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Therapy Manuals for Drug Addiction


Appendix A: Training Counselors in Brief Strategic Family Therapy

One of BSFT's strengths is its considerable flexibility, which makes it extremely adaptable to a broad range of family and youth situations and problems. The disadvantage of BSFT is that it is not a simple-tofollow recipe (a pinch of empathy and an ounce of joining). Rather, BSFT is an advanced clinical model that requires the counselors who use it to have considerable skill.

Selecting Counselors

Counselors need three levels of training and experience to conduct BSFT counseling. If a counselor does not have basic counseling skills, he or she would have to learn them. If a counselor does not have systemic skills, he or she would have to learn them. However, if the counselor already has basic skills and systemic skills, he or she only would have to learn skills specific to BSFT. The nature of the training and skills of the counselor should be an important consideration in selecting counselors for training in BSFT. Each of the following levels of training are discussed in more detail below:

  • Basic clinical skills common to many behavioral interventions
  • Training in basic family systems theory, as used in many family therapy approaches
  • Training specific to BSFT

Level One: Training in Basic Clinical Skills Common to Many Behavioral Interventions

Level one training is the kind of training that teaches counselors basic clinical skills common to many kinds of behavioral interventions, such as:

  • Interviewing skills
  • Active listening - reflecting back or repeating to the client the content and feelings the client has expressed
  • Empathy - understanding the client's experience at a cognitive and affective level and being able to express it
  • Treating all clients with respect
  • Providing counseling for the benefit of the client and not for the benefit of the counselor; placing the client's needs above the counselor's needs
  • Understanding oneself - feelings, reactions, what pushes one's buttons
  • Providing validation and support to clients needs

Level Two: Training in Basic Family Systems Theory

Level two training is the kind of training that is often provided in clinically oriented, master's level programs in social work, marriage and family therapy, and, occasionally, in counseling psychology. In this kind of training, counselors learn how to understand families as systems rather than as a conglomerate of individuals. Systemic work, as defined in Chapter 2, is based on the notion that family members are interdependent and that the family is more than the sum of its parts. That is, family members behave very differently when they are together than when they are apart. Consequently, the counselor may not always be able to predict how a family member behaves in the family as compared to the behavior of the family member outside the family. Similarly, family members' perceptions or reports of family interactions may be severely flawed. Counselors are taught to think and act in systems terms. That means that counselors are taught to consider how social context affects individual behavior. Counselors also have been taught the basics of entering a system, such as identifying and respecting the system's power structure.

Level Three: Brief Strategic Family Therapy Specific Training

Counselors who have basic clinical skills and family systems training can be trained in BSFT concepts and techniques. However, counselors who lack basic skills training are required to take extensive pre- requisite preparatory training. Counselors who lack family systems training must be trained in family systems (see Chapter 2) before they can be trained in BSFT concepts and techniques. It is suggested that counselors and their administrators should not underestimate the importance of obtaining the more basic counseling skills or the intensity of training required to obtain these more basic skills.

Required Brief Strategic Family Therapy Training: Four Phases

The required BSFT training has four phases.

  • Phase 1 - counselors learn the methods of BSFT
  • Phase 2 - counselors review videotapes to learn how to identify family process and family interactions
  • Phase 3 - counselors review videotapes to learn how family counseling interventions are conducted
  • Phase 4 - A BSFT supervisor supervises the BSFT counselors' therapy sessions or reviews videotapes of the therapy

In the first phase of training, the counselors must learn the methods of BSFT presented in this manual. As part of teaching these methods, considerable role playing is conducted to illustrate various aspects of the BSFT model.

In the second phase of training, counselors review a series of videotapes of families that were treated at the University of Miami Center for Family Studies, where BSFT was developed. This set of videotapes shows families by themselves (without a therapist present) responding to three standard stimuli. The three standard stimuli are tasks the family has been asked to do: (1) plan a menu together with which everyone agrees; (2) say what each likes and doesn't like about each other; and (3) talk about a recent argument, including what it was about, who was involved, and what happened. These videotapes are used to teach the counselors how to identify family process and family interactions at the most minute level, as discussed in Chapter 3. In other words, counselors are taught to identify who the family's leader is, how the family handles conflicts, who is allied with whom, and who the family's identified patient is. The counselors also learn how to tell if the family views itself as having problems other than the problems of the identified patient and which family members are enmeshed, which are disengaged, and so on. As part of this phase, counselors will be trained to identify how the behaviors of one family member are linked to those of another. For example, there may be two family members who always agree or always disagree with each other; this denotes an enmeshed alliance between these family members.

In the third phase of training, the counselors review videotapes of therapy sessions BSFT counselors conducted at the Center for Family Studies with families of drug-abusing adolescents. These sessions will be used to illustrate how counselors respond to various family processes, for example, how to join with a family, reframe negativity, shift boundaries, and other techniques. Trainees will observe what trained BSFT counselors do in the context of specific family interactions (e.g., blaming the identified patient). For example, it is important to note whether the counselor reframes or diverts the conversation, permits negativity to go unchecked for a long time, centralizes the conversation around himself or herself, or decentralizes the conversation so that most of the conversation is among family members. It is also important to note how the counselor brings about these various therapeutic maneuvers, both those that are effective and those that are not.

In the fourth and final phase of training, a BSFT trainer supervises a counselor's work in BSFT sessions as it takes place whenever possible, or if live supervision is not possible, reviews the counselor trainee's videotapes of the family sessions. BSFT trainees are taught to be comfortable with someone videotaping their work, to discuss videotaping with families, and to obtain a signed videotape permission form from the families. In addition, the BSFT counselor trainee also will be taught to explain the nature of the training activity and the supervisory relationship to the families so that they are fully informed that they are participating in the training of the counselor.

While counselors often fear that the families they work with might object to being videotaped, 30 years of experience has shown that families are willing and comfortable when the counselors themselves are comfortable with having their work videotaped. Thus, the highest priority is to help counselors become comfortable with having their work videotaped. Drug-abusing adolescents and their families usually do not have a problem with being videotaped. However, in our experience, when a parent is involved in high-level criminal activity, that parent is likely to refuse videotaping.

While some counseling modalities may be primarily concerned with the internal experience of clients and counselors, BSFT is primarily concerned with interactions, or linked behaviors. Both the interactions between family members and the interactions between the counselor and family members help the BSFT counselor understand the problematic interactions in a family. To diagnose a family's problems, the BSFT counselor observes the way families interact in the present (i.e., process), rather than attending to the details of the aspects of family life that they discuss (i.e., content). Similarly, to understand how a counselor interacts with a family, BSFT assumes that it is extremely difficult to adequately describe interactions between the counselor and the family, and so requires the use of live supervision or supervision using videotaped therapy sessions.

The authors' preference is to collaborate with counselor trainees in their therapy as a way of teaching BSFT. Therefore, BSFT trainers will be at the other end of a one-way mirror or a camera to help counselor trainees with their first BSFT cases. This is called "live supervision." In most training settings, the most likely approach to live supervision will be through a camera. The wide-angle lens camera is set in the therapy room, and it is connected by cable to a monitor in another room. In this fashion, the trainer can watch the session live on the monitor as it is being conducted in the therapy room.

In live supervision, the trainer is a collaborator who, along with the counselor, takes responsibility for the success of the session. From time to time, the trainer will knock on the door to have the counselor come out to discuss the direction of the session and to make recommendations. If phones connect the therapy and viewing rooms, the trainer is likely to call the counselor trainee with suggestions. Sometimes, in the case of very difficult families, the trainer may actually join the counselor trainee in the counseling session to co-conduct the session.

Required Supervision

BSFT was developed and evaluated for efficacy with counselors who had a lot of supervision. Therefore, to be implemented faithfully, BSFT must be implemented with plenty of supervision. There are several reasons why this is important. First, supervision is a support system for the counselor. Such support systems can help the trainee remain faithful to the model. Second, a counselor who works with families may encounter certain dangers that supervision and/or a supervisory support system can prevent. The most significant danger is that the counselor will be incorporated into the family system in a way that prevents the counselor from helping the family change. Because of this, beginning and intermediate BSFT counselors must be supervised abundantly during their therapy sessions. Supervisors are responsible for ensuring that counselor skills continuously improve and that counselors are faithful to the BSFT model.

There are four levels of counseling expertise:

  • Trainee
  • Counselor
  • Senior counselor
  • Master counselor

The BSFT trainee is in the early stages of learning. The BSFT counselor already knows the model but requires additional practice. The senior BSFT counselor is able to teach the model and may still require occasional supervision. The master BSFT counselor has treated several hundred families under supervision and is widely recognized as an excellent teacher. His or her videotaped sessions are used as examples to train other counselors. The master BSFT counselor conducts live demonstrations of BSFT in front of large audiences. The master counselor's skills must be of such high quality that he or she can conduct a counseling session with an unknown family, at an unknown venue, in front of a large audience, usually of more than 100 counselors, and do a great job.

How rapidly counselors advance in their careers depends on the amount of clinical work they do, the amount of supervision available, and how diligently they study their own videotapes, participate in self-study and supervisory groups, and seek additional training. Of course, how rapidly trainees move from stage to stage also depends on their beginning level of clinical and family systems expertise and on the amount of prior family counseling training and experience they have.

Appendix B: Case Examples

This appendix presents two examples of families who have undergone BSFT. These families come to therapy with different problems and illustrate different types of problematic family interactions. Dissimilar examples are provided to illustrate how BSFT can be used to work with different types of family problems. These case examples reflect, as much as possible, the realities of the cases from which they were drawn. However, all identifying information has been changed to protect the identities of the family members.

Case Example I: The Guerrero Family

Clinical Presentation

The Guerrero family consists of a mother, a father, and 11- and 14- year-old sons. They were referred to the clinic by the 14-year-old's school counselor after he was caught smoking marijuana in the school bathroom. The counselor visited the home and found the youngest son and the mother eating dinner. The identified patient and the father were not there. The mother immediately began to list excuses why her oldest son was not home when he should have been. She had trouble accepting what the school counselor had done and insisted that the teacher who had reported him "has it out for my son." Toward the end of the counselor's first visit, the father came home. He ignored his wife and younger son and went directly to the kitchen. Upon finding no food ready for him, he shouted over his shoulder at his wife, asking her why she had not made him dinner. When the father was asked to join the session, he declined, saying that his wife was in charge of discipline and that she was not doing a good job at it. The 14-year-old did not come home during the counselor's visit.

Establishing the Therapeutic System

When the counselor first arrived at the Guerrero home, he began to join with the mother. He sat at the dinner table with the mother and the younger son and validated the mother as she complained about the father's disengagement and the oldest son's out-of-control behavior. The younger son chimed in periodically about his older brother's sour attitude, and the counselor empathized with his grievances. Although the counselor's initial attempts to join with the father were unsuccessful, the counselor later adopted a more focused approach. When he spoke to the father, the counselor emphasized that his participation was needed to keep his son from getting into more serious trouble. The counselor also assured the father that participating in therapy could help reduce his wife's nagging about his disengagement from the family. Joining with the drug-abusing son was somewhat more difficult. He resisted the counselor's first few attempts to join with him over the phone and was absent from the home during the counselor's first few visits. Finally, the counselor approached the adolescent at the park after he and his father had had a major fight. The counselor assured the youth that being in BSFT could help ensure that that type of fight would not happen again.


When the counselor met with the whole family, the mother began to tell him about her son's problems. The counselor asked the mother to tell her son about her concerns. As the counselor encouraged the family members to speak with each other, he also observed the patterns of interaction along the following BSFT diagnostic dimensions.


A strong alliance exists between the mother and her 14-year-old (problem) son; the father is uninvolved. The children communicate with the father mostly through the mother. The mother and the father do not share much time as a couple. The mother is responsible for child-rearing nearly all the time. The mother and father ally occasionally, but only regarding unimportant issues such as what to eat for dinner.


The mother indicates what her 14-year-old son prefers to eat, and the mother and her 14-year-old son laugh together, both signs of enmeshment. The father is frequently "too busy" to participate in family activities, a sign of disengagement. Complaints of family members about other family members during the interview are highly specific, a sign of adaptive functioning along this dimension.

Developmental Stage

The children are not allowed to play outdoors at night. The mother uses her 14-year-old son as her confidante, complaining to him that his father comes home late.

Life Context

The father has a demanding job, while the mother finishes her work early and is home by 3 p.m. The family lives in a high crime neighborhood; drug dealing gangs recruit in the neighborhood. The mother and father are not involved in arranging or supervising activities for their adolescent son and his peers. The 14-year-old son is associating with antisocial youth in the neighborhood.

Identified Patient

The father comes home late and does not help with chores at home. His 14-year-old son is rebellious, refuses to do chores at home, and has conduct problems at home and in school. He also comes home late, often very excited and irritable. He stays up much of the night listening to music, then sleeps deep into the day. The 11-year-old son is a model child.

Conflict Resolution

Conflicts are diffused through angry blaming and recriminations.

General Discussion of the Diagnosis

In the Guerrero family, the parents have assigned themselves separate role responsibilities. The mother is fully responsible for all child rearing, while the father's responsibility in this area is very limited. Because there appears to be an unspoken agreement between the parents to be distant from each other, it can be assumed that they both prefer their separate role responsibilities for their own reasons. This is maladaptive behavior in terms of child-rearing issues because the father and mother do not cooperate in parenting functions. Rather, it may appear that the mother and the troubled son are the ones allied, with father off on the side. If one looks a little further, it would not be surprising to find that the same patterns of interaction occur around content areas other than child rearing. In fact, these kinds of interactive patterns or structures are almost always found to re-occur in most aspects of family life. If they occur around one content, they are almost invariably occurring around most, if not all, contents. The lack of a strong parental alliance with regard to child-rearing issues undermines the family's ability to chart an effective and successful course of action. This is particularly troublesome when there are forces external to the family that influence the adolescent's development of behavior problems. These forces include the adolescent's peer group and the behavioral expectations that exist or to which the youth is exposed outside the home. These ecological forces provide training and opportunity for a full rebellion on the part of the adolescent. A BSFT intervention will target changing the interactional patterns that are preventing the family from successfully charting the youth's path away from antisocial peer groups and externalizing behaviors. This intervention involves restoring parental leadership capabilities by first creating a parental leadership alliance. In resonance, it becomes clear that because the father is outside of the mother-child alliance, he is less concerned about what goes on within that alliance. Because he "stays out," he is emotionally distant (disengaged) from both his wife and his son. In contrast to this, the mother and her 14-year-old son are much closer emotionally and psychologically, and, thus, they are likely to be enmeshed. Whether or not one defines the mother as enmeshed with the son or the mother and son as disengaged from the father, it is obvious that there is a difference in the psychological and emotional distance that exists between father and mother and father and son on the one hand, and mother and son on the other. On the dimension of developmental stage, it appears that the 14-yearold son may be burdened with emotional responsibilities that are more appropriately assigned to a spouse, such as being the mother's confidante. The other child is not allowed out after dark. This seems appropriate given the dangerousness of the neighborhood. In this family, the identified patient is sometimes the troubled son and sometimes the isolated father. While the negativity the mother and the 14-year-old show toward the father functions to keep him out of the family, both the mother and father blame their current problems on their oldest son. If he were not rebellious, their separate role arrangement would work quite well for each of them. Unfortunately, conflicts between the mother and the father are not being resolved because their attempts to address their differences of opinion degenerate into blaming wars.

Planning Treatment Based on Diagnosis

Understanding the dimensions that describe family interactions goes a long way toward helping the BSFT counselor define what he or she must do as a counselor: diagnose the problem in terms of specific dimensions of family interactions and then implement strategies to correct problems along these dimensions. Often some dimensions are more problematic than others and need to be the greater focus of the intervention. The counselor diagnosed the oldest son's drug abuse problem in terms of ineffective behavior control resulting from:
  • Organization: absence of a parental subsystem that works together. Mother and father need to be assigned collaborative tasks that will bring them together.
  • Organization: improper alliances. Boundaries must be strengthened between mother and 14-year-old son.
  • Resonance: maladaptive boundaries in which one parent is too close (enmeshed) to the problem child, while a second parent is too far (disengaged) from the spouse and that same child. Boundaries need to be shifted so that the parents are closer to one another emotionally and interactionally, the children are more "in tune" with each other, and a healthy separation exists between the parents and the children.
  • Developmental Stage: developmental stage may be inappropriate in that the enmeshed child is burdened and confused by a spousal role (confidante to mom's unhappiness with dad). The counselor should encourage the mother and father to serve as each other's support system.
  • Identified Patient: enmeshed child is identified by the family as its major problem. The counselor needs to shift the family's attention to help family members understand that the "whole system," rather than only the adolescent, is part of the problem. Also, family members need to eliminate negative attitudes and enabling behaviors they display toward the adolescent identified patient to "free" him to act in a socially appropriate manner.
  • Life Context: 14-year-old identified patient is involved with a deviant peer group. The mother, father, and identified patient should negotiate rules and consequences for the adolescent's misbehavior, and boundaries between the family and the outside world need to be strengthened. Additionally, the parents may need to be more involved with the parents of their son's peers to make it easier to more effectively supervise their adolescent's activities.
  • Conflict Resolution: family may have certain conflicts repeatedly occur and never get resolved because each time differences emerge, they (sometimes) are avoided and/or (most often) are diffused through blaming wars. The counselor should refocus the interaction on the problem each time family members attempt to avoid the issue or to change the subject so that the conflict may be negotiated and resolved.

Producing Change

Having diagnosed the problem in terms of these dimensions, the counselor was able to target interventions directly at the problematic interactions within these dimensions. One of the BSFT counselor's first moves was to help the disengaged father get closer to his estranged 14-year-old son. At the same time, the counselor initiated a dialogue between the two parents about this youth to try to establish an alliance between the parents around the content of their mutual concern for their son. The next step was help the parents negotiate rules for the youth that, once implemented, would bring his "outof- control" behavior under control. As these changes were being negotiated, the family displayed frequent conflict avoidance and diffusion. When the family attempted to diffuse or avoid the conflict, the counselor would intervene and return the topic of conversation to the original conflict. In the process, the family acquired new conflict resolution skills. The parents were able to agree on rules and consequences for the identified patient's behavior, and these were discussed and, where appropriate, negotiated between the parents and the son. Ultimately, the parents were able to set consistent limits, and the adolescent's behavior improved.

Case Example II: The Hernandez Family

Clinical Presentation

The Hernandez family was referred to the clinic by the public defender at the time of Isabelita's third arrest, this time for drug possession. Isabelita was 15 years old, and she lived with her mother, a single parent, and a 12-year-old brother. Because the mother only spoke Spanish, the case was assigned to a Hispanic BSFT counselor who called the home and heard screaming and fighting in the background. The counselor spoke with the mother, who sounded overwhelmed. When the counselor explained that he was calling to set up a family session, Ms. Hernandez angrily told the counselor that she could never get Isabelita to attend.

The counselor asked Ms. Hernandez for permission to come to the home when she and Isabelita were both likely to be home. Because Ms. Hernandez worked as a domestic during the day, the appointment was set for 7 o'clock the next evening. When the counselor arrived at the home, he found the mother alone with her 12-year-old son. Ms. Hernandez explained that Isabelita often stayed out with her friends, and she could not predict what time Isabelita would be home. The 12-year-old son was quick to confirm his mother's story and added that Isabelita was always upsetting his mother and that he wished she would just go away.

Establishing the Therapeutic System

The counselor began to join with Ms. Hernandez by listening to the story of her hardships in this country and with Isabelita. Ms. Hernandez said how overwhelmed she felt by Isabelita's behavior and that she did not know what she could do. In fact, she said that, "It is all in God's hands now," as if there was nothing else she could possibly do. It appeared from the story that Ms. Hernandez did not have well-established rules or consequences for Isabelita's behavior. It also appeared that most of the communication that occurred between daughter and mother was angry, blaming, and fighting. Ms. Hernandez felt that they could argue for hours about the same thing and then have the same argument all over again the next day.

It was about 8:15 p.m., when Isabelita arrived. It was obvious to the counselor that her gait was unsteady and her speech was slurred. Her eyes were red. She barged into the home and went straight to the kitchen. When Ms. Hernandez said to Isabelita, "Come here, there is someone here who has come to see you about your arrest," Isabelita answered, "F--k them, I am hungry."

Ms. Hernandez went to the kitchen to serve Isabelita her dinner, screaming at her "Your food is already cold. You are late again. We had dinner two hours ago." The screaming between mother and daughter continued for another 10 minutes before the counselor came to the kitchen to attempt to introduce himself to Isabelita, as a way of extending the joining process. In this first encounter, the counselor listened and joined.


While the counselor listened and joined, he also observed the interaction between mother and daughter. Armed with these observations, the counselor understood the family's interactions along the following BSFT diagnostic dimensions.


There is a problem with this family's hierarchy and leadership. The identified patient is in a powerful position, while the mother is powerless and feels overwhelmed. The mother has no control over the identified patient's behavior. There is no sibling subsystem. The 12- year-old son triangulates between the mother and the identified patient.


The family is very enmeshed. The quality of the enmeshment between the mother and the identified patient is conflictive and hostile.

Developmental Stage

All three members of this family appear to be functioning below what would be appropriate for their ages and roles. The identified patient's demands on her mother are those of a younger child, and she does not help out at home. The mother is overwhelmed and does not know how to control the identified patient. The son is too attached to his mother and involved in supporting her, and he does not engage in age-appropriate social and play activities.

Life Context

The family is new to the United States, and the mother is disconnected from her host society (e.g., she has no English skills). The identified patient spends most of her time with acculturated peers who participate in drug use and risky sex.

Identified Patient

The identified patient is extremely rigid. The identified patient centralizes herself with her negative behavior. The relationships between the identified patient and other family members are characterized by intense negativity. This family has not identified other problems or persons as a concern.

Conflict Resolution

The typical pattern of interacting in the family is continuous conflict emergence without resolution.

General Discussion of the Diagnosis

In the Hernandez family, the mother is overwhelmed and is unable to manage her drug-abusing daughter's behavior. The daughter, in turn, has distanced herself from the family and spends the majority of her time with sexually active and drug-using friends. When the daughter is home, she and her mother fight constantly, with the brother intervening to take the mother's side against his sister. The brother's triangulating maneuvers serve only to further isolate the identified patient from her family.

Cultural issues also need to be taken into account in diagnosing the Hernandez family. Upon their arrival in the United States from Colombia 3 years earlier, the members of this family began to drift apart from one another. Isabelita began learning English and associating with Americanized peers, whereas her mother remained socially and culturally isolated. Ms. Hernandez had become increasingly uncomfortable with Isabelita's acculturating behavior and choices of friends, but the widening chasm between mother and daughter discouraged Ms. Hernandez from addressing these issues with Isabelita. By the time Isabelita was referred to treatment, the family system had become completely dysfunctional, and Ms. Hernandez had ceded nearly all of her power and authority to her daughter.

Planning Treatment Based on Diagnosis

A powerful identified patient is typically joined first in order to engage the family into treatment. In this case, however, Isabelita did not present an engagement problem. Although angry and rebellious in her behavior, she was present in therapy and willing to voice her complaints and feelings. The counselor thus starts by joining both the mother and the identified patient. It is important very early in the therapy to work to restructure the dysfunctional family hierarchy. By supporting the mother, the counselor needs to help her break the cycle of conflict between herself and her daughter so that the mother can begin to recapture some control. Essentially, the counselor needs to help move the mother into an appropriate parental role. The brother's attempts at triangulation need to be blocked, allowing the mother and daughter to resolve their issues directly, between the two of them. This also would permit the brother to engage in more ageappropriate activities. Isabelita's disobedient behavior needs to be reframed as a cry for help in order to change the affective tone of her relationship with her mother, and, thus, to permit them to interact more positively.

The treatment plan that the BSFT counselor formulated for the Hernandez family addressed all six of the structural dimensions introduced in Chapter 3:

  • Organization: A dysfunctional hierarchy exists in which the daughter holds the power and the mother is powerless and overwhelmed. Power must be transferred back to the mother.
  • Organization: The son is triangulated into the relationship between the mother and the daughter. The son's attempts to triangulate must be blocked.
  • Resonance: The mother and the daughter are enmeshed in a conflictive and explosive relationship; the daughter's behavior must be reframed as a call for help to reduce the negativity.
  • Developmental Stage: The daughter's behavior at home is immature and demanding, the son is playing a "mother's partner" role, and the mother does not assume appropriate parenting leadership. The daughter must be shown how to express her feelings, the mother must be encouraged to elicit and validate the daughter's feelings, and the son must be prompted to participate in ageappropriate social activities.
  • Identified Patient: The daughter is designated as the source of the family's problems. The problem must be framed in terms of the whole family and addressed by changing the family's patterns of interaction.
  • Life Context: Acculturation differences compound normative parent-adolescent disagreements and exacerbate the distance between the mother and the daughter. The counselor must help the two of them "get on the same page" in their interactions.
  • Life Context: The daughter is associating with high-risk peers. As power is transferred back to the mother, peer selection must be brought up, and the mother needs to encourage the daughter to select different peers.
  • Life Context: The mother and the son are socially isolated. The mother needs to familiarize herself with the English language and with American culture, and the son needs to associate with friends his own age.
  • Conflict Resolution: The mother and the daughter tend to shout at and insult one another with no resolution. The family must be taught to stay on topic and resolve issues without leaving the room or resorting to personal attacks.

Producing Change

One week later, the counselor came for the second session, and the same exact incident re-occurred, with Isabelita coming home late, clearly on drugs. The counselor had already established a therapeutic relationship with the whole family. While the counselor sat with Ms. Hernandez waiting for Isabelita to show up, he used the time to explain how Ms. Hernandez could respond differently to Isabelita when she arrived home late (i.e., a reversal). In BSFT, therapy can be conducted with family members even when the identified patient is not present, as happened in this case. The counselor coached Ms. Hernandez to remain calm, not let Isabelita engage her in a screaming match, and not provide or help her with food. When Isabelita arrived, her portion of the family dinner had been placed in the freezer. Upon her arrival, Isabelita as usual bolted to the kitchen and demanded food. Encouraged by the counselor, Ms. Hernandez continued to sit in the living room, which, in their small home, was just next to the kitchen. Isabelita came into the living room and began shouting at her mother about the food. The mother yelled back to Isabelita, "You are a drug addict," and this began anew the cycle of blaming and recrimination. The counselor stood up, walked up to Ms. Hernandez, placed his hand on Ms. Hernandez's shoulder, and said, "You need to stay calm and not let her control you with her fighting." After several such interventions, Ms. Hernandez finally looked at the counselor and said, "I am trying to do it, but it is very hard." This statement represented Ms. Hernandez's initial step in using the counselor to help her detach from the conflict with her daughter. Furthermore, when the son stepped in, the counselor encouraged the mother to hold him back as well.

Isabelita continued to scream at her mother without getting a response for another 15 minutes before storming to her bedroom in a fury. Having been unsuccessful in engaging either her mother or brother in a fight, she was frustrated and gave up. After the counselor gave the mother ample support and praise for having controlled the situation and avoided a fight, the counselor moved the conversation to the next step. He discussed other ways in which Isabelita would "push her mother's buttons," and he gave Ms. Hernandez the task of using the newly learned skills on these other occasions.

This was a great gain for a single session, and it was clear that the gains from this session needed to be followed up and extended as soon as possible. The counselor told Ms. Hernandez that "we can keep making things better if we meet again in a few days." To Isabelita, the counselor said, "You see, these fights between you and your mom don't have to happen. If you'll agree to have me here again next week, we can keep working toward having peace in your life." As a result, both Ms. Hernandez and Isabelita agreed to hold another session the following week.

At the beginning of the next session, the counselor followed up on the previous week's gains by reviewing how Ms. Hernandez and Isabelita had made progress around the issue of fighting. The counselor intervened to block the brother's attempts to triangulate himself into interactions between Ms. Hernandez and Isabelita. Throughout the session, the counselor praised Ms. Hernandez whenever she avoided a fight, and empathized with her when she did not ("I understand how hard it is, but I know you tried."). The counselor also praised Isabelita amply for her ability to follow her mother's lead in avoiding fights that are "so upsetting to you." Hence, both the mother and Isabelita received credit and praise for accomplishing changes in their relationship. Having experienced a major accomplishment in placing the mother in control of the interactions, the counselor was now ready to move to the next level: negotiation of rules and consequences. The counselor also began to reinforce changes in Isabelita's behavior, no matter how small, by showing empathy for "how difficult all of this must be for you." The counselor also took an active role in helping Ms. Hernandez move into a more appropriate parental role by gradually praising each of the mother's attempts to guide or set limits for her daughter. The counselor also consistently reframed Isabelita's disrespectful behavior as a cry for help and as her way of expressing pain.

Gradually, over time, Isabelita's externalizing behavior and drug abuse decreased. Ms. Hernandez learned to befriend her daughter and to remain calm and not engage in conflict (i.e., a reversal) whenever Isabelita would throw a tantrum. Isabelita began to phrase her complaints in the form of respectful disagreements rather than hostile attacks. The brother, sensing that the tension between his sister and mother was decreasing, slowly backed away from the triangulated relationship with them and began to seek out his own social activities.



Therapy Manuals for Drug Abuse:
Manual 5




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