EP85 Clinical Presentation 09 - Structural Family Therapy (Video & Discussion) - Salvador Minuchin, MD

Description:

Educational Objectives:

1. To list basic tenets of the structural approach
2. To demonstrate how an understanding of structure leads to effective therapeutic interventions 

*Sessions may be edited for content and to preserve confidentiality*

Outline: 

Introduction and Context Setting

• Begins by referencing prior publications and assumes audience familiarity

• Introduces a two-hour video as a representation of his thinking process

• Family shown was seen a year earlier at a New York conference

• Family includes father, mother, two daughters (one with cerebral palsy), and a son

Family Background and Therapy History

• Family has seen multiple therapists over the years

• Expelled from a family therapist at the Jewish Board after three years

• Daughter with cerebral palsy spent two months in inpatient care

• Family was satisfied with therapy until daughter attempted suicide

Session with the Family

• Session occurs while the daughter is still hospitalized

• Therapist initially focuses on the daughter with cerebral palsy for 15 minutes

• Present in the room: parents, cerebral palsy daughter, and a student therapist

• Daughter uses a tripod cane and has limited mobility

Discussion on Family Dynamics

• Daughter does clerical work but requires mostly seated tasks

• Parents describe daughter’s physical dependency and birth complications

• Son was born following a miscarriage; parents were hesitant about having more children

• Cerebral palsy attributed to premature birth and medical complications

Sandra's Role and Responsibilities

• Sandra has always been the family motivator and initiator

• Often assumes the role of the family therapist

• Parents deny placing burdens on her, but Sandra feels over-responsible

• She believes failing to help would waste three lives—hers and her parents'

Family Trauma and Depression

• Past year marked by financial and health setbacks—father lost business; mother had back surgeries

• Family's closeness serves as both a strength and a liability

• Over-involvement contributes to Sandra’s emotional distress and suicide attempts

• Therapist highlights the enmeshment and its effects on Sandra’s mental health

Therapist's Intervention and Family Reactions

• Links Sandra’s symptoms to dysfunctional family organization

• Parents resist the notion that Sandra’s issues are tied to family dynamics

• Father admits closeness but denies exploiting Sandra

• Parents share the burden of raising a daughter with cerebral palsy

Sandra's Struggles and Family Dynamics

• Sandra reiterates her role as the driver of family change and support

• Despite denial from parents, she internalizes responsibility for the family’s wellbeing

• The family’s protective dynamic stifles individual autonomy

• Sandra’s emotional crises are understood within the family’s over-reliant structure

Sandra's Decision to Quit

• Sandra declares she will no longer act as the family’s emotional caretaker

• Parents acknowledge the challenges of caregiving and over-identification

• Therapist suggests the parents take initiative in helping Sandra relinquish the role

• Sandra’s suicidality is seen as a byproduct of these embedded family patterns

Follow-Up and Family Changes

• Sandra begins disengaging and spending more time outside the home

• Daughter with cerebral palsy starts assuming more personal responsibility

• Parental anger emerges when daughter refuses to bathe, asserting independence

• Daughter returns to work and resumes personal hygiene on her own terms

Conclusion and Reflections

• Core focus: promoting autonomy in chronically ill family members

• Therapist reflects on the difficulty of working with enmeshed, crisis-prone families

• Notes how protectiveness can stunt development in disabled or chronically ill individuals

• Ends by stressing the importance of structural change and role redistribution within the family