Georg Ivanovas From Autism to Humanism - systems theory in medicine

5.2 Systemic psychotherapy

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a) structural psychotherapy

The basic idea of structural psychotherapy “is that families develop structures (i.e., regulating codes and patterns in which they relate), in order to carry out functions or roles (e.g., partner, breadwinner, care giver, disciplinarian)… It is assumed that there is an invisible set of rules, based on the family’s culture and societal demands, that organize and regulate people’s behavior” (Hayes 1991). It is a normative model that refers to the question which authority is held by the family members (Hayes 1991). „The parents have the right to make decisions that are related to the survival of the total system” (Minuchin/Fishman: 18). If authority is not correctly performed then dysfunction or diseases might arise. Chaotic families are a source of many health problems and even influence negatively the cognitive abilities of its members (Petril/Plomin 2004).

The structural approach stresses the importance of clear boundaries (both internal and external), as healthy families are characterized by such boundaries (Roberto: 446).

Families are seen to be endangered to become dysfunctional, when natural boundaries are violated. An example is when children become the parents of their parents, the so-called parentification of a child. This might happen when the children have to take the decisions for their parents, a breeding ground for problems (Papp: 171). Another known pattern is the mother who has to mother her husband, because he behaves like a child in most issues of life.

Another issue are stable coalitions between the mother and the child against the father, or by the grandmother and the grandchild against the mother, etc. Sometimes families are enmeshed, such that nobody seems to decide what happens and every member pretends to behave only for the good of the others. In such families a sense of obligation, self sacrifice and self-denial prevails (Roberto: 450)

All this involves a certain judgment from outside, from the therapist. But structural therapists do not try to impose their concept onto the families. They try to induce a change in the family, in order to help the family to overcome the deadlock of a repetitive and/or inadequate pattern. The structural approach is not concerned with the symptoms but with the general structure, bringing forth the inadequate behaviour. It is a therapy on a higher level of order.

Some techniques to influence the family pattern are

  • changing the perception of the process,
  • proposing alternative possibilities that make sense,
  • introducing new relations and reinforce them (Hayes 1991) (1)

There is a main difference to the causal approach. The therapist does not force the family to obey a pattern the therapist judges to be correct. He might propose some tasks or induces new reflections.

If an asthmatic child governs the family and protects an endangered marriage (at least according to the theory from outside), the therapist has many possibilities to influence the rigid pattern. He might encourage the child to undertake new activities outside from home (with the danger that the child is unable to do this because it becomes symptomatic). He might work with the parents and look where their needs are unfulfilled (with the danger that the child becomes symptomatic if something changes). He might impose some exercises where the parents definitively decide and the child has to follow, such that the parents learn or relearn how it is like to decide and to be responsible for a situation. If there are coalitions, such as a mother and child dyad, he might give some exercises where the father and the child have to undertake something together (with the danger that suddenly the mother might become symptomatic). There are a lot of possibilities and the therapeutical process has to be handled creatively as always unforeseen events happen.

Although the basic theory is normative, the therapeutical practice is based on a stimulus-response pattern (chap. 6.10) which obeys the principles of equifinality (chap. 4.7). That is, the system family has, if a change is induced, the ability to find its own solution according to its inner structure. In the synergetic model this means that the ball will find a new state or changing states, if the dysfunctional valley is abandoned. To achieve this, it might as well be necessary to ‘heat the situation up’. This represents a form of ‘initial deterioration’ (chap. 6.11).

The largest ever trial in structural psychotherapy was the combat of crime in New York at the end of the 20th century. After all attempts had failed to control criminality with first order strategies, there was a shift of paradigm based on the concept of fixing the ‘broken window’. A car with a broken window is immediately robbed, something not (or at least less) true for a car in ‘order’. The strategy of the city of New York was to keep an outer order. All graffiti were immediately removed, streets were held clean from rubbish or animal’s excrements, etc. With such interventions, not concerned with the symptom, but with the structure, crime rate fell about to the half, a wonder nobody had expected. This structural intervention was probably the most effective intervention for the health of New Yorkers ever, prohibition (a first order intervention) included.

Another structural intervention was to reduce the class size in U.S. primary schools. The health of the children improved impressingly. It was even chaeper to reduce classes than to treat diseases (Columbia University's Mailman School of Public Health 2007).

(1) The introduction of new relations (öinks)is a general method to increase robustness, even in genetics. (chap. 6.4)

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