THE THEORY AND PRACTICE OF STRUCTURAL AND STRATEGIC FAMILY THERAPIES: A DELPHI STUDY

Journal of Marital and Family Therapy 1987, Vol. 13, NO. 2,113-125

THE THEORY AND PRACTICE OF STRUCTURAL AND STRATEGIC FAMILY THERAPIES: A DELPHI STUDY

Linda Stone Fish Syracuse University

Fred

F!

The present study employed the Delphi procedure to examine the similarities and differences in the theory and practice of structural and strategic family therapy. A three-phase Delphi questionnaire was sent to a national panel of knowledgeable structural and strategic therapists, who were asked to identify and reach a consensus of opinion about items they thought important to a profile

of either structural or strategic family therapy. In addition, questions were devised to examine the Mental Research Institute, MRI, HaleylMadunes, and Milan1 Ackerman approaches to strategic family therapy. The final profiles are described and discussed.

Clinicians throughout the country increasingly are calling themselves “structural- strategic” family therapists (Henry, 1983) and outcome research often combines both schools into the same category (e.g., Stanton & Todd, 1979; Schwartz, Barrett & Saba, 1985). On the other hand, there are many leading theoreticians in the field (Fraser, 1982, 1984; MacKinnon, 1983; de Shazer, 1984; Rohrbaugh, 1984) who believe that it would be a grave mistake to integrate these two approaches.

This integration issue is aggravated by a lack of theoretical and practical consis- tency when describing structural and strategic therapies. Similarities and differences between the two approaches seem to wax and wane, depending on the theoreticians’

interpretation of original material. Although there may be specific differences between structural and strategic family therapy, these differences are not always clearly observ- able. For instance, both structural and strategic therapists place emphasis on eliminat- ing the presenting problem; strategic therapists seem to place more emphasis, but the

“more” is not clearly defined. Also, although strategic therapists generally present the goal of therapy as elimination of presenting problems, and structural therapists gen- erally present the goal as change in family structure, this may appear to be a question of semantics.

This lack of clarity is further highlighted when one considers the divergence within strategic family therapy. For example, Jay Haley, Mara Palazzoli Selvini and her asso- ciates, and authors associated with the Mental Research Institute (MRI) all have devel- oped their own unique styles and approaches t o strategic family therapy. It has even been suggested that some of the approaches subsumed under the term “strategic” be categorized separately (MacKinnon, 1983).

Linda Stone Fish, PhD, is a n Assistant Professor of Family Therapy and Coordinator of Clinical Services, Department of Child, Family and Community Studies, College for Human Development, Syracuse University, Syracuse, NY 13244-1250.

Fred P. Piercy, PhD, is a n Associate Professor of Family Therapy and Director of Training and Research, Family Therapy Program, Department of Child Development and Family Studies, Pur- due University, West Lafayette, IN 47906.

April 1987 JOURNAL OF MARITAL AND FAMILY THERAPY ₁₁₃

The lack of theoretical and practical consistency when describing these approaches only leads to confusion for the theoretician, researcher and clinician. A need exists to define both the structural and the strategic approaches to family therapy, as well as their similarities and differences. Without a clear definition of these approaches, the integration issue can never be resolved or even properly addressed. Moreover, until these approaches gain in conceptual and practical clarity, adequate links among theory, research and practice (Sprenkle, 1976; Liddle, 1980; Beavers, 1981) appear difficult, at best. The present study represents a n attempt to clarify the tenets of theory and practice for these family therapy approaches. Specifically, the present study examined the simi- larities and differences in the theory and practice of structural and strategic family therapy by surveying a national panel of experienced structural and strategic family therapists.

METHOD

The Delphi Technique

The Delphi technique employs multiple-wave questionnaires to sample a group of knowledgeable persons in order to establish a consensus of opinion on a particular topic (Dalkey, 1972).

The Delphi technique originated at the RAND Corporation and was first applied to defense and military issues (Dalkey & Helmer, 1963). In the defense research, the objective was to bring together a highly reliable consensus of opinion from a panel of experts (Linstone & Turoff, 1975). Now, the Delphi technique is finding application in a variety of other fields. Its use in the field of family therapy includes the development of a model family therapy curriculum (Winkle, Piercy & Hovestadt, 19811, the development of a feminist model of family therapy (Wheeler, 1985), as well as procedures for teaching such a model (Avis, 1986).

The Delphi technique, according t o Dalkey (1972), has overcome the following drawbacks of traditional methods of pooling opinions: (a) the influence of dominant individuals; (b) irrelevant and biasing communication; and (c) group pressure for con- formity. Anonymity in the Delphi technique reduces the effect of dominant individuals, controlled feedback reduces irrelevant communication, and the use of medians and interquartile ranges allows each subject to consider his or her opinion in light of the opinions of the rest of the panel while reducing group pressure for conformity (Dalkey, 1972). The technique allows participation from all panel members with economy of time and expense, and aids the formation of opinion consensus.

Panel Selection

Delphi panelists are chosen for their knowledge of a subject rather then through a random process. The population from which the current Delphi panel was drawn con- sisted of selected structural and strategic family therapists throughout the country and around the world. Fourteen prominent structural therapists and 14 prominent strategic therapists from diverse geographic regions were selected, who met three of the following criteria: (a) published a t least two articles or books on strategic or structural family therapy, (b) made at least two national convention presentations on structural or stra- tegic family therapy, (c) had at least 5 years of clinical experience in strategic or structural family therapy, (d) had at least 5 years of experience teaching structural or strategic family therapy, and (e) held a qualifying degree in a mental health discipline.

Each of these 28 therapists was asked t o participate as a panelist in the present study and also was asked to nominate 5 additional structural or strategic family therapists

114 JOURNAL OF MARITAL AND FAMILY THERAPY April 1987

who met the above qualifications. Through this nomination procedure, 18 structural and 27 strategic therapists were nominated as additional panelists.

In all, 46 (74%) panelists agreed to participate in this project. Thirty-two of the 46 panelists (70%) (14 structural and 18 strategic therapists) actually completed the entire wave of Delphi Questionnaires.

These 32 panelists also were asked to complete a personal information form. From this personal information form it was found that 12 of the 32 panelists were directors of family therapy institutes or family therapy training institutes. In addition, 7 were professors in colleges and universitites and 17 were facultykrainers in family therapy training centers. The remaining 6 panelists were therapists, either in private practice or family therapy centers.

Thirteen panelists had a Ph.D., and 7 had a n M.S.W. An additional 7 panelists had a doctoral degree other than the Ph.D. (i.e., Ed.D., M.D., Psy.D., D. Min.). The remaining panelists held various degrees in other disciplines.

The most highly represented fields of the panelists were psychology (11) and social work (9). Marriage and family therapy was also highly represented (7), as was counseling and guidance (5). One participant listed psychiatry.

The panelists reported an average of slightly less than 8?h years practicing family therapy, and an average of slightly more than 6 years teaching and supervising family therapists. They had presented a n average of 10.5 national presentations on structural or strategic family therapy, and had written an average of slightly less than 9 published articles. In all, the panelists published a total of 278 articles and 3 books. There were also 6 books in progress listed.

Procedures

The Delphi technique employed in the present study involved a three-part ques- tionnaire sent by the senior author to each participant. Delphi Questionnaire I (DQI) was an open-ended form with major category headings supplied to stimulate and guide participants’ thinking. The completed DQI was returned t o the senior author, who edited every panelist’s response for redundancy and readability, and developed nonoverlapping response categories. As a validity check, three raters, all family therapy doctoral stu- dents familiar with strategic and structural therapy, attempted to place each panelist’s initial response in one of the edited response categories. There were no items for which two or more raters could not agree on placement in one of the identified categories.

Consequently, these categories became DQII.

Panelists were then asked to rate the responses listed in DQII on a 7-point scale, indicating their degree of agreement, and return their responses to the senior author.

The median and interquartile ranges of the panelists’ responses to DQII were computed and sent to each panelist along with the panelist’s initial ratings on each item as DQIII. In light of this new information, the respondents were asked, once again, to rate the items on a scale indicating agreement and return them to the senior author.

The present study employed two identical, initial Delphi Questionnaries to compare and contract structural and strategic therapy. The major headings that were provided by the researcher in DQI were the same for both questionnaires, as were the statistics utilized to rate panelists’ responses. The procedure throughout the three questionnaire mailings was identical. Panel selection criteria were also identical, and mailings were sent simultaneously.

The difference between the two questionnaires was that one Delphi was designed for structural family therapists and one for strategic family therapists. Inherent in the Delphi technique is the need to employ knowledgeable individuals as panel members.

Structural therapy panelists were, thus, asked questions pertaining only t o structural therapy, and strategic therapists were asked questions pertaining only to strategic

April 1987 JOURNAL OF MARITAL AiVD FAMILY THERAPY 115

therapy Both the structural and the strategic panelists were also asked to respond to questions concerning the similarities and differences between the two approaches.

In the DQI for strategic therapists, many respondents found it difficult to answer certain questions because of differences within the strategic approach itself. It was suggested by one of the raters that DQII be revised by adding an additional component to the questionnaire. Three different approaches to strategic family therapy were iden- tified as the Haley/Madanes approach, the MiladAckerman approach, and the MRI approach.’ Strategic respondents were asked not only to respond to the DQII, but also to identify the three major assumptions within each major category underlying the three different strategic schools. The additional items attached to the strategic DQII were compiled into an adjunct form for strategic panelists. Those items that were identified by more than one panelist were listed under their major category heading. The form contained 176 items.

In order to assure high levels of consensus and agreement, only those items in Delphi 111 whose medians were 6.00 or above and whose interquartile ranges were 1.50 or below were accepted as part of the final profile of the two approaches (Binning, Cochran & Donatelli, 1972, p. 26).

FINDINGS

Structural family therapists identified a total of 213 items in Delphi Questionnaire I (DQI). Thirty-eight percent ( n ⁼ 82) of those items were deemed important enough to be retained in the final profile (i.e., medians of 6.00 or above and interquartile ranges of 1.50 or below) of structural family therapy. The strategic family therapy panel iden- tified 271 items in DQI and rated 97 of those items (36%) important enough to be retained in the final profile of strategic therapy. Strategic panelists further identified 95 of the 176 items (53%) to be retained in the final profile of the three schools of thought (Haley/Madanes, MiladAckerman, MRI) within strategic family therapy.

DISCUSSION

The structural family therapy author in the final profile (i.e., those with a rating of 6.00 or above and an interquartile range of 1.5 or below) included: Salvador Minuchin, H. Charles Fishman, Harry Aponte, Jorge Colapinto, Braulio Montalvo, Bernice Ros- man, Ron Liebman, and Jay Lappin. The strategic family therapy authors in the final profile were: Paul Watzlawick, John Weakland, Lynn Segal, Milton Erikson, Richard Fisch, Jay Haley, Cloe Madanes, J . Scott Fraser, Steve de Shazer, Mara Palazzoli Selvini, Gianfranco Cecchin, Giuliana Prata, Luigi Boscolo, Peggy Papp, and Carlos Sluzki.

None of the authors appeared in both profiles.

In the adjunct profile to strategic therapy, Cloe Madanes and Jay Haley were the only two authors in the final profile of the Haley/Mananes approach. The strategic panelists approved Palazzoli Selvini et al., Lynn Hoffman, Karl Tomm, and Peggy Papp as authors associated with the MiladAckerman approach. The MRI approach yielded Richard Fisch, John Weakland, Paul Watzlawick, James Coyne, Lynn Segal, and Steve de Shazer, as authors in its final profile. Unlike the Haley/Madanes approach, both the MRI and the MiladAckerman approach include authors (Lynn Hoffman, Karl Tomm, James Coyne, and Richard Fisch) who were nominated for, but not included in, the final generic strategic profile.

Tables 1 and 2 include the major theoretical assumptions underlying structural family therapy and strategic family therapy.’ The techniques/interventions associated with each approach are detailed in tables 3 and 4, while panelists’ perceptions of how change occurs in therapy are described in tables 5 and 6. Tables 7 and 8 include the major goals of the differing approaches.

116 JOURNAL OF MARITAL AND FAMILY THERAPY April 1987

Table 1

Major Theoretical Assumptions Underlying Structural Family Therapy Interquartile

Median Range Theoretical Assumption

6.80 6.80 6.80 6.72 6.50 6.50 6.50 6.36 6.33 6.33 6.33 6.30 6.30 6.21 6.17 6.17 6.13 6.10 6.10 6.00 6.00 6.00

0.82 0.82 0.90 0.99 1.08 1.20 1.38 1.06 1.17 1.17 1.17 1.32 1.32 1.09 1.22 1.22 0.94 1.43 1.43 1.06 1.25 1.29

Families are hierarchically organized with rules for interacting across and within subsystems.

Insight is not sufficient for change.

Normal developmental crises can create problems within a family.

Inadequate hierarchy and boundaries maintain symptomatic behavior.

Improving a subsystem’s boundary improves the functioning of the parts of the subsystem.

Problems are a product of social relationships, e.g, they have a context.

Families are evolving organizations continually regulating their internal structure in response to internal and external change.

Developmental life demands change in the structure of the family, as well as rules and roles.

Good functioning is determined by the fit of a family’s structure to its operational functions.

Conflict is not to be avoided, but used for change.

Family members develop a preferred degree of emotional proximity/

distance in relating to one another.

Structures and substructures are related.

The individual is a subunit of her or his family as well as a subunit of other social contexts.

Family members relate to each other in patterned ways that are observable.

Family structure determines the effectiveness of family functioning.

People are competent and resourceful, although interactional circumstances handicap competent functioning.

A faulty structure prohibits movement through various stages (accomplishment of life tasks).

Families are organized entities (developmentally and economically).

Families are their own best resource for change.

Family structure is defined by family transactional patterns (rules).

Families inherently promote predictable organization (structure) for stability.

Repetitive patterns around family roles and rules evolve in a complementary fashiodfit.

Theoretical Assumptions

Although similarities do exist between the theoretical assumptions endorsed by structural and strategic panelists (e.g., both believe that insight is not necessary and both utilize a developmental life cycle perspective), the majority of items favored by the two approaches were quite different. Those items that structural panelists endorsed that were different from strategic endorsements dealt with hierarchy, boundaries, sub- systems, substructures, and families as organizations. Strategists, on the other hand, highlighted issues of circularity, sequences of interaction, behavior as communication in a relationship, and therapeutic issues as a part of theoretical assumptions.

April 1987 JOURNAL OF MARITAL AND ^FAMILY THERAPY ¹¹⁷

Table 2

Major Theoretical Assumptions Underlying Strategic Family Therapy Interquartile

Median Range Theoretical Assumption

6.97 6.89 6.85 6.85 6.79 6.79 6.79 6.73 6.73 6.73 6.73 6.69 6.67 6.65 6.65 6.65 6.65 6.65 6.50 6.44 6.40 6.40 6.27 6.27 6.25 6.14

0.53 0.61 0.64 0.64 0.80 0.83 0.83 0.91 0.96 0.96 1.05 0.83 0.95 0.97 1.03 1.13 1.26 1.49 1.30 1.06 1.42 1.42 0.91 1.21 1.35 1.23

Behavior occurs as a part of a sequence of ongoing interactional recursive events.

Therapy can be brief and be effective.

Strategic theory is a systemic oriented theory.

Causality is circular, not linear.

One cannot not influence one’s clients, and therefore, one ought to do so according to a plan.

Behavior can only be understood in context.

All behavior is communication.

Clients are always influencing the therapist and vice versa.

Problems develop from, and are maintained by, ineffective solutions.

Insight is not necessary to interrupt redundant patterns.

Families may have difficulty making the needed changes during life cycle transitions and problems tend to occur a t these times.

Symptoms are embedded in redundant behavioral sequences and are maintained in ongoing cycles of current interaction.

Less is best-above all, we should not become part of the problem.

Therapist is action oriented.

Specific behavior change is more important than insight for its own sake.

Reality is created more than it is discovered.

Problems are not “inherently” problems but are, rather, constructed as such.

Process is more important than content.

Structural beginning and end points are arbitrary.

Client’s unique model of the world must be used t o lay a rationale for change in behavior.

Communication can become repetitive and dysfunctional.

If sequences are interrupted, more adaptive sequences can occur.

Strategic therapy does not require the presence of all family members.

Change occurs by interrupting maladaptive behavioral sequences, i.e., changing the way people behave towards one another.

Many problem clients come to therapy for a problem in living together rather than underlying pathology.

The importance of a recognition of the distinction between first-order change (i.e., more of the same) and second-order change (a

transformation of rules).

6.11 1.01 Pragmatic strategies are utilized, i.e., do what works.

The theoretical assumptions that were endorsed as most closely associated with the Haley/Madanes approach are most similar to structural endorsements. The endorsed items from t h e MRI approach, on the other hand, seem to summarize, well, the generic strategic approach. The MiladAckerman endorsements deal only with the issues of circularity and context.

118 JOURNAL OF MARITAL AND FAMILY THERAPY April 1987

Table 3

Major Therapeutic Techniques/Interventions Associated with Structural Family Therapy

Interquartile

Median Range !kchnique/Intervention

6.96 0.54 Joining

6.96 0.54 Boundary makingtmarking

6.96 0.54 Restructuring

6.92 0.58 Tracking

6.92 0.58 Enactment

6.80 0.78 Unbalancing

6.80 1.15 Promoting dyadic interaction

6.86 0.64 Accommodation

6.63 0.98 Focusing

6.63 1.40 Creating a workable reality

6.50 1

.oo

6.50 1.20 Relabelingireframing

6.21 1.09 Creating a crisisiintensifying

6.13 0.94 Escalating stress

6.10 1.47 Working complementarily

Therapeutic Techniquesllnteruentions

The only therapeutic techniquelintervention t h a t was endorsed by both structural and strategic panelists is the technique of relabelinglreframing. Accommodation, a structural item, could also be seen as paralleling the strategic item, use of the client’s language and position.

Although minor similarities are apparent when comparing structural and strategic therapeutic techniqueslinterventions, the differences are more pronounced. For exam- ple, while structural panelists endorsed items pertaining to creating crises, strategic panelists, in direct contrast, favored going with resistance and avoiding confrontation.

Structural panelists, unlike their strategic counterparts, did not choose any indirect techniques to include in the final profile of structural family therapy. Only direct approaches to dealing with clients, from joining to creating a crisis, were chosen as structural therapeutic techniqueslinterventions. Strategic panelists endorsed direct methods of dealing with clients, but they also endorsed 9 indirect techniqueslinterventions, from restraining change to prescribing a relapse.

Panelists endorsed only the use of paradox as a n item that describes all three differing approaches to strategic family therapy. While panelists endorsed some items in both the HaleylMadanes and the MilanlAckerman approach t h a t also are included in the generic strategic profile, the majority of items endorsed for inclusion in the MRI approach, once again, are all included in the generic strategic profile, and seem to summarize the profile fairly well.

How Change Occurs

Panelists share perceptions of how change occurs in structural and strategic ther- apies. Both groups of panelists endorsed items that pertain to change occurring when dysfunctional, repetitive patterns are interrupted. Panelists also agree that altering clients’ perceptions, expanding their world views, or reframing their behavior, can lead to change in therapy. Change, then, according to both the strategic and structural

April 1987 JOURNAL OF MARITAL AND FAMILY THERAPY 119

a b l e 4

Major Therapeutic Techniquesflnterventions Associated with Strategic Family Therapy

Interquartile

Median Range Techniqueflntervention

6.89 0.61 Reframinglrelabeling

6.89 0.61 Obtaining an identifiable problem

6.89 0.61 Restraining change

6.89 0.61 Prescribing the symptom

6.79 0.83 Use of client’s language and position

6.79 0.83 Determining the “interactional dance” in which

the problem is embedded and interrupting the sequence in some way

6.73 1.20 Use of paradox

6.65 1.26 Ascertaining and utilizing resistance

6.61 1.16 Prescribing relapse, reenactment of symptom

6.42 1.26 Accept the premise, alter the behavior (reframe

6.40 1.42 Go slow

6.40 1.42 Prescribing the rules of the troubled system

6.40 1.47 Positive connotation

6.31 1.12 “Uncommon” approaches

6.29 1.21 Explore the dangers of improvement

6.25 1.35 Going with the resistance and avoiding

6.25 1.35 Alter the premise, alter the behavior (reframe

6.14 1.26 Use of outsiders/team/consultants/supervisors

6.14 1.26 Giving homework tasks

6.11 1.01 Use of rituals

6.00 1.10 Various hypnotic techniques

action on premise)

confrontation premise)

panelists, seems to occur when dysfunctional sequences are disrupted, through a change in behavior or perceptions.

A major difference between the two groups of panelists’ views of how change occurs, lies in the structuralists’ endorsement of items pertaining to the therapist’s provision of new action. While the strategic panelists do not endorse any items pertaining to the therapist’s relationship with the client families, the structuralists make it clear that the therapeutic relationship helps create needed change. Not surprisingly, structural panelists also endorse items pertaining to change in family structure, while strategists endorsed putting a problem in solvable form.

Once again, when comparing the final profile of strategic therapy to the adjunct form, the MRI approach seems to summarize the generic list of the strategic approach to family therapy. While the majority of items chosen for inclusion in the Haley/Madanes approach are the same as those listed in the generic strategic profile, none of the Milad Ackerman items are included in the generic list.

Major Goals

The major goals of structural family therapy are different from the major goals of strategic family therapy, according to the panelists in the present study. Structural goals

120 JOURNAL OF MARITAL AND FAMILY THERAPY April 1987

Table 5

How Change Occurs in Structural Family Therapy Interquartile

Median Range How Change Occurs

6.80 0.82 Change in family structure or organization

6.50 1

.oo

contributes to change in individual members.

functional hierarchy and boundaries to a resolution of symptomatic behavior.

Change occurs in the here and now; the past is enacted in the present.

challenging the system.

fashion with the family.

members and subsystems.

experimentation of alternative transactional possibilities the family can accept until new patterns emerge which become self-reinforcing.

6.10 1.43 Dysfunctional, repetitive patterns are disrupted

by the therapist.

6.50 1.00

6.38 0.97 Through the combination of joining and

6.38 0.98 The therapist engages actively and in a direct

6.17 1.22 Broadening possibilities/competencies of family

6.10 0.70 The therapist helps support the continual

Table 6

How Change Occurs in Strategic Family Therapy Interquartile

Median Range How Change Occurs

6.85 0.64 When dysfunctional sequences are interrupted in

6.73 1.05 Through second-order change, i.e., a change in

6.73 1.05 Meaning defines behavior, behavior defines

such a way that the problem cannot continue.

perception, meaning, or reality.

meaning. Therefore, reframing is seen to lead to new behavior and behavioral tasks are seen to lead to new meaning.

6.42 1.26 Through the expansion of world view or new

perceptions which direct behavior.

6.19 1.14 By putting a problem in a solvable form (through reframing or relabeling).

6.06 1.12 “If change occurs without the client knowing how

or why, that is sufficient” (and often preferable).

6.05 0.85 Through interdicting a vicious positive feedback

cycle of problem solution, a new action is initiated which serves as a “ k i c k point for a new and hopefully beneficient cycle.

include reorganization of the family structure, and the lessening of ruledroles dictated by narrow bonds of transactions, i.e., an increased flexibility in both families and their members. While the presenting problem should be resolved, according to structural panelists, it is done through structural reorganization, and is as important as mastering

April 1987 JOURNAL OF MARITAL AND FAMILY THERAPY 121

Table 7

Major Goals of Structural Family Therapy

Median Range Goals

6.92 0.58 To support the family’s ability, through structural reorganization, to resolve the presenting problem and master relevant and essential tasks within family life.

Interquartile

6.63 0.98 Reorganization of family structure.

6.06 0.78 That families will not be restricted by rules/roles

6.00 1.29 That families, as a whole, and members,

dictated by narrow bonds of transactions.

individually, will have greater flexibility and be more open t o alternatives.

increased complexity (organizationally and in each family member).

6.00 1.47 Emergence of new behavioral alternatives and

Table 8

Major Goals of Strategic Family Therapy Interquartile

Median Range Goals

6.79 0.83 To solve the presenting problem.

6.73 1.05 To break the immediate redundant behavior

6.65 1.03 Change-identifying and resolving the client’s

sequence which maintains symptoms.

stated and agreed upon problems. It is a problem- solving oriented therapy.

possible.

presenting problem.

eliminate presenting complaints.

6.65 1.49 To resolve problems as quickly and efficiently as

6.35 0.97 To produce concrete behavioral change in the

6.25 1.35 To alter client solution patterns and, thus,

6.00 0.77 Second-order change.

relevant and essential tasks within family life. Six of the 7 items endorsed by the strategic panelists, on the other hand, pertained to change of the presenting problem as the major goal of therapy. In the adjunct profiles, strategic panelists believe the goals of the generic strategic approach are identical to the MRI approach.

The Final Profiles: A Summary

Structural therapy, according to the final profile, is based on the theoretical assump- tion that families are evolving, hierarchical organizations, with rules, or transactional patterns, for interacting across and within subsystems. It was agreed that symptomatic behavior is maintained by a n inadequate hierarchy and boundaries, and improving a family’s organization will change not only the symptomatic behavior, but the individuals who are a part of that organization.

The panelists also agreed that the structural therapist, whose major goal is to reorganize the family’s structure, actively directs the course of therapy using techniques that unbalance and restructure the present context. Joining and accommodating to the

122 JOURNAL OF MARITAL AND FAMILY THERAPY April 1987

family, structural therapists use direct techniques to create workable realities, reframe present behavior and intensify stress. Reorganization of the family’s structure, synon- ymous with change, occurs when therapists interrupt dysfunctional sequences and provide alternative transactional patterns for the family. The structural therapist helps support the continual experimentation of alternative transactional possibilities the family can accept, until new patterns emerge which become self-reinforcing.

The final strategic therapy profile is based on the theoretical assumption that behavior, which occurs a s a part of a sequence of ongoing interactional recursive events, can only be understood in context. Symptoms, according to strategic panelists, are embedded in these sequences of interaction, and are developed and maintained by ineffective solutions. The strategic panel of experts do not perceive symptomatic behav- ior as “inherently” problematic, but rather, as construed as such, based on the reality that is created by the family. Therapy, according to the panelists, aims to change this reality, with a belief in the necessity of second-order change.

The final profile of strategic family therapy also is based on the assumption that a systemically oriented theory underlies all of strategic therapy. The strategic family therapist, according to strategic panelists, utilizes systemic concepts to interrupt mala- daptive sequences and change the way people relate to one another. These interruptions change the meaning of behavior and the behavior, itself. The final profile exemplifies the goal of strategic family therapy a s change in the presenting problem, which is accomplished through the use of direct and indirect interventions.

The HaleyIMadanes approach to strategic therapy, according to a consensus of opinion among strategic panelists, is different from the generic strategic profile in its emphasis on symptoms as metaphors, the use of ordeals, and the use of pretending.

Symptoms also are seen as arising from dysfunctional hierarchies.

The MiladAckerman approach to strategic therapy seems to be different from the generic strategic profile in more ways than the Haley/Madanes or the MRI approach.

For example, the strategic therapists could not find any goals of therapy mentioned in the strategic profile that could be endorsed for the MiladAckerman approach. According to strategic panelists, the differences lie in the emphasis placed on circularity, and the inextricable nature of symptoms and systems.

On the other hand, the items endorsed as examples of the MRI approach to strategic therapy are quite similar to the generic strategic profile. It appears that the MRI approach is the treatment most closely associated with the generic term “strategic”

family therapy.

Similarities and Differences

Structural and strategic panelists agree that both approaches: (a) are present focused, (b) are change, rather than insight, oriented, (c) view problems in their relationship context, (d) give directives, (e) assign tasks, (0 are interactional, or contextually ori- ented, and (g) are goal directed and concerned with the outcome of therapy. While many similarities exist between the two approaches, the final profiles of structural and stra- tegic family therapies yield two distinct schools of thought.

The theoretical emphases of both approaches are different. While structural ther- apists emphasize a family structure, strategic therapists do not. Although both use direct techniques to intervene in family therapy, strategic therapists use mostly indirect ones, while no indirect techniques were found on the final structural profile. Goals of therapy are also quite distinct. Strategic therapists aim to solve the presenting problem, while structuralists aim towards restructuring the family. It appears that strategic panelists endorsed the following item quite aptly: “Structuralists see the symptom as one manifestation of underlying family pathology and therefore logically try t o reor-

April 1987 JOURNAL OF MARITAL AND FAMILY THERAPY 123

ganize the family structure. Strategists take the symptom at face value, and the aim then is to identify those interactional patterns which maintain the problem.”

The major similarity between the two approaches to family therapy lies in how both schools believe that change occurs. Both perceive change occurring as dysfunctional sequences are interrupted, producing a change in behavior and a change in perception.

Although this similarity is apparent, structuralists believe that crisis is needed to produce change (and also believe strategists view crisis in the same light) while strategic therapists produce change more indirectly.

CONCLUSIONS

More differences than similarities were found when comparing the final profiles of structural and strategic family therapies. The theoretical and pragmatic distinctions between the two approaches have potential ramifications for the family therapy researcher, educator and clinician.

Researchers, for example, should design empirical studies with a sensitivity toward theoretical assumptions implicit in various therapies. The different assumptions, tech- niques, and goals of structural and strategic therapy found in the present study would appear to suggest a need for different process and outcome criteria in studies examining structural and strategic therapies (e.g., increased versus decreased in-session intensity;

structural change versus alleviation of the presenting problem; etc.).

Regarding the teaching and practice of family therapy, it seems premature t o learn an integrated “structural-strategic” approach without first being exposed to the often subtle theoretical distinctions between the two approaches. Some trainers accomplish this by teaching or supervising beginning clinicians in either structural or strategic therapy alone, but not both in combination. Others teach structural-strategic therapy, but emphasize the distinctions through ongoing supervision. The present study suggests that such distinctions do, indeed, exist and should be taken seriously. As integrated models of structural-strategic therapy continue to expand, trainers and clinicians will be challenged t o responsibly reflect theoretical clarity in their training, supervision and practice. The results of the present study represent one potential resource in facilitating the understanding of important conceptual and practical distinctions between structural and strategic family therapies.

REFERENCES

Avis, J. M. (1986). Feminist informed training in family therapy: A Delphi study. Unpublished Beavers, R. A. (1981). A systems model of family for family therapists. Journal of Marital and Binning, D., Cochran, S. & Donatelli, B. (1972). Delphipanel to explorepost-secondary needs in the Dalkey, N. (1972). Studies in the quality of life. Lexington, MA: Lexington Books.

Dalkey, N. & Helmer, 0. (1963). An experimental application of the Delphi method to the use of de Shazer, S. (1984). Fit. Journal of Strategic and Systemic Therapies, 3,34-37.

Fraser, J. S. (1982). Structural and strategic family therapy: A basis for marriage or ground for Fraser, J. S. (1984). Process level integration: Corrective vision for a binocular view. Journal of Henry, P. (1983). The family therapy profession: University and instituteperspectiues. Unpublished

doctoral dissertation, Purdue University, West Lafayette, IN Family Therapy, 7,299-307.

State of New Hampshire. Manchester, New Hampshire: Decision Research, Inc.

experts. Management Science, 9,458-467.

divorce? Journal of Marital and Family Therapy, 8, 13-22.

Strategic and Systemic Therapies, 3,43-57.

doctoral dissertation, Purdue University, West Lafayette, IN.

124 JOURNAL OF MARITAL AND FAMILY THERAPY April 1987

Liddle, H. _(1980). On teaching a contextual or systemic therapy: Training content, goals, and Linstone, H. A. & Turoff, M. (1975). The Delphi method: Techniques and applications. Reading, MacKinnon, L. _(1983). Contrasting strategic and Milan therapies. Family Process, 22,425-437.

Rohrbaugh, M. (1984). The strategic systems therapies: Misgivings about mixing the models.

Journal of Strategic and Systemic Therapies, 3,28-32.

Schwartz, R. C., Barrett, M. J. & Saba, G. (1985). Family therapy for bulimia. In D. Garner & P.

Garfinkel (Eds.), Handbook for psychotherapy for anorexia nervosa and bulimia (pp. 280-310).

New York: Guilford Press.

Sprenkle, D. H. _(1976). The need for integration among theory, research, and practice in the family field. The Family Coordinator, 25, 124-127.

Stanton, M. D. & Todd, T. C. (1979). Structural family therapy with drug addicts. In E. Kaufman

& P. Kaufman (Eds.), Family therapy of drug and alcohol abuse. New York: Gardner Press.

Wheeler, D. (1985). A feminist modeE of family therapy: A Delphi study. Unpublished doctoral dissertation, Purdue University, West Lafayette, IN.

Winkle, W. C., Piercy, F. P. & Hovestadt, A. J. (1981). A curriculum for graduate-level marriage and family therapy education. Journal of Marital and Family Therapy, 7,201-210.

methods. American Journal of Family Therapy, 8,58-69.

MA: Addison-Wesley.

NOTES

‘Although all three subschools are also known by different names (e.g., Haley/Madanes has been termed “the problem solving approach” and MiladAckerman “the systemic school”), the names used here are those the panelists in the present study most often utilized to describe these differing approaches.

2For the complete final profile of the three differing strategic approaches, please contact the first author.

April 1987 JOURNAL OF MARITAL AND FAMILY THERAPY 125