Salvador Minuchin’s Contributions to Psychotherapy:

A Comprehensive Review

Shumrithi Nagarajan

ABSTRACT

Salvador Minuchin is a prominent figure in the field of family therapy and has left an
incredible mark in the practice and theory of psychotherapy. This research article
explores his significant contributions, theories and techniques that have shaped the field
of family therapy.
Family therapy is a branch of Psychology that focuses on the improvement of
relationships among family members. In the 1960’s, Salvador Minuchin developed
structural family therapy. It is a therapeutic approach that focuses on understanding and
addressing the underlying structure and dynamics within a family system. A structural family
therapist works to improve communication between members of the family and encourage
adjustments in the rules that govern how a family functions.
The study further examines the evolution of his ideas, starting from his groundbreaking
development of Structural Family Therapy (SFT) and its foundational concepts. The article
critically reviews the key components of Minuchin's approach such as his emphasis on
the family system, structural assessment, boundary work and its applications in anorexia
nervosa. It explores case studies that illustrate the efficacy and clinical outcomes of
Minuchin's interventions, shedding light on the practical implications of his work.
The article also examines the influence of his theories beyond family therapy, including
his contributions to the broader field of psychotherapy, its sociological perspective and
his impact on understanding the intersection of family dynamics and mental health.
By examining and synthesising the breadth of Minuchin's work, this research article
contributes to a deeper understanding of his contributions and legacy. This study
recognizes his lasting impact on the field and the countless families who have benefited
from his insights and interventions.

STRUCTURALIST THEORY

Salvador Minuchin introduced the structuralist theory in response to the limitations he

observed in traditional psychoanalysis method. He recognised that many individual’s
problems and challenges were deeply rooted in their family systems and dynamics. He
recognised this in the early 1970’s.

Three medically unstable juvenile youngsters were admitted at the Children’s Hospital of
Philadelphia, United States. They were diagnosed with diabetes mellitus. Minuchin and
his team identified that their diabetes mellitus worsened only once during the evening
while staying with their family members. The team decided to investigate the family
dynamics and systems. Similar patterns were identified among other diabetic children at
the hospital. The team classified the pattern of diabetes mellitus into three categories.

● Physiological reasons where medical aetiology had not been discovered.

● Behavioural diabetes where children would deliberately worsen their symptoms for
personal gain.

● Psychosomatic diabetes caused by family dynamics.

Psychosomatic diabetic families manifested specific, observable interactional family patterns

such as rigidity, perfectionism, triangulation, overprotectiveness and conflict avoidance.
(Minuchin et al., 1978).

An experiment was conducted to determine the system of family interactional tasks to

determine the linked patterns of psychosomatic families. The families were recorded
answering questions such as talking about their recent family conflict. The experimenters
set up significant differences in the interactional patterns between the psychosomatic
families and the other two types of families in the study. To further test the relationship
between family interactional processes and the medical symptomatology, they conducted
individual stress interviews with all three types of families. They were apprehensive that
an increase in adipose acids in the blood is an index of increased stress in the body. To
check this factor, they conducted a session where the child and the separate parent
where blood samples were taken at regular intervals. These samples served as a measure
of the stress the family members were passing. When the blood was analysed later to
check the situations of free adipose acids, the experimenters set up the physiological
data that verified their proposition. When the therapist asked the parents to share a
recent conflict, their free adipose acid position would rise acutely. While the parents
diffused their conflict by involving their child, their free adipose acid levels reduced,
while their child’s increased more acutely. If left unnoticed this could cause a diabetic
ketoacidosis in the child. This was a clear, substantiation - grounded demonstration of the
interaction between the child’s physiology and the family’s interactional patterns.
Crucially, this passed only in the psychosomatic families.
This exploration had helped Minuchin to understand that numerous existent problems and
challenges were deeply embedded in their family systems and dynamics. He believed that
individualities are not insulated realities but are profoundly told by their families and
larger systems that they belong to. He saw families as a complex system retaining
patterns of communication, power dynamics and structures. Siimilar family systems could
moreover contribute towards an individual well-being or serve as sources of dysfunction
and torture. Minuchin’s proposition of Structural Family Therapy ( SFT) is defined as
family problems are embedded in the beginning structure of the family system. He
utilised ways to bring structural changes within the family system. These ways were
designed to disrupt dysfunctional patterns, enhance communication and promote healthier
relations among family members. One similar term is known as family mapping to
uncover and understand patterns and family relations. During this process, the therapist
identifies the problems of the family and understands how those issues are maintained
through family dynamics. This chart is a diagrammatic representation of the introductory
structure of the family, including members of the family unit, their age, gender and
connections to one another. Such aspects of the family are similar as rules, patterns and
structure of the family. Such maps are a diagrammatic representation of the basic
structure of the family, including members of the family unit, their age, gender and
relationships to one another. This process involves family members making their own
maps describing their family. This gives the therapist a better understanding of how
individual family members view their place within the family. After this original process,
the therapist observes the family during remedy sessions and in the home terrain to track
relations and develop a thesis about the nature of the connections and commerce patterns
of the family. Other ways include joining, enactment, restructuring, tracking, deranging,
sculpturing and unity. Joining involves the therapist to establish a cooperative and a
compassionate relationship with the family. By laboriously engaging with family
members, the therapist builds empathy, earns trust and gains a deeper understanding of
the family's dynamics. In enactment family members are encouraged to reenact a specific
situation that contributes to problematic patterns. By observing the family's behaviours
and dynamics in real-time, the therapist can identify the underpinning issues,
conversations and interventions to address them. Restructuring involves laboriously
intermediating to modify the family's structure. The therapist may disrupt and challenge
patterns by reassigning places, altering boundaries or introducing new ways of relating
within the family system. This intervention aims to produce healthier and further
functional patterns of commerce. Tracking refers to the therapist's capability to follow
and punctuate patterns and relations within the family. The therapist observes and
comments on the communication styles, power dynamics and relational patterns to
increase the family's mindfulness and understanding of their own dynamics. Minuchin
emphasised the significance of clear and applicable boundaries within the family. The
therapist may intermediate to help establish or review such boundaries between the
family members, icing that each existent has a sense of autonomy and particular space.
Unbalancing involves the therapist creating a temporary imbalance within the family
system to disrupt settled patterns. By aligning temporarily with one family member or a
subsystem, the therapist can now challenge power dynamics and encourage the family to
explore new ways of relating. Sculpting is a fashion where the therapist physically
arranges family members in space to represent their connections and dynamics. By
manipulating the physical positions and movements of family members, the therapist can
explore and challenge the family's comprehensions and feelings. Orchestration refers to
the therapist's active involvement in directing and guiding the family's relations. The
therapist may give directives or suggestions to the family members during sessions to
help them trial using new ways of communicating and relating.

He proposed several skills that therapists can utilise to effectively work with families and
bring about structural changes. These skills are for therapists to understand and intervene
in family dynamics to promote healthier patterns of interaction. They include observation
skills used to observe and assess family's interactions, patterns and dynamics. Therapists
need to be skilled in observing non-verbal cues, communication styles, power dynamics
and relational patterns within the family system. He emphasised the importance of a
systemic perspective in understanding families. Therapists develop the ability to think in
terms of systems, recognizing that changes in one part of the family system could impact
the entire system. This skill involves considering the interconnections, interdependencies
and reciprocal influences among family members. Joining skills help the therapist to
establish rapport, build trust and create a collaborative therapeutic alliance with the
family. Therapists need to develop skills in empathetic listening, validation and show
genuine interest in the family's experiences and concerns. Assessment skills help to
conduct a comprehensive assessment of the family's structure, boundaries, communication
patterns and power dynamics. Therapists need to gather relevant information, formulate
hypotheses and identify areas for intervention. Minuchin advocated for active and
directive interventions. Therapists need to develop skills in providing guidance, structuring
sessions and directing family interactions. This involves setting clear goals, offering
suggestions and orchestrating the family's communication and behaviour during sessions.
Effective communication skills are essential for therapists. Therapists need to be able to
facilitate open and constructive communication within the family, encourage active
listening and promote assertiveness and respectful expression of feelings and needs.
Therapists need to aid families to develop problem-solving skills and address conflicts,
make decisions and find solutions to challenges. This includes teaching negotiation skills,
helping families identify and evaluate options and facilitating collaborative
problem-solving processes. He also emphasised the importance of clear and appropriate
boundaries within the family system. Therapists need to help families establish and
maintain healthy boundaries, promoting autonomy, individuality and connectedness within
relationships. Therapists also need to be culturally sensitive and aware of the diverse
backgrounds and beliefs of the families they work with. This includes recognising and
respecting cultural values, norms and traditions that may influence family dynamics.

SOCIOLOGICAL PERSPECTIVE

Family therapy technique of Minuchin is primarily sociological. He represents the school

of thought that sociologists have named ‘structural functionalism’. Structural functionalism
was developed by Talcott Parsons, Robert Merton, Kingsley Davis and others. It is one
of the three major perspectives used by sociologists today. The essential premise of the
structural functionalist perspective is that social structures, such as the family and society
are systems with interdependent parts with each part making some contribution to overall
group stability. The component elements of a given structure are analysed in terms of
their specific function for that system's maintenance. Critics of this approach argue that a
practice that is functional for equilibrium at one level may be dysfunctional at another
level and that change is an inherently disruptive process (Abrahamson, 1981: 61–62).
Minuchin's theory would represent a revision of the traditional structural functional model
in that it is dynamic and that it considers disequilibrium to be potentially functional for
the social group.

Minuchin's theory reads like a sociology textbook on structural functionalism. Even

before he presents his theory, he talks about the social context of the individual. . . . He
is concerned with family as an interlocking set of small groups arranged hierarchically.
The task of the therapist is to restructure these small groups (subsystems) so that the
whole (family system) can function adequately. (Hansen and L'Abate, 1983:142)

ANOREXIA

The psychosomatic family model of Minuchin and his colleagues is one of the best
known works in the field of family therapy. In 1975, Minuchin published an article on a
conceptual model of psychosomatic illness in children in which they described three
necessary conditions for the development and maintenance of psychosomatic problems in
children. These essential pathogenic factors are:

● a certain type of family organisation

● an involvement of the child in parental conflict
● a physiological vulnerability of the child.
The typical family organisation is characterised by four interaction patterns including
enmeshment, rigidity, overprotectiveness and lack of conflict resolution. Minuchin then
focused on applying this model to anorexia nervosa. Their outcomes were published in
the book, Psychosomatic Families. In a total of 52 cases, 86% recovered in terms of
weight and psychosocial functioning (Minuchin et al. 1978).
He highlighted the concepts of enmeshment and disengagement in families. Enmeshment
refers to overly involved and blurred boundaries within the family while disengagement
refers to emotional distance and limited communication. These dynamics may be present
in families of individuals with anorexia. Addressing and balancing these patterns can be
important in supporting the individual's recovery. He emphasised on the significance of
family structure and boundaries in shaping an individual behaviour. In the context of
anorexia nervosa, exploring the hierarchical relationships, power dynamics and
communication patterns within the family could help identify areas for intervention.
Creating healthier boundaries and establishing appropriate roles within the family is
beneficial. Exploring the ways in which family members communicate about food, body
image and emotions can shed light on maintaining factors for the eating disorder.
Promoting open and constructive communication and addressing any dysfunctional patterns
can support the individual's recovery.

MINUCHIN CENTER FOR THE FAMILY

In 1981 Minuchin came to New York and founded Family Studies Institute where he
could teach family therapists and provided consultation services to the foster care.
(Nichols, 2010) With the assistance of a small group of collaborators, researchers and
therapists, he continued training family therapists and expanded the application of
Structural Family Therapy to the understanding and transformation of the interaction
between marginalised families and the agencies that serve them.
Upon his retirement, the institute was renamed as The Minuchin Center For The Family
and remains committed to the mission of empowering families, agencies and practitioners
who work on their behalf. This shows his devotion towards family therapy among
young delinquents, being the initial cause for formulating Structural Family Therapy.

AN ILLUSTRATION OF A CASE

The following case was consulted by a child psychiatrist. It was considered to be a

complex case where for the past three years, none of the hospital’s medical, surgical and
mental health professionals were able to diagnose the underlying cause. The case was
described to the psychiatrist by a fellow clinical psychologist as:
A 15-year-old female with a history of chronic pain syndrome, started after her family
moved to another community three years ago. She had been hospitalised for a
“wandering” pain that was not curable. The pain causes increasing discomfort and
frustration with each reoccurrence.
The original pain was in the legs, causing medical professionals to diagnose it as a
neurological disorder. She would develop weakness in the legs. The specialists inserted a
neural-stem implant that was helpful for a short period of time and later was not
helpful. She began to experience pain in other parts of her body causing her to miss
classes. In fact, she had not been to school for most of the last academic year.
Few weeks ago she was hospitalised for abdominal pain. The surgeons removed her
gallbladder. This helped in reducing abdominal pain but then started experiencing lower
back pain that was unresponsive to medication. Most recently, she developed arm
weakness and was unable to return to school because of the pain.
She had missed an appointment with a clinical psychologist who had been working with
her through hypnotherapy sessions. The psychologists were going to assess her based on
pen-and-paper tests. This could determine how her pain was affecting her on a daily
basis. However she did not attend the session due to excessive pain.

The child psychiatrist asked the psychologist about the patient’s family and the picture
then became clear. The mother is a working professional and is not around to take care
of her daughter. The girl appears to be tethered to the dad. As he further described the
family, there was evidence of these interactional patterns such as protectiveness, conflict
avoidance, rigidity and triangulation.
The psychiatrist referred to Minuchin’s book, Psychosomatic Families: Anorexia Nervosa
in Context (Minuchin, Rosman & Baker, 1978). He explained the need for a change in the
treatment paradigm referring to it as a family related issue. This adolescent girl and as
her family had agonised for the past three years, resulting in following one piecemeal
approach after another, each dealing with a different organ system.

CONCLUSION

From my perspective the lesson we could learn from Dr. Minuchin’s life, in addition to
his brilliant writings and teaching is to identify and provide unique perspectives in
worsening of physiological problems apart from following traditional psychological
methods such as psychoanalysis. He set the pace for perspectives to shift from individual
to broader scopes. He used families as the delivery systems for change. His work and
approach in family therapy can be seen as a departure from the traditional psychoanalytic
perspectives. While psychoanalysis often focuses on the individual and intrapsychic
processes, Minuchin's Structural Family Therapy (SFT) emphasised the importance of
understanding and working with the family system as a whole. His approach to therapy
was more action-oriented and directive compared to the more exploratory and
insight-based techniques of psychoanalysis. He focused on the present moment and the
observable interactions within the family rather than delving deeply into unconscious
processes and childhood experiences. He aimed to address patterns of interaction and
communication within the family that contributed to problems or dysfunction. He viewed
symptoms and issues as resulting from imbalances or dysfunctions within the family
structure rather than solely as products of individual psychodynamics. While his approach
may be seen as a departure from traditional psychoanalysis, it is important to note that today
there is room for integration and collaboration between different therapeutic approaches.
We can integrate various theoretical perspectives and techniques, drawing from both
psychoanalytic and systemic approaches to understand better and address the complexities
of human experience and relationships. His works still remain influential and relevant in
the current clinical practice. His emphasis on understanding the structure and dynamics
of the family system has provided therapists with a valuable framework for identifying
and addressing issues within families. By focusing on the interactions, boundaries and
hierarchies within the family, structural family therapy aims to bring a positive change
and healthier functioning.

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