Chapter 3 - Diagnosing Family System Problems

The BSFT approach to assessing and diagnosing family system problems differs drastically from that used by other kinds of psychotherapies. Unlike other psychotherapies that assess and diagnose by focusing on content, such as talking about a family's history, BSFT assesses and diagnoses by identifying the current family process. BSFT focuses on the nature and characteristics of the interactions that occur in the family and either help or hinder the family's attempts to get rid of the adolescent's problem behaviors.

The following six elements of the family's interactions are examined in detail:

• Organization
• Resonance
• Developmental stages
• Life context
• Identified patient
• Conflict resolution

As repetitive patterns of interaction in a family occur over time, they give the family a specific form, or "organization." Three aspects of this organization are examined below: leadership, subsystem organization, and communication flow.

Leadership

Leadership is defined as the distribution of authority and responsibility within the family. In functional two-parent families, leadership is in the hands of the parents. In modern societies, both parents usually share authority and decisionmaking. Frequently, in one-parent families, the parent shares some of the leadership with an older child. The latter situation has the potential for creating problems. In the case of a single parent living within an extended family framework, leadership may be shared with an uncle, aunt, or grandparent. In assessing whether leadership is adaptive, BSFT counselors look at hierarchy, behavior control, and guidance.

Counselors look at the hierarchy, or the way a family is ranked, to see who is in charge of leading the family and who holds the family's positions of authority. BSFT assumes that the leadership should be with the parent figures, with supporting roles assigned to older family members. Some leadership responsibilities can be delegated to older children, as long as those responsibilities are not overly burdensome, are age-appropriate, and are delegated by parent figures rather than usurped by the children. BSFT counselors look at behavior control in the family to see who, if anyone, keeps order and doles out discipline in the family. Effective behavior control typically means that the parents are in charge and the children are acting in accordance with parental rules. Guidance refers to the teaching and mentoring functions in the family. BSFT assesses whether these roles are filled by appropriate family members and whether the youngsters' needs for guidance are being met.

Subsystem Organization

Families have both formal subsystems (e.g., spouses, siblings, grandparents, etc.) and informal subsystems (e.g., the older women, the people who manage the money, the people who do the housekeeping, the people who play chess). Important subsystems must have a certain degree of privacy and independence. BSFT looks at issues such as the adequacy or appropriateness of the subsystems in a family. It also assesses the nature of the relationships that give rise to these subsystems and especially looks at subsystem membership, triangulation, and communication flow, which are discussed below.

Subsystem Membership

BSFT identifies the family's subsystems, which are small groups within the family that are composed of family members with shared characteristics, such as age, gender, role, interests, or abilities. BSFT counselors pay particular attention to the appropriateness of each subsystem's membership and to the boundaries between subsystems. For example, parent figures should form a subsystem, while siblings of similar ages should also form a subsystem, and each of these subsystems should be separate from the others.

Subsystems that cross generations (e.g., between a parent and one child) cause trouble because such relationships blur hierarchical lines and undermine a parent's ability to control behavior. Relationships in which one parent figure and a child unite against another parent figure are called "coalitions." Coalitions are destructive to family functioning and are very frequently seen in families of drug-abusing adolescents. In these cases, the adolescent has gained so much power through this relationship that he or she dares to constantly challenge authority and gets away with it. The adolescent has this power to be rebellious, disobedient, and out of control by having gained the support of one parent who, to disqualify the other parent, enables the adolescent's inappropriate behavior.

Triangulation

Sometimes when two parental authority figures have a disagreement, rather than resolving the disagreement between themselves, they involve a third, less powerful person to diffuse the conflict. This process is called "triangulation." Invariably this triangulated third party, usually a child or an adolescent, experiences stress and develops symptoms of this stress, such as behavior problems. Triangles always spell trouble because they prevent the resolution of a conflict between two authority figures. The triangulated child typically receives the brunt of much of his or her parents' unhappiness and begins to develop behavior problems that should be understood as a call for help.

Communication Flow

The final category of organization looks at the nature of communication. In functional families, communication flow is characterized by directness and specificity. Good communication flow is the ability of two family members to directly and specifically tell each other what they want to say. For example, a declaration such as, "I don't like it when you yell at me," is a sign of good communication because it is specific and direct. Indirect communications are problematic. Take, for example, a father who says to his son, "You tell your mother that she better get here right away," or the mother who tells the father, "You better do something about Johnny because he won't listen to me." In these two examples, the communication is conducted through a third person. Nonspecific communications are also troublesome, as in the case of the father who tells his son, "You are always in trouble." The communication would be more constructive if the father would explain very clearly what the problem is. For example: "I get angry when you come home late."

"Resonance" defines the emotional and psychological accessibility or distance between family members. A 6-year-old son who hangs onto his mother's skirt at his birthday party may be said to be overly close to her. A mother who cries when her daughter hurts is emotionally very close. A father who does not care that his son is in trouble with the law may be described as psychologically and emotionally distant.

One of the key concepts related to resonance is boundaries. An interpersonal boundary, just as the words imply, is a way of denoting where one person or group of people ends and where the next one begins. People set their own boundaries when they let others know which behaviors entering their personal space they will allow and which ones they will not allow. In families, resonance refers to the psychological and emotional closeness or distance between any two family members. This psychological and emotional distance is established and maintained by the boundaries that exist between family members. In particular, the boundaries between two family members determine how much affect, or emotion, can get through from one person to the other. If the boundaries between two people are very permeable, then a lot gets through, and there is high resonance-- great psychological and emotional closeness--between them. One's happiness becomes the other's happiness. If the boundaries between two people are overly rigid, then each person may not even know what the other is feeling.

Enmeshment and Disengagement

The firmness and clarity of boundaries reflect the degree of differentiation within a family system. At one extreme, boundaries can be extremely impermeable. If this is the case, the emotional and psychological distance between family members is too large, and these family members are said to be "disengaged" from each other. At the other extreme, boundaries can be far too permeable or almost nonexistent. When boundaries are that permeable, the emotional and psychological closeness between people is too great, and these family members are said to be "enmeshed." Each of these extremes is problematic and becomes a target for intervention.

Interactions that are either enmeshed or disengaged can cause problems. When these interactions cause problems, they need to be altered to establish a better balance between the closeness and distance that exists between different family members. For each family, there is an ideal balance between closeness and distance that allows cooperation and separation.

Resonance and Culture

Resonance needs to be assessed in the context of culture. This is important because some cultures encourage family members to be very close with each other, while other cultures encourage greater distance. One important aspect of culture involves the racial or ethnic groups with which families identify themselves. For example, Hispanics are more likely than white Americans to be close and, thus, appear more enmeshed (have higher resonance) (e.g., Woehrer 1989). Similarly, an Asian father may be quite distant or disengaged from the women in his family, which is considered natural in his culture (Sue 1998). However, whether the culture dictates the distance between family members, it is important for counselors to question if a particular way of interacting is causing problems for the family. In other words, even if an interaction is typical of a culture, if it is causing symptoms, then it may need to be changed. This type of situation must be handled with great knowledge and sensitivity to demonstrate respect for the culture and to allow family members to risk making a change that is foreign to their culture.

Enmeshment (high resonance) and Disengagement (low resonance)

Sometimes "enmeshment" (excessive closeness) and "disengagement" (excessive distance) can occur at the same time within a single family. This happens frequently in families of drug-abusing youths, when one parent is sometimes very protective and is closely allied with the youth (i.e., enabling), while the other parent may be somewhat disinterested and distant.

BSFT counselors look for certain behaviors in a family that are telltale signs of either enmeshment or disengagement. Obviously, some of these behaviors may happen in any family. However, when a large number of these behaviors occur or when some occur in an extreme form, they are likely to reflect problems in the family's patterns of interaction. Easily observable symptoms of enmeshment include one person answering for another, one person finishing another's statements, and people interrupting each other. Observable symptoms of disengagement include one family member who wants to be separated from another or a family member who rarely speaks or is spoken about.

Individuals go through a series of developmental stages, ranging from infancy to old age. Certain conditions, roles, and responsibilities typically occur at each stage. Families also go through a series of developmental stages. For family members to continue to function adaptively at each developmental stage, they need to behave in ways that are appropriate for the family's developmental level.

Each time a developmental transition is reached, the family is confronted by a new set of circumstances. As the family attempts to adapt to the new circumstances, it experiences stress. Failure to adapt, to make the transition, to give up behaviors that were used successfully at a previous developmental stage, and to establish new behaviors that are adaptive to the new stage will cause some family members to develop new behavior problems. Perhaps one of the most stressful developmental changes occurs when children reach adolescence. This is the stage at which a large number of families are not able to adapt to developmental changes (e.g., from direct guidance to leadership and negotiation). Parents must be able to continue to be involved and monitor their adolescent's life, but now they must do it from a distinctly different perspective that allows their daughter or son to gain autonomy.

At each developmental stage, certain roles and tasks are expected of different family members. One way to determine whether the family has successfully overcome the various developmental challenges that it has confronted is to assess the appropriateness of the roles and tasks that have been assigned to each family member, considering the age and position of each person within the family. When a family's developmental stage is analyzed, four major sets of tasks and roles must be assessed: (1) Parenting tasks and roles are concerned with the parent figures' ability to act as parents at a level consistent with the age of the children; (2) Marital tasks and roles assess how well spouses cooperate and share parenting functions; (3) Sibling tasks and roles assess whether the children and adolescents are behaving in an age-appropriate fashion; and (4) Extended family's tasks and roles target the support for and intrusion into parenting functions from, for example, grandparents, aunts, and uncles, if extended family members are part of the household or share in parenting responsibilities.

Developmental transitions may be stressful. They are likely to cause family shake-ups because families may continue to approach new situations in old ways, thus making it possible for conflict to develop. Most often, families come to the attention of counselors precisely at these times. Of all of these developmental milestones, reaching adolescence appears to be one of the most risky and critical stages in which drug abuse can occur in most ethnic groups (Steinberg 1991; Vega and Gil 1999). Although the adolescent is the family member who is most likely to behave in problematic ways, often other members of the family, such as parents, also exhibit signs of troublesome or maladaptive behaviors and feelings (Silverberg 1996).

Assessing Appropriate Developmental Functioning

Careful judgments are needed to determine what is developmentally appropriate and/or inappropriate for each family member. It is particularly difficult to make these judgments when assessing the tasks and roles of children and extended family members. In every instance, the BSFT counselor should take into account the family's cultural heritage when making these judgments. For example, it is useful to know that some traditional African-American and Hispanic families tend to protect their children longer than non-Hispanic whites do (White 1994). Thus, it would not be unusual for children to have a longer period of dependence among traditional Hispanic groups than among non-Hispanic white families. Similarly, it would not be unusual for the African-American caretaker of a 12-year-old to continue to behave in an authoritarian manner without the child rebelling or considering it odd. In fact, researchers have suggested that African-American inner city youths experience an authoritarian command as caring, while a child from another cultural group might experience it as rejecting (Mason et al. 1994). However, as suggested earlier, as an adolescent in the United States grows older, his or her parent, who may be from any culture and in any setting, may have to moderate his or her level of control and increase his or her authoritative parenting, or the youth may rebel.

Common Problems in Assessing Appropriateness of Developmental Stage

It is often difficult for parents to determine what is developmentally appropriate for children of different ages; for example, how much or how little responsibility should a child 6, 10, or 16 years old have in a household? In families of drug-abusing and conduct-disordered adolescents, parents and their children often have a difficult time determining what is developmentally appropriate for a child's age.

One of the main problems family members encounter is how to determine the degree of supervision and autonomy that children should have at each age level. This is a highly complex and conflictive area, even for the best of parents, because as children grow older, they experience considerable pressure from their peers to demonstrate increasing independence. It is also complex because many parents are not aware of what might be the norm in today's society. Therefore, they may allow too little or too much autonomy, based either on their own comfort or discomfort level, their own experience, and/or their culture. Moreover, children's peer groups may vary considerably in the level of autonomy they expect from parents. In working with the notion of "developmental appropriateness," a BSFT counselor needs to examine issues such as roles and functions, rights and responsibilities, limits and consequences, as they are applied to the adolescents in the family. Examples of these standards are available from adolescent development research (Steinberg 1998).

While the dimensions of family functioning discussed up to now are all within the family, life context refers to what happens in the family's relationship to its social context. The life context of the family includes the extended family, the community, the work situation, adolescent peers, schools, courts, and other groups that may have an impact on the family, either as stressors or as support systems.

Antisocial Peers

A careful analysis of the life context is useful in many situations involving the treatment of substance abuse. For example, a youngster who uses drugs may be involved with a deviant or antisocial peer group. These friendships affect the youth and family in an adverse way and will certainly need to be modified to successfully eliminate the youth's drug use. Parents need help to identify less acceptable and more acceptable adolescent peers so that they can encourage their teens to associate with more desirable peers and discourage them from associating with less desirable peers.

Parent Support Systems and Social Resources

Parenting is a difficult task. Parents often lack adequate support systems for parenting. Parents need support from friends, extended family members, and other parents (Henricson and Roker 2000). The availability of support systems needs to be assessed, particularly in the case of single-parent families. The availability of social resources needs to be assessed, both in terms of what is already being used or what could potentially be used.

Juvenile Justice System

Increasingly, probation officers and the courts have become critical players in the families of drug-abusing adolescents. It is the BSFT counselor's job to assess how juvenile justice representatives such as probation officers interact with the family to determine whether they are supporting or undermining the family. One way to assess the probation officer's role, for example, is to invite him or her to participate in a family therapy session.

The "identified patient" is the family member who has been branded by the family as the problem. The family blames this person, usually the drug-abusing adolescent, for much of its troubles. However, as discussed earlier, the BSFT view of the family is that the symptom is only that: a symptom of the family's problems. The more that family members insist that their entire problem is embodied in a single person, the more difficult it will be for them to accept that it is the entire family that needs to change. On the other hand, the family that recognizes that several of its members may have problems is far healthier and more flexible and will have a relatively easier time of making changes through BSFT. The BSFT counselor believes that the problem is in the family's repetitive (habitual, rigid) patterns of interaction. Thus, the counselor not only will try to change the person who exhibits the problem but also to change the way all members of the family behave with each other.

The other aspect to understanding a family's identified patient is that usually families with problematic behaviors identify only one aspect of the identified patient as the source of all the pain and worry. For example, families of drug-abusing youths tend to focus only on the drug use and possibly on accompanying school and legal troubles that are directly and overtly related to the drug abuse. These families usually overlook the fact that the youngster may have other symptoms or problems, such as depression, attention deficit disorder, and learning deficits.

While solving differences of opinion is always challenging, it is much more challenging when it is done in the context of a conflictive relationship that is high in negativity. The following are five different ways in which families can approach or manage conflicts. Some are adaptive and some are not. In the case of drug-abusing adolescents, with few exceptions, the first four tend to be ineffective, whereas the fifth tends to be effective in most situations:

• Denial
• Avoidance
• Diffusion
• Conflict emergence without resolution
• Conflict emergence with resolution

Denial

"Denial" refers to a situation in which conflict is not allowed to emerge. Sometimes this is done by adopting the attitude that everything is all right. At other times, conflict is denied by arranging situations to avoid confrontation or establishing unwritten rules with which no one dares to disagree outwardly, regardless of how they feel. The classic denial case is the one in which the family says: "We have no problems."

Avoidance

"Avoidance" refers to a situation in which conflict begins to emerge but is stopped, covered up, or inhibited in some way that prevents it from emerging. Examples of avoidance include postponing ("Let's not have a fight now."), humor ("You're so cute when you're mad."), minimizing ("That's not really important."), and inhibiting ("Let's not argue; you know what can happen.").

Diffusion

"Diffusion" refers to situations in which conflict begins to emerge, but discussion about the conflict is diverted in another direction. This diversion prevents conflict resolution by distracting the family's attention away from the original conflict. This change of subject is often framed as a personal attack against the person who raised the original issue. For example, a mother says to her husband, "I don't like it when you get home late," but the husband changes the topic by responding: "What kind of mother are you anyway, letting your son stay home from school today when he is not even sick!"

Conflict Emergence Without Resolution

"Conflict emergence" without resolution occurs when different opinions are clearly expressed, but no final solution is accepted. Everyone knows exactly where everyone else stands, but little is done to reach a negotiated agreement. Sometimes this occurs because the family, while willing to discuss the problem, simply does not know how to negotiate a compromise.

Conflict Emergence With Resolution

Emergence of the conflict and its resolution is generally considered to be the best outcome. Separate accounts and opinions regarding a particular conflict are clearly expressed and confronted. Then, the family is able to negotiate a solution that is acceptable to all family members involved.

A Caveat

In some cases, conflicts need to be postponed for more appropriate times. For example, if a family member is very angry, tired, or sick, it may be reasonable to table the conflict until he or she is ready to have a meaningful discussion. However, in such instances, it is critical that the family set a specific time to address the conflict. Indefinitely postponing conflict resolution is a sign of avoidance. A postponement for a definite amount of time is adaptive.

In other instances, a person may decide that the issue at hand is not worth having an argument about. For example, one person may want to stay home while his or her partner wants to go dancing. Either partner may opt to compromise by agreeing to the other's preference. So long as partners take turns compromising, this is adaptive and balanced. However, if the same person is always the one to give in, this may reflect the use of denial by one partner to avoid conflict with the other.

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