
ship skills by helping his/her co-workers in providing
guidance with their BSFT work, and has the support
of his/her co-workers and the agency leadership.
In addition to providing ongoing on-site supervision,
this person becomes the BSFT advocate or cham-
pion within the agency, ensuring that agency func-
tioning continues to support BSFT fidelity and
sustainability.

Benefits for Clinicians

Despite their initial hesitations, clinicians often enjoy
the parallel process in which they observe the BSFT
Implementation consultant applying BSFT princi-
ples at an organizational level that are parallel to the
BSFT principles clinicians are learning to apply at a
family level. Often to a fault, clinicians are dedicated
to their clients. BSFT clinicians develop a broader
and more thorough skill set, which enhances their
ability to work effectively with families and often
improves their clients’ outcomes. Consequently,
when clinicians first realize that they are able to
engage and retain families in treatment, they become

130 J. Szapocznik et al.

excited by their new skill set, but more importantly
by their newly acquired abilities to help their client
families. Ultimately, clinicians realize that they no
longer experience the frustration of so many family
drop-outs, and that they can bring more families to
treatment completion—which is highly rewarding
both because families are being helped and because
of the feeling of success that comes with helping
families.

The supervision that BSFT therapists receive
promotes a consistently high-quality level of therapy
and provides sustained support for their professional
and often times their personal growth. Additionally,
BSFT-trained therapists tend to be well regarded by
others within the organization and are afforded the
potential for enhanced career growth as they often
become leaders within their respective organizations.
After all, developing skills to manage complex sys-
tems, such as families, provides therapists with skills
that can be used at the organizational level as well.
BSFT therapists also find that they are more mar-
ketable, which increases their chances for career
development; and as they learn to become leaders
of the family-therapeutic system, they develop lead-
ership skills that serve them well inside and outside
therapy.

Implementing the BSFT approach into a commun-
ity setting also confers broader benefits on the organ-
ization and community. Like any evidence-based
treatment, the BSFT model provides a structured
framework for an organization, with demonstrated evi-
dence for effectiveness and support for strong clinical
outcomes. The BSFT Institute provides support
throughout the process of adoption as well, providing
guidance and recommendations that often improve
the agency’s functioning. For example, communica-
tion between segments of an agency may be improved
as a result of the BSFT Implementation process—
such as reducing the number of people required to
approve administrative decisions related to the BSFT
unit. Communities are likely to benefit as well when
the prevalence and severity of adolescent drug
abuse, delinquency, and other forms of risk-taking
are reduced. The BSFT model may serve as a sec-
ondary or tertiary prevention strategy. Secondary and
tertiary prevention efforts may help to decrease costs
involved with incarceration, hospitalization, and res-
idential drug treatment (McCollister, French, &
Fang, 2010).

Future Research

The field of implementation science is quite new,
and much of what has been written is theoretical or
anecdotal. The implementation science field within
substance abuse prevention and treatment emerged

out of a collective recognition within the research,
practice, and policy communities that evidence-
based treatments cannot simply be “installed” into
treatment agencies, and that systemic barriers within
the agency (or said more systemically, “developers’
naiveté about integrating new services into existing
organizations”) often interfered with the successful
delivery of the intervention (Fixsen et al., 2009). We
have much to learn about how to achieve successful
implementation, including designing appropriate
measures to index and quantify “buy-in” from various
members of the treatment agency, to examine the
efficacy of the training program, and to evaluate the
systemic strategies used to transform the agency in
the service of facilitating adoption, fidelity, and
sustainability (Landsverk et al., 2007).

One of the first steps that should be taken in the
implementation science field, and that we plan to take
with the BSFT approach, is to conduct a randomized
clinical trial—the gold standard for evaluating the effi-
cacy of an intervention approach (where the systemic
implementation strategy is an intervention)—to evalu-
ate the BSFT Implementation program. As is typical
in the implementation science field (Fixsen et al.,
2009) and of BSFT Implementation (Szapocznik,
Muir, & Schwartz, 2013), community providers
would be full partners in all aspects of the design,
conduct, and analysis of the study. Treatment
agencies might be randomly assigned to “interven-
tion” and “control” conditions. The intervention
agencies would receive the full BSFT Implementa-
tion intervention, whereas the control agencies
would receive only standard BSFT training, includ-
ing therapist monitoring, coaching, and feedback on
BSFT fidelity. An alternative trial would be to
compare the full BSFT Implementation intervention
to an implementation model derived from organiza-
tional theory, such as the models now being used to
deliver other evidence-based interventions (Glisson &
Schoenwald, 2005). Outcomes would be assessed
at multiple levels, including (i) changes in family
functioning and adolescent problem behavior for
individual client families; (ii) therapists’ BSFT
adherence and fidelity; (iii) cost-effectiveness of the
implementation intervention; (iv) therapists’ satis-
faction with their work and with the outcomes of
their cases; (v) agency, stakeholder, and referral
source support for the BSFT approach; and (vi)
sustainability of the BSFT model over time.

Because the field of implementation science is so
new, mixed-methods research—including qualitative
as well as quantitative components—should be con-
ducted (Palinkas & Soydan, 2012). Such research
will provide first-person perspectives from therapists
and agency leadership regarding the experience of
participating in a structured implementation process

Brief Strategic Family Therapy 131

versus an alternative condition. What specific chal-
lenges does BSFT Implementation address? Are
therapists’ initial concerns—such as concerns about
manualized intervention strategies, discomfort with
intensive supervision, and reluctance to engage
whole families into treatment—diminished by the
end of the implementation intervention? What
aspects of the BSFT Implementation system are
most beneficial for therapists, and are there interac-
tions between the implementation approach and
specific therapist and agency characteristics? And
perhaps most importantly, do decreases in thera-
pists’ objections and concerns predict increased
fidelity to the BSFT model and improved client
outcomes? Answering these questions will help to
advance not only BSFT Implementation, but also
the field of implementation science as a whole.

Funding

Preparation of this article was supported by Clinical
Translational Science Institute Grant 1UL1TR000460
from the National Center for Clinical and Transla-
tional Science and the National Institute on Minority
Health and Health Disparities, and U10 DA013720
and RC2 DA028864 from the National Institute on
Drug Abuse to José Szapocznik, by Grant DA026595
from the National Institute on Drug Abuse to Seth J.
Schwartz, and by Grant AA021888 from the National
Institute on Alcohol Abuse and Alcoholism to
Jonathan G. Tubman and Seth J. Schwartz, and
Grant P30 DA027828 from the National Institute on
Drug Abuse to C. Hendricks Brown. The informa-
tion presented in this article is the sole responsibility
of the authors and does not necessarily reflect the
views of the funding agencies involved.

References

Addiction Technology Transfer Center (ATTC) Network Tech-
nology Transfer, W. (2011). Research to practice in addiction
treatment: Key terms and a field-driven model of technology
transfer. Journal of Substance Abuse Treatment, 41, 169–178.
doi:10.1016/j.jsat.2011.02.006

Bowen, M. (1978). Family therapy in clinical practice. New York:
Jason Aronson.

Breuk, R. E., Sexton, T. L., van Dam, A., Disse, C., Doreleijers,
T. A. H., Slot, W. N., & Rowland, M. K. (2006). The imple-
mentation and the cultural adjustment of functional family
therapy in a Dutch psychiatric day-treatment center. Journal of
Marriage and Family Therapy, 32, 515–529. doi:10.1111/j.1752-
0606.2006.tb01625.x

Coatsworth, J. D., Santisteban, D. A., McBride, C. K., &
Szapocznik, J. (2001). Brief strategic family therapy versus
community control: Engagement, retention, and an explora-
tion of the moderating role of adolescent symptom severity.
Family Process, 40, 313–332. doi:10.1111/j.1545-5300.2001.
4030100313.x

Faggiano, F., Vigna-Taglianti, F., Burkhart, G., Bohrn, K.,
Cuomo, L., Gregori, D., … the EU-Dap Study Group. (2010).

The effectiveness of a school-based substance abuse prevention
program: 18-month follow-up of the eu-dap cluster rando-
mized controlled trial. Drug and Alcohol Dependence, 108, 56–
64. doi:10.1016/j.drugalcdep.2009.11.018

Fernandez, M. A., & Eyberg, S. M. (2009). Predicting treatment
and follow-up attrition in parent-child interaction therapy.
Journal of Abnormal Child Psychology, 37, 431–441. doi:10.
1007/s10802-008-9281-1

Fixsen, D. L., Blase, K. A., Naoom, S. F., & Wallace, F. (2009).
Core implementation components. Research on Social Work
Practice, 19, 531–540. doi:10.1177/1049731509335549

Fixsen, D. L., Blase, K. A., & Van Dyke, M. K. (2011). Mobilizing
communities for implementing evidence-based youth violence
prevention programming: A commentary. American Journal of
Community Psychology, 48, 133–137. doi:10.1007/s10464-010-
9410-1

Fixsen, D., Scott, V., Blase, K., Naoom, S., & Wagar, L. (2011).
When evidence is not enough: The challenge of implementing
fall prevention strategies. Journal of Safety Research, 42, 419–
422. doi:10.1016/j.jsr.2011.10.002

Glisson, C., & Schoenwald, S. K. (2005). The ARC organiza-
tional and community intervention strategy for implementing
evidence-based children’s mental health treatments. Mental
Health Services Research, 7(4), 243–259. doi:10.1007/s11020-
005-7456-1

Gorman-Smith, D., Tolan, P. H., & Henry, D. B. (2000). A
developmental-ecological model of the relation of family
functioning to patterns of delinquency. Journal of Quantitative
Criminology, 16, 169–198. doi:10.1023/A:1007564505850

Haley, J. (1976). Problem-solving therapy. San Francisco, CA:
Jossey-Bass.

Henggeler, S. W. (2011). Efficacy studies to large-scale transport:
The development and validation of multisystemic therapy
programs. Annual Review of Clinical Psychology, 7, 351–381.
doi:10.1146/annurev-clinpsy-032210-104615

Institute of Medicine (IOM). (2007). The state of quality improve-
ment and implementation research: Expert views and workshop
summary. Washington, DC: Author.

Landsverk, J., Brown, C. H., Chamberlain, P., Palinkas, L.,
Horwitz, S. M., & Ogihara, M. (2012). Design and analysis in
dissemination and implementation research. In R. Brownson,
G. Colditz, & E. Proctor (Eds.), Dissemination and implementa-
tion research in health: Translating science to practice. Oxford:
Oxford University Press.

Madanes, C. (1981). Strategic family therapy. San Francisco, CA:
Jossey-Bass.

McCollister, K. E., French, M. T., & Fang, H. The cost of crime
to society: new crime-specific estimates for policy and program
evaluation. Drug and Alcohol Dependence, 108, 98–109. doi:10.
1016/j.drugalcdep.2009.12.002

Minuchin, S., & Fishman, C. (1981). Family therapy techniques.
Cambridge, MA: Harvard University Press.

Moran, G., Diamond, G. M., & Diamond, G. S. (2005). The
relational reframe and parents’ problem constructions in
attachment-based family therapy. Psychotherapy Research, 15,
226–235. doi:10.1080/10503300512331387780

National Registry of Evidence-based Programs and Practices.
(2012). Brief Strategic Family Therapy. Retrieved from http://
nrepp.samhsa.gov/ViewIntervention.aspx?id=151.

Palinkas, L. A., & Soydan, H. (2012). Translation and implementa-
tion of evidence based practice. New York: Oxford University Press.

Phares, V., Lopez, E., Fields, S., Kamboukos, D., & Duhig, A. M.
(2005). Are fathers involved in pediatric psychology research
and treatment? Journal Pediatric Psychology, 30, 631–643.
doi:10.1093/jpepsy/jsi050

Robbins, M. S., Alexander, J. F., & Turner, C. W. (2000).
Disrupting defensive family interactions in family therapy with

132 J. Szapocznik et al.

http://dx.doi.org/10.1016/j.jsat.2011.02.006

http://dx.doi.org/10.1111/j.1752-0606.2006.tb01625.x

http://dx.doi.org/10.1111/j.1752-0606.2006.tb01625.x

http://dx.doi.org/10.1111/j.1545-5300.2001.4030100313.x

http://dx.doi.org/10.1111/j.1545-5300.2001.4030100313.x

http://dx.doi.org/10.1016/j.drugalcdep.2009.11.018

http://dx.doi.org/10.1007/s10802-008-9281-1

http://dx.doi.org/10.1007/s10802-008-9281-1

http://dx.doi.org/10.1177/1049731509335549

http://dx.doi.org/10.1007/s10464-010-9410-1

http://dx.doi.org/10.1007/s10464-010-9410-1

http://dx.doi.org/10.1016/j.jsr.2011.10.002

http://dx.doi.org/10.1007/s11020-005-7456-1

http://dx.doi.org/10.1007/s11020-005-7456-1

http://dx.doi.org/10.1023/A:1007564505850

http://dx.doi.org/10.1146/annurev-clinpsy-032210-104615

http://dx.doi.org/10.1016/j.drugalcdep.2009.12.002

http://dx.doi.org/10.1016/j.drugalcdep.2009.12.002

http://dx.doi.org/10.1080/10503300512331387780

http://nrepp.samhsa.gov/ViewIntervention.aspx?id=151

http://nrepp.samhsa.gov/ViewIntervention.aspx?id=151

http://dx.doi.org/10.1093/jpepsy/jsi050

delinquent adolescents. Journal of Family Psychology, 14, 688–
701. doi:10.1037/0893-3200.14.4.688

Robbins, M. S., Feaster, D. J., Horigian, V. E., Puccinelli, M. J.,
Henderson, C., & Szapocznik, J. (2011). Therapist adherence
in brief strategic family therapy for adolescent drug abusers.
Journal of Consulting and Clinical Psychology, 79, 43–53.
doi:10.1037/a0022146

Robbins, M. S., Feaster, D. J., Horigian, V. E., Rohrbaugh, M.,
Shoham, V., Bachrach, K., … Szapocznik, J. (2011). Brief
strategic family therapy versus treatment as usual: Results of a
multisite randomized trial for substance using adolescents.
Journal of Consulting and Clinical Psychology, 79, 713–727.
doi:10.1037/a0025477

Robbins, M. S., Liddle, H. A., Turner, C. W., Dakof, G. A.,
Alexander, J. F., & Kogan, S. M. (2006). Adolescent and
parent therapeutic alliances as predictors of dropout in multi-
dimensional family therapy. Journal of Family Psychology, 20,
108–116. doi:10.1037/0893-3200.20.1.108

Santisteban, D. A., Szapocznik, J., Perez-Vidal, A., Kurtines, W.
M., Murray, E. J., & LaPerriere, A. (1996). Efficacy of an
intervention for engaging youth and families into treatment and
some variables that may contribute to differential effectiveness.
Journal of Family Psychology, 10, 35–44. doi:10.1037/0893-
3200.10.1.35

Santisteban, D. A., Coatsworth, J. D., Perez-Vidal, A., Mitrani,
V., Jean-Gilles, M., & Szapocznik, J. (1997). Brief structural
strategic family therapy with African American and Hispanic
high-risk youth. Journal of Community Psychology, 25, 453–471.
doi:10.1002/(SICI)1520-6629(199709)25:5%3C453::AID-JC
OP6%3E3.0.CO;2-T

Santisteban, D. A., Coatsworth, J. D., Perez-Vidal, A., Kurtines,
W. M., Schwartz, S. J., LaPerriere, A., & Szapocznik, J. (2003).
Efficacy of brief strategic family therapy in modifying Hispanic
adolescent behavior problems and substance use. Journal of
Family Psychology, 17, 121–133. doi:10.1037/0893-3200.17.
1.121

Schoenwald, S. K., Sheidow, A. J., & Letourneau, E. J. (2004).
Toward effective quality assurance in evidence-based practice:
Links between expert consultation, therapist fidelity, and child
outcomes. Journal of Clinical Child and Adolescent Psychology, 33,
94–104. doi:10.1207/S15374424JCCP3301_10

Steinberg, L. (2001). We know some things: Parent-adolescent
relationships in retrospect and prospect. Journal of Research on
Adolescence, 11, 1–19. doi:10.1111/1532-7795.00001

Szapocznik, J., & Coatsworth, J. (1999). An ecodevelopmental
framework for organizing the influences on drug abuse: A
developmental model of risk and protection. In M. Glantz &
C. Hartel (Eds.), Drug abuse: Origins and interventions (pp. 331–
366). Washington, DC: American Psychological Association.

Szapocznik, J., Hervis, O., Rio, A. T., Mitrani, V. B., Kurtines, W., &
Faraci, A. (1991). Assessing change in family functioning as a

result of treatment: The Structural Family Systems Rating scale
(SFSR). Journal of Marital and Family Therapy, 17, 295–310.
doi:10.1111/j.1752-0606.1991.tb00897.x

Szapocznik, J., Muir, J. A., & Schwartz, S. J. (2013). Brief
Strategic Family Therapy for adolescent drug abuse: Treatment
and implementation. In P. M. Miller (Ed.), Encyclopedia of
addictive behaviors (Vol. 3, pp. 97–108). New York: Elsevier.

Szapocznik, J., Perez-Vidal, A., Brickman, A., Foote, F., Santis-
teban, D., Hervis, O., & Kurtines, W. (1988). Engaging
adolescent drug abusers and their families in treatment: A
strategic structural systems approach. Journal of Consulting and
Clinical Psychology, 56, 552–557. doi:10.1037/0022-006X.56.
4.552

Szapocznik, J., Rio, A. T., Murray, E., Cohen, R., Scopetta, M.
A., Rivas-Vazquez, A., … Kurtines, W. (1989). Family versus
child therapy for problematic Hispanic boys. Journal of Con-
sulting and Clinical Psychology, 57, 571–578. doi:10.1037/0022-
006X.57.5.571

Szapocznik, J., Scopetta, M. A., & King, O. E. (1978b). Theory
and practice in matching treatment to the special characteristics
and problems of Cuban immigrants. Journal of Community
Psychology, 6, 112–122. doi:10.1002/1520-6629(197804)6:2%
3C112::AID-JCOP2290060203%3E3.0.CO;2-R

Szapocznik, J., Scopetta, M. A., & King, O. E., (1978a). The
effect and degree of treatment comprehensiveness with a Latino
drug abusing population. In D. Smith, S. Anderson, M.
Burton, N. Gotlieb, W. Harvey, & T. Chung (Eds.), A
multicultural view of drug abuse (pp. 563–573). Cambridge,
MA: G. K. Hall.

Tai, B., Sparenborg, S., Liu, D. S., & Straus, M. M. (2011). The
National Drug Abuse Treatment Clinical Trials Network:
Forging a partnership between research knowledge and com-
munity practice. Substance Abuse and Rehabilitation, 2, 21–28.
doi:10.2147/SAR.S16756

Tai, B., Straus, M., Liu, D., Sparenborg, S., Jackson, R., &
McCarthy, D. (2010). The first decade of the national drug
abuse treatment clinical trials network: Bridging the gap
between research and practice to improve drug abuse treat-
ment. Journal of Substance Abuse Treatment, 38, S4–S13.
doi:10.1016/j.jsat.2010.01.011

Véronneau, M.-H., & Dishion, T. J. (2010). Predicting change in
early adolescent problem behavior in the middle school years:
A mesosystemic perspective on parenting and peer experiences.
Journal of Abnormal Child Psychology, 38, 1125–1137.
doi:10.1007/s10802-010-9431-0

Watkins, K. E., Hunter, S. B., Hepner, K. A., Paddock, S. M., de
la Cruz, E., Zhou, A. J., & Gilmore, J. (2011). An effectiveness
trial of group cognitive behavioral therapy for patients with
persistent depressive symptoms in substance abuse treatment.
Archives of General Psychiatry, 68, 577–584. doi:10.1001/
archgenpsychiatry.2011.53

Brief Strategic Family Therapy 133

http://dx.doi.org/10.1037/0893-3200.14.4.688

http://dx.doi.org/10.1037/a0022146

http://dx.doi.org/10.1037/a0025477

http://dx.doi.org/10.1037/0893-3200.20.1.108

http://dx.doi.org/10.1037/0893-3200.10.1.35

http://dx.doi.org/10.1037/0893-3200.10.1.35

http://dx.doi.org/10.1002/(SICI)1520-6629(199709)25:5%3C453::AID-JCOP6%3E3.0.CO;2-T

http://dx.doi.org/10.1002/(SICI)1520-6629(199709)25:5%3C453::AID-JCOP6%3E3.0.CO;2-T

http://dx.doi.org/10.1037/0893-3200.17.1.121

http://dx.doi.org/10.1037/0893-3200.17.1.121

http://dx.doi.org/10.1207/S15374424JCCP3301_10

http://dx.doi.org/10.1111/1532-7795.00001

http://dx.doi.org/10.1111/j.1752-0606.1991.tb00897.x

http://dx.doi.org/10.1037/0022-006X.56.4.552

http://dx.doi.org/10.1037/0022-006X.56.4.552

http://dx.doi.org/10.1037/0022-006X.57.5.571

http://dx.doi.org/10.1037/0022-006X.57.5.571

http://dx.doi.org/10.1002/1520-6629(197804)6:2%3C112::AID-JCOP2290060203%3E3.0.CO;2-R

http://dx.doi.org/10.1002/1520-6629(197804)6:2%3C112::AID-JCOP2290060203%3E3.0.CO;2-R

http://dx.doi.org/10.2147/SAR.S16756

http://dx.doi.org/10.1016/j.jsat.2010.01.011

http://dx.doi.org/10.1007/s10802-010-9431-0

http://dx.doi.org/10.1001/archgenpsychiatry.2011.53

http://dx.doi.org/10.1001/archgenpsychiatry.2011.53

Copyright of Psychotherapy Research is the property of Routledge and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder’s
express written permission. However, users may print, download, or email articles for
individual use.

Abstract
• Brief Strategic Family Therapy®: Theory, Research and Practice

Specific Techniques Used in the BSFT Model
BSFT Engagement
BSFT Research
BSFT Efficacy
BSFT Engagement
BSFT Effectiveness
BSFT Therapist Behaviors, Therapy Process, and their Relationship to Outcomes

• Transporting and Implementing the BSFT Model in Community Settings: Challenges and Solutions

Outline placeholder
Our early implementation experience
How the BSFT model informs ”adoption” in our implementation model
Fidelity
Sustainability

Benefits for Clinicians
Future Research
Funding
References

The American Journal of Family Therapy, 42:

167

–174, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 0192-6187 print / 1521-0383 online
DOI: 10.1080/01926187.2013.794046

The Intersection of Facebook and Structural
Family Therapy Volume 1

NINA ANNE MÉNDEZ, MISBHA ENAM QURESHI, RENATA
CARNERIO, and FLORINA HORT

Drexel University, Philadelphia, Pennsylvania, USA

Facebook has quickly been made into a household name with more
than 700 million users worldwide (Carpenter, 2011). With the pop-
ularity of Facebook continuously growing, it is important to analyze
the influence of Facebook on relationships. This article examines
the intersection of Facebook and family therapy. More specifically,
Facebook is viewed through the lens of structural family therapy.
Key concepts in structural family therapy are provided along with
a case vignette to demonstrate how Facebook can be used as a tool
to help heal struggling relationships. Suggestions for future recom-
mendations related to treatment and research are discussed.

A TECHNOLOGICAL WORLD

The word “connection” has transformed to a different meaning due to the
many technological advances that have occurred over the past few decades.
In a world that once communicated through telegrams and standard letter
mail, human communication is being completed simply by the click of a
button. The culture of communication is focusing less on human-to-human
connection and more on human-device-human connections. More and more
people are communicating with one another through the use of social net-
working sites, cell phones, face-to-face video streaming (i.e., Skype, Ovoo),
and e-mail.

In 2010, the Nielsen Company reported that there are over 300 million
cell phone users in the United States. In addition, within those 300+ million
users, by 2009, 21% of United States households converted to cellphone-
only homes, ditching the once popular land line telephone (Nielsen, 2010).
Further statistics support the enormous amounts of communication being

Address correspondence to Nina Anne Méndez, 2056 East Arizona Street, Philadelphia,
PA 19125. E-mail: nam36@drexel.edu

167

168 N. A. Méndez et al.

completed through the use of various technologies. The Wireless Association
reported in 2009, American’s used 2.3 trillion cell phone use minutes and
sent 152.7 trillion text messages (The Wireless Association, 2009). Beyond
cell phone use, Skype is keeping over 37.5 million people connected through
face to face streaming on the computer (Wolff, 2012).

The unprecedented popularity of social networking sites is prevalent in
the world’s most popular internet site, Facebook.com. Facebook has become
a household name that is reaching dominance in cultures beyond the United
States. Facebook not only transformed the meaning of the word “friend”
but due to the alarming growth and consistency of users, Facebook is the
sole contributor to the word “unfriend” being added to the Oxford American
Dictionary in 2009 (Gross, 2009).

Since the site’s launch in 2004, Facebook.com has expanded to over 700
million users today. In this article, authors will review key concepts in struc-
tural family therapy. Using the key concepts of structural family therapy, the
authors will compare ways Facebook use and the concepts intersect. The key
components and concepts of structural family therapy will be described, fo-
cusing on potential impacts Facebook use can bring to therapy. The authors
will then provide a clinical case example to help demonstrate ways thera-
pists can have an awareness of how Facebook is integrated into relationships
today. Lastly, clinical implications, treatment, and future recommendations
will be provided.

STRUCTURAL FAMILY THERAPY

In order to evaluate the intersection of Facebook and structural family ther-
apy (SFT), one must first review the key concepts associated with the SFT
model. Structural family therapy, developed by Salvador Minuchin, became
one of the most influential and widely practiced approach to family ther-
apy by the 1970s. Structural family therapy offers a framework from which
to analyze the process of family interactions, such that it provides a basis
for consistent strategies (Nichols & Schwartz, 2006). Based on the model, a
functional family is able to cope and adapt to various stressors that main-
tains family continuity while being able to restructure itself (Umbarger, 1983).
Therefore, dysfunction occurs when the family is unable to cope or adapt to
stressors resulting in a lack of growth in its family members or dysfunctional
patterns of interaction.

The goal of the therapist using SFT as a model, is to assist the family in
changing its structure or its organization; specifically, establishing a structure
in which members and its subsystems are clearly differentiated from one
another and hierarchically integrated (Navaree, 1998, p. 559; Silver, 1983).
In doing so, it is important to grasp a clear understanding of some of the
main concepts that are essential to SFT, which include: structure, subsystems,

Facebook and Structural Family Therapy 169

boundaries, alignments, and coalitions. There are several more concepts
within SFT, however, for the purposes of this paper only these concepts
will be discussed. For an in-depth understanding of SFT, we recommend
Families and Family therapy by Salvador Minuchin.

Structure

As defined by Minuchin (1974, p. 51), “family structure is the invisible set
of functional demands that organizes the ways in which family members
interact. A family is a system that operates through transactional patterns
and these repeated transactions establish patterns of how, when, and with
whom to relate, and these patterns underpin the system.” Therefore, family
structure refers to the organized patterns in which family members interact
and it is reinforced by the expectations that establish rules in the family
(Nichols & Schwartz, 2006).

Subsystems

According to Minuchin (1974), subsystems can contain an individual family
member, dyad, or more and be formed according to generation, gender,
common interests, and role within the family. Within the model of SFT,
there are three main identified subsystems in each family system: spousal,
parental and sibling. Each family member has his or her own role, skills, and
power within each subsystem. It is these relationships between subsystems
that help define the structure of the family and helps maintain functionality
(Becvar & Becvar, 1995). Additionally, different members of the family hold
different positions in each of these subsystems; one member can hold a
position in more than one subsystem (i.e., a mother would be part of a
spousal and parental subsystem).

Boundaries

Minuchin states that functional families possess well-organized boundaries.
Boundaries are defined as rules regulating who participates, how someone
participates, and serves to protect the differentiation of a system (Minuchin,
1974). Boundaries are based upon the ideal structure of the family, which
should include essential functions, such as support, nurturance, and social-
ization of each family member (Navaree, 1998). These functions are usually
carried out by different family members within each subsystem (spousal,
parental, sibling), therefore, what happens within each subsystem impacts
the whole family. There are three different types of boundaries Minuchin

170 N. A. Méndez et al.

describes that are rigid, diffuse, and clear. Dysfunction occurs as a result of
these boundaries being too weak or overly rigid.

A rigid boundary is exemplified by impermeable barriers between the
subsystems. Family members will not or do not share and participate within
the subsystems. This results in a disengaged family, where there is great
interpersonal distance and little potential for connectedness. On the other
hand, a diffuse boundary is easily permeable, blurred, and there is no clear
distinction between subsystems. A diffuse boundary results in enmeshment,
where there is little interpersonal distance between family members who
are over involved and over concerned. Lastly, clear boundaries are firm yet
flexible in that there is an allowance of new information between subsystems
and the structure does not falter due to stress or struggles (Becvar & Becvar,
1995). Family members are able to grow, be nurtured, and be supported.

Alignments and Coalitions

The other concepts of structural family therapy are alignments and coalitions.
As was previously described, boundaries regulate the amount of interactions
between the subsystems. On the other hand, alignments are a way in which
members can interact; in this case, an alignment is when at least two members
of the system create an alliance. Even though an alliance can be neutral,
the members can join and oppose another member of the family, which is
called a coalition (Umbarger, 1983). There are certain types of alignment that
Minuchin (1974) considers triangulation of which are detouring and cross-
generational coalition. A cross-generational coalition is when a parent and a
child are in a continual union against the other parent. A detouring coalition
occurs when members hold a third member responsible for the conflicts or
struggles in their coalition (Umbarger, 1983).

CASE VIGNETTE

Now that the key concepts in SFT have been described, the following case
vignette will provide a detailed account of a common way an issue related
to Facebook use is presented in a therapy session. An analysis of the case
will be provided particularly looking at structure, subsystems, boundaries,
and coalitions. For confidentiality purposes, clients’ name and identifiable
information were changed to protect privacy.

Beatrice Kiamma was a 15-year-old Japanese-American young girl, who
was referred to treatment by the principal of her high school. According
to the principal, Beatrice once a good student, was skipping classes
frequently and engaging in physical altercation with other students.

Facebook and Structural Family Therapy 171

Beatrice lived with her father and younger sister. Her mother had passed
five years ago due to a tragic car accident. The family had immigrated
to the United States when Beatrice was a baby. The principal, Mrs. Mor-
rison, has always felt sorry for Beatrice and treated her as if she was
her own daughter. They knew each other since elementary school. Mrs.
Morrison could not understand how a sweet girl like Beatrice was acting
so strange lately.
According to Mr. Kiamma, Beatrice has always been the “good daughter”
but, since three months ago everything has changed. Beatrice who was
raised to obey her parents was very disrespectful towards her father. She
was argumentative, refused to go to church and did not follow the house
rules especially when came to terms of giving up her cell phone before
bed time. Beatrice was “stealing” her younger sister cell phone to chat
with her friends. Her father had monitored her Facebook account, and
just found that Beatrice had created a new Facebook account for her
“real” friends. According to father, Beatrice started communicating with
this “boy” who claimed to be in prison. Her father had forbidden Beatrice
to continue the relationship, so Beatrice created a new Facebook account
just to be with her “boyfriend.”
Beatrice’s father found out about the boyfriend through his youngest
daughter, Bianca. According to Bianca, Beatrice was planning to run
away with her allegedly boyfriend when he got out of prison. Fearing
that her sister was at risk Bianca decided to tell her father what she
knew. Mr. Kiamma confronted Beatrice. She was furious with her father
and sister and tried to run away. However, Mr. Kiamma caught her trying
to escape the house with a backpack. Feeling in a bind Mr. Kiamma,
decided to ask the school principal Mrs. Morrison for help. Mrs. Morrison
immediately alerted the school’s therapist to see Beatrice right away, as
she was at a high risk to flee school.
The therapist’s initial reaction was to refrain from discussing the context
of what occurred on Facebook. The therapist worked toward removing
the discussion of Facebook from therapy because there is much more
beneath the relationship of this family that existed before the use of
Facebook.

CASE ANALYSIS

Although the therapist was correct in identifying and sensing that there was
an underlying issue within Kiamma family, the approach was problematic.
It is correct that there are issues related to the systems, boundaries, and
coalitions within this family but rather than attempting to remove Facebook
from the discussion, the therapist could utilize it as a tool to gather more
information. How the family has organized themselves around Facebook
could be used as a way to better understand the way the family system is
organized as well.

172 N. A. Méndez et al.

Facebook and Structural Family Therapy

The way in which the Kiamma family is organized can be seen through the
apparent rules that were established around Beatrice’s Facebook use and
her attempts to defy them. Her father allowed her to use Facebook with
the understanding that he is able to monitor her use. The patterns that exist
within the family demonstrate an unbalanced hierarchy between father and
daughter. The father establishes rules and Beatrice has been defying the
rules since the new relationship was introduced to the system. The therapist,
rather than attempting to take Facebook out of discussion, should allow the
family to engage in an enactment and join them in order to fully understand
the dynamic of their relationships.

The father-daughter system is one that would be the main focus of the
session. However, it would be important for the therapist to fully understand
the relationship between Facebook and the family. The father has been using
Facebook as a way to monitor his daughter’s behavior. Additionally, Beatrice
has been building intimate relationships through Facebook. Therefore it is
safe to say that Facebook is an integral part of understanding the dynamics
between the systems and subsystems in the family.

As mentioned previously, boundaries as described through a structural
family therapy model can be rigid, diffuse, or clear. In the case vignette
the father was attempting to establish clear boundaries through Facebook.
However, in looking at the pattern that existed in their relationship, the
father-daughter relationship is currently at a rigid stance where little to no
information is being exchanged. The daughter is creating her own rules and
has been utilizing Facebook as a platform to do so.

Although Facebook is simply a social media website, some may ar-
gue that children who engage in behaviors like Beatrice, have aligned with
the site and use it as a way to engage in negative behaviors. It could be
considered the equivalent to a husband disengaging from his wife and his
wife therefore attempting to engage more. With the case vignette, Beatrice is
struggling to align with the rules established by her father and changes are
being seen through her school work and other rule breaking behaviors. As
her father attempts to establish rules in the home, Beatrice rebels more on
the site and finds ways to break the rules.

CLINICAL IMPLICATIONS AND TREATMENT

There is much more to learn about Beatrice and her family. The outcome
of this case entailed the therapist learning to utilize Facebook as a way to
reconnect father and daughter. The therapist worked to help reinforce the
father’s rules and establish his role in the hierarchy. However, the therapist
ensured to work with Beatrice on understanding what void the gentleman
in jail was fulfilling for her.

Facebook and Structural Family Therapy 173

Therapeutic change is when the process of helping the family to out-
grow its stere-otyped patterns of which the presenting problem is a part
(Colapinto, 1982). In looking at this definition, the therapist implemented
new patterns the family abided by to help re-establish the father daugh-
ter relationship. The father was able to establish his role by implementing
stricter rules on the use of Facebook in the house. However, the therapists
cleverly encouraged the family to set up father-daughter events, a feature
on Facebook, to add structure and consistency of time spent with one an-
other. Beatrice and her father responded well to this as they share a common
interest for their love of technology.

Creating an intervention in using Facebook was a way that the therapist
stopped fighting against the intersection of relationships and technology and
used it to help bridge connections within the system. This is one of many
examples of how therapists can utilize Facebook to be an asset rather than
a deterrent.

FUTURE RECOMMENDATIONS

Future recommendations start with the acceptance that technology is here
to stay and rather than fighting against it, family therapists should accept it
and learn to use it to meet therapeutic goals. It important that we accept
people for where they are and with Facebook being involved in the lives
of over 700 million people world wide, it is quite possible that Facebook is
a huge part of day-to-day living and relationships. When clients reach out
to therapists with a situation related to Facebook, we must accept this and
learn to utilize responses to questions about Facebook use as another tool
to get to know our clients more.

The couple and family therapy field should conduct more empirical
research to help understand the impact that Facebook and other advances
in social media have on human-to-human connections. We must understand
its impact through research, in order to potentially use aspects of it for the
greater good of therapeutic success and relationships. A child who spends all
of their time on Facebook or a cell phone can give the therapists some insight
to the type of connections and patterns that exist within a family. Similarly,
a mother or father who spends hours on their cell phones or computers
can give the therapist some insight as to what occurs in the home related to
loving and nurturing relationships within the system.

Regardless of how technology and social media have caused the system
to reorganize itself, until research is conducted on the topic, theories on
how to use technology and social media in session remain just that, theories.
Family therapists should overall accept that technology and social media is
here to stay. We must learn it, research it, and rather than fight against its
advances, use it for the benefit of our clients.

174 N. A. Méndez et al.

REFERENCES

Becvar, D. S., & Becvar, R. J. (1995). The structural approach. Family therapy: A
systemic integration (3rd ed.). Boston, MA: Allyn & Bacon.

Carpenter, C. J. (2011). Narcissism on Facebook: Self-promotional and anti-social
behavior. Personality and Individual Differences, 52, 482–486.

Colapinto, J. (1982). Structural family therapy. In A. M. Horne & M. M. Ohlsen (Eds.),
Family counseling and therapy (pp. 112–140). Itasca, IL: F. E. Peacock.

Gross, D. (2009). Dictionary word of the year: “Unfriend.” Retrieved on April 5,
2012, from http://articles.cnn.com/2009-11-17/tech/unfriend.word_1_unfriend-
defriend-facebook?_s=PM:TECH

Navarre, S. E. (1998). Salvador Minuchin’s structural family therapy and its application
to multicultural family systems. Issues in Mental Health Nursing, 19, 557–570.

Nichols, M. P., & Schwartz, R. C. (2006). Family therapy: Concepts and methods (7th
ed.). Boston, MA: Pearson Education.

Nielsen Company, Inc. (2010). 2010 media industry fact sheet. Retrieved on
April 1, 2012, from http://blog.nielsen.com/nielsenwire/press/nielsen-fact-
sheet-2010

Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University
Press.

Silver, W. (1983). Techniques of structural family therapy. In P. A. Keller, & S. R.
Heyman (Eds.), Innovations in clinical practice: A source book (Vol. 2). Sarasota,
FL: Professional Resource Exchange.

The Wireless Association. (2009). Cell phone usage statistics: United States. Re-
trieved on April 2, 2012, from http://www.ctia.org/media/industry_info/index.
cfm/AID/10323

Umbarger, C. C. (1983). Structural family therapy. New York, NY: Grune & Stratton.
Wolff, P. (2012). Skype journal: Collaboration, communication, identity, and

plat forming. Retrieved on April 2, 2012, from http://skypejournal.com/blog/
category/statistics

Copyright of American Journal of Family Therapy is the property of Routledge and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.