A critique of the structural approaches

1. Adopted Families and
Systemic Family Therapy
A critique of the structural approaches

2. Overview
• Relevant adoption information
• Structural family therapy
• Attachment and trauma
• Strengths and criticisms
• Research issues
• Ethical issues
• Suggestions

3. Adoption
• Over 4000 children adopted in 2017 in UK (Department for Education, 2017)
• Loss of primary care giver can be traumatic in itself (James & Mackinnon, 2012)
• Estimated 72% of children adopted in UK have experienced abuse and trauma
(Selwyn, Wijedasa & Meakings, 2014)
Consequences
• Children who have been adopted are at high risk of emotional and behavioural
problems (Gilbert et al., 2009; Dejong, Hodges & Malik, 2016; Bernard, Lind &
Dozier, 2013)
• Complex symptom presentation (DeJong, 2010)

4. Relevance
• Families who have adopted children face specific challenges
• More likely to present at Child and Adolescent Mental Health services
(CAMHS) (Oreilly, Bowlay-Williams, Svirydzenka, & Vostanis, 2016)
• Range of specialist services within CAMHS to support adoptive families
• Lack of specific focus in family systems therapist training programmes
• Family therapy provided in over 80% of CAMHS (NHS Benchmarking
Network, 2013)

5. Structural Family therapy
• Salvador Minuchin
• Shift towards systemic approaches in
therapy in mid 20th century
• First wave of family systems treatment
approaches
• Therapist takes “expert” stance

6. Structural family therapy
Theory
• A dysfunctional family structure is the cause of the problem
• Clear hierarchy is needed
• Subsystems
• Boundaries shouldn’t be too close or distant
• Past matters but only in how it affects the present
(Minuchin, 1974)

7. Structural Family therapy
Methods
Joining: Therapists “joins” the family and builds rapport with all members
Assessment:
Intervention:
• Therapist is direct
• Therapist takes control
• Escalate emotion during “enactments”
• Create new communication channels
• Establish new boundaries between subsystems
(four-step model: Minuchin, Nichols, & Lee, 2006)
1. Decentralise the
problem
2. Observe and
explore patterns in the
family set up
3. Consider how past
influences present
4. Redefine the
problem presentation

8. Example of structural intervention
“Sarah”
12 year old female presenting with multiple behavioural issue. She was adopted at three by
Terry and Jackie. Terry reports that Jackie and Sarah are too close and that he and Jackie
don’t agree on parenting strategies
Problem with structure:
Sarah and Jackie’s relationship is too “enmeshed”
Jackie and Terry’s relationship is too distant
Intervention
1. Sarah and Terry enact disagreements
2. Move Sarah away from Jackie
3. Bring together parent subsystem

9. Attachment and Complex Trauma
Attachment theory (Bowlby, 1982, Ainsworth, 1979)
• Relationship with first key attachment produces patterns of relating to others
• Insecure relationships can develop from unresponsive, chaotic or scary parental behaviour
Hughes (2011) suggests that these relational boundaries are robust but not rigid
Can result in an acute shame (Debelinger, 2005)
Complex trauma (Courtois & Ford, 2014)
• Cause and presentation share similarities with PTSD but also differences
• Results from repeated “small” relational traumas e.g. neglect, observing parental violence
• Usually caused by the person a child goes to for protection
Leaves an imprint on the brain (Perry, 2009)
Affects ability to regulate emotions and results in “hypervigilance” (Cook et al, 2005)

10. Strengths of structural approaches in the
context of attachment and trauma
• “De-blaming”: Shame is an important mediating factor in recovery from abuse
(Deblinger, & Runyon, 2005). Shame is high in trauma experiences (cite) Helpful
in engagement
• Compliments relational focus of attachment theory
• Co-parenting: important for Psychological adjustment (Teubert & Pinquart,
2010).

11. Criticism 1: Power and control
Therapeutic alliance
• Confrontation in structural therapist can have a negative impact on the therapeutic
alliance (TA) (Hammond & Nichols 2008)
• Historic negative impact of people in charge taking control, sometimes as a threat to life
• Problematic because TA has been suggested to be a key factor in therapeutic change
(Robbins et al, 2010)
Distress in child
• Children who have experienced physical abuse may be hypersensitive and interpret
therapist movement as threatening (Al Odhayani, Watson, & Watson, 2013)
• Difficult to manage potential reactions to this in session (e.g. fight, flight)

12. Criticism 2: Too Reductionist?
Complex presentations
• Mental health problems in children who have been looked after are often complex (Rao, Ali & Vostanis, 2010)
• Adverse circumstances before adoption can lead to developmental delays (Haugaard, & Hazan, 2003; Wretham & Woolgar, 2017)
• Adoptive families may have experienced loss on multiple dimensions e.g. loss of imagined child via infertility (Goodwatch, 2003)
Restructuring and separating (Hughes, 2011)
• Emotional development missed in abuse
• Close relationship viewed as healthy and reparative
• May be viewed as “enmeshment” in session and split apart by therapist
Favours nuclear family set up
• Single adopters
• Kinship adoption
Are structural approaches too reductionist for these families?

13. Criticism 3: Focus away from historic
trauma
“the tool of this therapy is to modify the present, not to explore and interpret the past”
Minuchin, 1974
• Not addressing the route cause could be problematic (James, 2012)
• Could lead a child to feel ashamed
• Processing in context of family has been found to be effective (Lance, 2003)
• Individual treatment for historic trauma has been found to be effective (Courtious, 2008)

14. Evidence informing practice
• Lack of generalizability in family systems research to adopted families
• Focussed on biological related families (e.g. Shaw, Criss, Schonberg & Beck, 2004; )
• Difficult to measure outcomes
• Debate around whether outcomes of FST more generally fit into the favoured
scientific model (e.g. Larner, 2004)
• Reality of practice is that a number of interventions show promising results but lack of
control groups
• British Psychological Society (2007) “practice sometimes needs to precede evidence
base”.

15. Ethical and professional issues
Future help seeking
Families: high level of professional input, could this lead to “intervention fatigue”?
Adopted individual: Does the trauma specific critiques reduce change of future
therapeutic engagement? What are the risks of this given the increased chance of
mental health problems in this population?
Safeguarding
Systemic focus: Could carry risk: e.g. Sexually harmful behaviour present in a number
of adopted children (Tarren-Sweeney, 2008), this needs to be addressed explicitly and
treatments we know work

16. Moving forward
• More collaborative approaches e.g. Milan, solution focussed, narrative
attachment therapy
• Incorporate a “trauma lens” (Goldfinch, 2009; James, 2012) into work and FT
training
• Research into the efficacy of treatment approaches needs to be
considered carefully. Ethics of control groups?
• Therapist to regularly reflect and risk assess in supervision
• Individual therapeutic intervention considered in addition or parent-child
interventions e.g. MST (Leschied & Cunningham, 2002)

17. Summary
• Unique complexity in history, presentations and family set up
• Structural approaches may be useful in some circumstances
• Number of challenges in relation to legacy of childhood trauma
• Ethical issues surrounding intervention may be amplified in
adoptive families
• More specialist training and further research is needed

18. Personal learning
1. Influenced thinking in my current professional role
2. There may be strengths of the structural approaches but methods can
counteract some other theoretical perspective that apply to this
population
3. Considering the context and applicability of treatments in future work
Questions?

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Al Odhayani, A., Watson, W. J., & Watson, L. (2013). Behavioural consequences of child abuse. Canadian Family Physician, 59(8),
831–836.
Bernard, K., Lind, T., & Dozier, M. (2013). Neurobiological Consequences of Neglect and Abuse. Handbook of Child Maltreatment Child
Maltreatment, 205-223.
British Psychological Society (2007) Attachment theory into practice. Leicester: British Psychological Society.
Bowlby, J. (1982). Attachment and loss: Vol 1. Attachment. New York: Basic Books.
Clarke, A. & Clarke, A. (2000). Early experience and the life path. London: Jessica Kingsly Publishers
Cook A, Spinazzola J, Ford J, Lanktree C, Blaustein M, Cloitre M, DeRosa R, Hubbard R, Kagan R, Liautaud J, Mallah K, Olafson E,
van der Kolk B. Complex Trauma in Children and Adolescents. Psychiatry Annals. 2005; 35: 390-398.
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England: Open University Press.
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