Journal of Systemic Therapies, Vol. 35, No. 2, 2016, pp.

25–37

A QUICK GUIDE TO CASE

CONCEPTUALIZATION IN STRUCTURAL
FAMILY THERAPY
MICHAEL D. REITER
Nova Southeastern University, Fort Lauderdale, Florida

This article presents a way to conceptualize families when operating from a

structural family therapy orientation (Minuchin, 2012; Minuchin & Fishman,
1981). This quick guide to case conceptualization entails utilizing 6 Ps: prob-
lem, process, pattern, proximity, power, and possibilities. Two cases (one from
Dr. Salvador Minuchin and one from the author) where the therapist functioned
from a structural perspective will be presented to describe how this method
can be used to deconstruct what occurred or to help orient the therapist to
understand the family’s functioning and potential pathways in therapy.

Structural family therapy has been one of the most popular forms of family therapy
over the past 30 or 40 years. Developed by Salvador Minuchin and colleagues
primarily during his time at the Wyltwick School for Boys in New York and the
Philadelphia Child Guidance Clinic, the model helps explain how families main-
tain problematic behaviors while also providing direction for how to intervene in
the family system (Minuchin, 2012). The basis of the approach is to challenge the
family organization, which leads to symptom reduction because a new structure
develops in the family—one with more functional interactional patterns (Minuchin
& Fishman, 1981).
This article presents a new way to quickly conceptualize families through a
structural family therapy lens—either post-facto or during the course of treatment.
This guide utilizes a 6 P format: problem, process, pattern, proximity, power, and
possibilities. These concepts are related to one another and, while they may be
viewed separately, are inextricably linked. Each of these concepts will be explained,
and then two case examples will be presented to demonstrate the use of the 6 Ps in
analyzing and conceptualizing what happened in each case as well as how a therapist
can utilize the guide when currently working with a family. Using these areas of
foci, therapists are able to make a structural conceptualization to determine what
is currently occurring in the family as well as to plan for therapeutic intervention.

Address correspondence to Michael D. Reiter, PhD, Department of Family Therapy, Nova Southeastern
University, 3301 College Ave., Fort Lauderdale, FL 33314. E-mail: mdreiter@nova.edu

25

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 26 Reiter

Case conceptualizations have recently garnered much attention, being viewed

as an important core competency in therapy (Sperry & Sperry, 2012) and perhaps
one of the most foundational skills a therapist can develop (Betan & Binder, 2010;
Sperry, 2010). A case conceptualization includes two main areas of focus: a theory
of problem formation and a theory of problem resolution (Reiter, 2014). A case
can be conceptualized from any theoretical model. While there are overlaps in the
conceptualization, each is distinct based on the particulars of the model (Berman,
2010). This article explores the particularities of a conceptualization based on
structural family therapy.
Structural family therapists emphasize assessment of a family’s process and
organization (Liddle, 1983). There are many different ways in which therapists
have attempted to assess what happens in structural sessions, including how and
whether structural therapists implemented the model (Nichols & Tafuri, 2013), a
focus on areas of assessment (Liddle, 1983), understanding families as both a noun
and a verb (i.e., static and changing) (Fishman, 1983), and viewing structural family
concepts along a continuum of concreteness and abstractness (Nelson & Utesch,
1990). This article attempts to provide a new and streamlined manner in which to
understand what happened and is happening in a structural session. Each of the
6 Ps will be briefly explained, and then they will be used together to analyze a past
session and as a guide for a current session.

THE 6 Ps
Problem
Family therapy models hold that families tend to come to therapy presenting one
person in the family as the problem. This person is designated the “identified
patient” (IP). At the beginning of therapy, there is a difference between the fam-
ily’s perspective of the problem and the therapist’s perspective (Minuchin, Reiter,
& Borda, 2014). The family usually holds an internal focus—where the problem
is housed within one person and if that person changed, the family would be
better. However, the family therapist’s position is quite different. Instead of this
individualistic perspective, s/he holds a contextual view. This shifts the notion of
problems from within a person to people displaying symptoms that are related to
family relational interactions.
The first way a structural therapist begins to conceptualize a family is in un-
derstanding how the symptom is housed not within family members but between
family members (Minuchin, Nichols, & Lee, 2007). This is usually not an easy
task as family members, even sometimes the identified patient, tend to be invested
in viewing the problem as they currently do. Once the therapist recognizes the
person who is the identified problem (although sometimes the IP is conflict be-
tween two people), there are several ways to shift the IP from an individualistic to
a contextual view. The therapist could highlight the IP’s competence, reframe the

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 Case Conceptualization in Structural Family Therapy 27

problem, examine the context in which the symptom presents, discuss how other
family members experience various difficulties, and provide space for the IP to
have a richer voice in the family (Minuchin et al., 2007).

Process
People are intrinsically linked with one another. The idiosyncratic way in which people
come together at a specific point in time is called the family’s process. This way of
being is inextricably connected to the rules of interaction between members. While
family members are interacting with one another, there are multiple levels occurring
simultaneously. On a more basic level, there is the content of what the members
are saying (i.e., “Please do the dishes,” “You did not call to let me know you would
be late,” or “Piper did not do her homework today”). This is what family members
tend to pay attention to—“he said this” or “she did that.” However, there is a more
important level—that of process—how members are interacting with one another.
Structural therapists tend to focus on the mutuality and complementarity that
occurs between people. Mutuality is more than a feeling of closeness to family mem-
bers; it is rather that the other people help to create their identity. These identities
can be seen as roles. Family members tend to have a very limited view of what their
identity/role is. The family therapist’s job is to help expand those identities, showing
members that an individual identity is actually multiple (Minuchin et al., 2014).
Complementarity is the notion that people are woven together and create one
another. For instance, there cannot be a leader in a family without someone agreeing
(consciously or not) to be a follower. In relationships, complementarity can be seen
by the give and take between people. The more person A engages in a behavior (i.e.,
household chores, childcare, or connection to others), the less person B has to engage
in those same behaviors. Conversely, the less person B engages in these behaviors,
the more person A must. Complementarity not only occurs between two individuals,
but between subsystems as well. For instance, if a mother and father do not caretake
for their children, another subsystem (perhaps the grandparents) must do so.
One of the primary means of determining a family’s process is to watch them
in action. Sometimes families will organically begin to interact with one another
in a session, usually when they disagree or argue with one another. Therapists
can help initiate this dynamic by asking some or all family members to talk to
one another about what is happening for them. This tool is called an enactment
(Minuchin & Fishman, 1981). Enactments are the defining practice of structural
family therapy (Simon, 1995). On the surface, initiating and utilizing enactments
seems easy—get the family members to talk with and interact with one another.
However, in practice, enactments are much more difficult, as they require quite
complex operations to be used properly (Nichols & Fallenberg, 2000). Enactments
allow the therapist to determine the various family processes: who is connected to
whom, who is excluded, who has power, who gives up power, and what the various
triangles in the family are.

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 28 Reiter

Pattern
Human beings tend to engage one another in typical and repetitive ways—patterns.
Patterns are family processes that occur over time. The configuration of these
interactions determines the family’s structure (Lappin & Reiter, 2014). Structural
family therapists attempt to decipher what the primary patterns are in families—
especially those that involve the problem-maintaining behavior (Minuchin, 2012).
There are multiple patterns happening simultaneously in a family. The way
that these patterns all interlock helps to shape the family’s organization. Patterns,
in themselves, are neither good nor bad or what we might call functional or dys-
functional. It is when patterns become rigid and are not able to accommodate to
a change in the developmental context of the family (i.e., a remarriage or a child
leaving home) that problems in the family tend to occur.
Most forms of family therapy operate through some type of pattern interruption.
Structural family therapists attempt to decipher the family’s problem-maintaining
patterns and get one or more members to operate in a different manner. This can
be seen in changing the dynamics of complementarity. If a wife is overinvolved
with the children, it allows the husband to not be as involved (and conversely, if a
father is disengaged with his children, it forces the mother to be more engaged).
Once this pattern is determined, the therapist has several options. First, the therapist
can get the mother to be less involved, which will most likely force the father to
become more engaged. Second, the therapist can attempt to get the father to be
more engaged, which allows the mother to start to disengage. Third, the therapist
can attempt to connect the children more to the father than to the mother. Given
that people’s behaviors are interconnected to others, a change in one part of the
system leads to a change in other parts of the system.

Proximity
Structural therapists pay attention to people’s proximity—distance and closeness—
with one another, as this is one clue to the family’s organization (Minuchin, 1987).
It is also a guide to what the therapist’s next step with the family will be. Proximity
is determined by how people tend to come together with one another. This distance
between people is based on rules of engagement, which form boundaries between
people or subsystems. These boundaries have varying levels of permeability, rang-
ing from diffuse (a lot of permeability) to rigid (little permeability), with clear
boundaries in the middle (Minuchin, 2012). The therapist’s determination of how
clear the boundaries are—or how far towards the end of the proximity continuum
people are—allows the therapist to evaluate the family’s functioning.
For some dyads and subsystems, there tends to be a wide gap where information
does not flow smoothly and easily. These individuals are considered to be disen-
gaged, usually having a rigid boundary between them (Minuchin, 2012). This might
be a parent who attempts to have his/her word as law with no possible negotiation

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 Case Conceptualization in Structural Family Therapy 29

from the child. For those people whose proximity is quite close, structural thera-
pists call this enmeshment (Minuchin, 2012). Enmeshment usually happens when
people have a diffuse boundary between them. Functioning at either of these two
extremes of the proximity continuum (disengagement and enmeshment) usually
suggests possible problems.
Other individuals are not overly close or too distant. These individuals are con-
sidered to have a clear boundary between them (Minuchin, 2012). This is usually
the most functional boundary to have between people and subsystems (however,
given circumstances in a family’s context, there are times when a more rigid or dif-
fuse boundary is more useful—but these times are usually more temporary). When
there is too much closeness—overaffiliation—the therapist will most likely try to
move those members apart. When there is too much distance—­underaffiliation—the
therapist will attempt to bring those members closer.

Power
Power is usually a notion that is not viewed favorably in systemic work, especially
in the more postmodern approaches. However, it is not an individualistic concept,
but rather one based on mutuality and interconnectedness. In structural family
therapy, power can be viewed in people’s influence in constructing the identities
of self and others. While the typical notion of someone being powerful is having
a leadership position, power can also come from taking what may be considered
a one-down position.
All members, to varying degrees at varying times of the family’s development,
display power. Perhaps paradoxically, the person who has a lot of power in the
family is the identified patient. Even a position of what seems like dysfunction
is actually a powerful position, as other family members accommodate to the
symptom behaviors. What to the layperson may be seen as weakness is viewed by
the structural family therapist as an active force (Minuchin & Nichols, 1993). For
example, an adolescent who is getting into trouble has power in that the parents
must change their behaviors to focus on the adolescent.
Determining the power relations allows the therapist to better understand the
processes and patterns of the various subsystems in the family. There are four pri-
mary units or subsystems in a family: the individual, spouse, parental, and sibling
subsystems (Minuchin & Fishman, 1981). This focus, away from the initial problem
story and to the way in which the family organizes into various subsystems, provides
the therapist a unique avenue into alternatives for the family. The interactions of
members within subsystems as well as between subsystems provide a richer and
more complex view of the family—exploring at first the rigidity and pathology of
the family, but also its resilience and strength (Minuchin et al., 2014).
The understanding of who has power in the family, combined with the various
patterns and proximity (i.e., boundaries), allows the structural family therapist to
conceptualize the family’s hierarchy. This leads to the development of a picture

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 30 Reiter

of the family, what structural therapists call a family map (Minuchin, 2012). The
family map is both a diagnostic of the family’s current organization and a guide to
where the therapy may go (Lappin & Reiter, 2014).

Possibilities
Structural therapy is a very hope-oriented approach where the therapist comes
into contact with a family with an understanding that the family is richer than they
thought they were. As Minuchin and Nichols (1993) stated, “The basic quest of fam-
ily therapy is to release unused possibilities” (p. 45). This is based on the structural
therapist having an assumption of competence about the family (Simon, 1995). The
uncovering of the possibilities during the session occurs through a collaborative
relationship, based on empathy, but in which the therapist can challenge the family
in a variety of areas and through a variety of means (Hammond & Nichols, 2008).
When a family first comes to therapy, they have been stuck in their current pat-
terns with little hope or optimism that not only the identified patient, but the family
as a whole, has more possibilities than were previously available to them. This is
the dialectic between stability and change. While the family states that they desire
change, their behaviors have become somewhat inflexible patterns that limit the
range of potential options (Minuchin & Nichols, 1993).
Possibilities can also be viewed in the therapeutic system. Every intervention
the therapist makes tests the possibilities of movement for the family. When the
therapist moves a child from sitting between her parents, a new potential subsystem
boundary is drawn—a spousal subsystem without the child. When the therapist
blocks a grandparent from intervening during an enactment, a different relational
pattern can develop.
The structural therapist engages in exploring the alternatives available to the
family (Minuchin et al., 2014). These alternatives can be in how the family is view-
ing the situation (i.e., through a reframe) or how they are behaving (i.e., through
an enactment). What usually happens when the therapist focuses on the family’s
alternatives is that family members are put into new roles—ones where they become
healers to each other. The possibilities for change happen mainly in the therapy
room through the therapist’s active engagement to transform the family. Lappin
and Reiter (2014) explained, “The availability of those hidden strengths, however,
or the ‘I didn’t know she/he/I could do that!’ moments of discovery, is actualized
when the person’s context changes to permit those new discoveries” (p. 168).

QUESTIONS FOR A STRUCTURAL

CASE CONCEPTUALIZATION

The lenses used in this article to develop a structural family therapy case conceptu-
alization are not all inclusive. There are other areas that could help provide a richer

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 Case Conceptualization in Structural Family Therapy 31

view of the family. However, the 6 Ps tend to be the primary areas of inclusion. In this
final section before the case examples, I provide various questions that could be used
to examine each area (see Figure 1). These questions are for the therapist to ask him/
herself when meeting with a family. They can guide the therapist to having a richer
understanding of the family and open up pathways for possible interventions. These
questions are not exhaustive of the useful ways of thinking that can help the therapist
develop an understanding of problem formation and problem resolution. Yet, they can
be highly efficient in developing a structural understanding of the family’s context.

Problem Proximity
• What is the family’s perspective of what • Who is closest to whom?
the problem is? • Who in the family is distant and disen-
• Who is the identified patient? gaged?
• How might this symptom be seen as • What position should I take at this point
interactional rather than individual? in the session? Close, median or distant?
• Who makes the IP upset? (rather than an
individualistic view: What makes the IP
upset?)
• How might the IP be decentralized in the
family?

Process
• What are the rules of interaction?
• Who is allowed to say what to whom?
How are they allowed to interact?
• Who should I join with at this point and
how might I challenge them?
• How can I get people interacting with
one another in the session? What are the
openings for an enactment?
Power
• Whose behavior helps to regulate the
behavior of other members?
• What is the hierarchy of the family?
• How is the identified patient in a strong
position rather than being weak?

Pattern
• What are the ways of interacting that
family members engage in that allow the
symptom to continue?
• How might the family’s dynamics have
been useful for a previous family life
stage, but not the current context?
FIGURE 1. Internal therapist questions for a structural case conceptualization.
Possibilities
• What other ways of viewing the situation
may increase flexibility for members?
• How might members develop newer
identities?
• How are family members richer than
they thought they were?
• What new transactions may occur in the
family?
• How can I get two people who were
very close to move farther away? How
can I connect one of these people to the
person who is quite distant?

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 32 Reiter

APPLYING THE CASE CONCEPTUALIZATION

In the following section, I present two cases to demonstrate how this quick guide
to case conceptualization can be used. The first was conducted by Salvador Mi-
nuchin who worked with this family utilizing structural family therapy principles
(Minuchin et al., 2007), but not using this guide. I provide it here to show how
the 6P guide can be used to understand what happened in a previous case. The
second case was conducted by the author, using this guide as a roadmap, and
presented here to demonstrate how the guide is used during the course of work
with a family. The guide was developed by the author based on an understanding
of structural family therapy writings as well as actual cases. These case examples
were chosen for their clarity—any structural family therapy case could be used.
For each of the six areas of the conceptualization, I provide questions or state-
ments the therapist made that help bring light to that component. Please note
that this is only a brief explanation and that there was a lot more complexity that
occurred for each therapy.

Case Example #1
The first case example, entitled The Teenager Who Was a Liar, was presented by
Minuchin in multiple sources (Minuchin et al., 2007, 2014) and conducted toward
the end of his therapeutic career. It is presented here to demonstrate how the 6 Ps
can be used to conceptualize what occurred in a previous session.

Problem. The Boyd family met with Minuchin for a consultation session. It con-
sisted of Richard and Mary, the parents, as well as 15-year-old Whitney and 2-year-
old Joe. Whitney is Mary’s daughter from a previous marriage. Joe is the son of
Richard and Mary. The family is coming to therapy because the parents state they
do not trust Whitney, as she has lied repeatedly in the past. Early on in the session,
Minuchin asks Whitney if she knows what a metaphor is. He then explains that
it is a poetic lie. This is his first attempt to normalize her behavior—lying can be
something that is beautiful. Later in the session he says to mother, “At this point,
you and your daughter are hooked together. She’s pulling at you so you will watch
her continuously. How will you free yourself from her?” (Minuchin et al., 2014,
p. 53). The problem now is between mother and daughter.

Process. Within the first two minutes of the session, Minuchin attempts an en-
actment in order to view the family’s process. To the parents, he states, “Can you
talk with Whitney? I’m a stranger, and you’ve come to see me about something
that’s very significant for your family. Maybe you can talk together, and that will
help me to know how you deal with each other” (Minuchin et al., 2014, p. 51). In
seeing how mother has become a detective trying to figure out if Whitney is lying,
Minuchin paid attention to one process in the family. He points this out, “They’re

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 Case Conceptualization in Structural Family Therapy 33

both caught. Whitney needs Mary to look at her, and Mary is hooked into observing
and responding to Whitney. It’s a circle” (Minuchin et al., 2007, p. 58).

Pattern. Minuchin explored the reaction the parents have when Whitney lies.
He says to Richard, “I think Mary has become a detective, and I’m worried about
her. She might be trying to do the impossible. She’s overstressed, and she may
break” (Minuchin et al., 2014, p. 55). Minuchin also tries to assess some of the
family’s patterns by asking, “Is that how conversations go on between you? You
become caricatures of yourselves—fisherman and fish” (Minuchin et al., 2007,
p. 60). This question points out the complementarity between family members
that happens over and over.

Proximity. Minuchin sees very early on in this family that mother and daughter are
very close, which, based on complementarity, allows stepfather to not be as close.
This leads to a conceptualization where the mother-daughter dyad may be separated
to some degree. This can be achieved by bringing closer the father-daughter dyad
as well as strengthening the husband-wife dyad. Minuchin explains this to Richard,
“I think you need to help them. Mary spends more time worrying about Whitney
than enjoying you. Talk to her about how she can be freer to become your wife”
(Minuchin et al., 2007, p. 60). Besides shifting subsystems through strengthening
affiliation via proximity, this intervention is also a means to reinforce the decon-
struction of the symptom. The problem is not Whitney’s lying, but rather Mary’s
worrying. Throughout the session, the IP will move and eventually find itself as
being between people.

Power. Knowing that the identified patient usually has a lot of power in the
family, Minuchin focuses on Whitney and her role in the family process. He asks
Whitney, “And you make sure she [mother] doesn’t trust you. What are you doing
that makes her watch you so closely? How can you help her to release her hold on
you?” (Minuchin et al., 2014, p. 54). These questions highlight mutuality in the
family process. To demonstrate how power is an interpersonal process, Minuchin
then utilizes a metaphor to explain the family members’ power over each other:
“Something strange has happened in a family where the jailers are prisoners and
the prisoners are jailers” (Minuchin et al., 2014, p. 54).

Possibilities. In the first session, Minuchin attempts to enlist Richard, the step-
father, as a co-therapist and healer for the family. He asks Richard, in relation to
the overly close dilemma happening between mother and daughter, “Can you help
them? Can you free these two people from this vicious circle?” (Minuchin et al.,
2014, p. 53). However, all members of the family can help to enact change. Minuchin
asks the wife, in the second session, “How will you change him [Richard] so he
becomes available” (p. 64). These possible directions for the family come from
an understanding that the problem is more than Whitney, that the symptoms are

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 34 Reiter

maintained by the family acting in patterned ways, over time, with various levels
of closeness and distance. Thus, the information from the first 5 Ps is utilized to
provide possibilities toward change for the family.

Case Example #2
The second case example is the Trewavas family1 that was recently seen in therapy
by the author. It is presented here to demonstrate how the 6 Ps can be used in a ses-
sion to help the therapist understand what is happening with a family that brought
them to therapy and possible pathways toward positive change.

Problem. The Trewavas family consisted of Liam (36), Mara (34), and Morgan
(10). Liam was born and raised in Ireland and moved to the United States in his
early 20s. He soon met and married Mara, who was born and raised in the Mid-
west. A few years after marrying, Mara gave birth to Morgan, and they moved to
the Southeastern United States. They came to therapy because Morgan was having
difficulties in school, both academically and socially. At home, he was getting into
verbal altercations with his mother, calling her a “bitch” and saying things like, “I
don’t have to listen to you.”
During the first session, the therapist used the 6P format and began by focusing
on problems and attempting to decentralize the IP—Morgan. In that session, Mara
had said that Morgan was very disrespectful to her. The therapist asked, “And where
did he learn that?” This question shifted the problem from being internal in Morgan
(that he is a disrespectful child) to being interpersonal (there are rules of transaction
that allow son to challenge mother). Using a hypothesis that symptoms in children
tend to originate in relationships between parents, the therapist then focused on
the spousal subsystem. Later in the session, the therapist asked Liam, “When are
you able to talk to your wife about something other than Morgan? Where the two
of you can be husband and wife.” This statement suggested that Morgan served as
a buffer between husband and wife.

Process. During the session, Liam complained that Morgan was disrespectful and
that Mara was not firm enough with him. The therapist stated, “Could you talk to
each other about this so I can observe and maybe understand better?” This was the
beginning of an enactment. During that conversation, Liam began talking with Mara
but quickly brought Morgan into the conversation, telling him what he was doing
wrong (i.e., not doing his homework, not listening at home, etc.). This allowed the
therapist to engage in blocking Liam and Mara from triangulating Morgan into their
discussions. He stated, “You two are very interesting. When things seem to heat
up between the two of you, somehow that heat gets blasted onto Morgan instead
of working it out between the two of you. Can you keep talking with one another

1All names and identifying information have been changed to protect for anonymity.

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 Case Conceptualization in Structural Family Therapy 35

without addressing Morgan?” In this situation, the therapist utilized a stroke/kick

(Minuchin et al., 2014) and tried to change the family’s process of triangulation.

Pattern. While enactments allow the therapist to see how the family acts outside
of the therapy room and demonstrates the family process, seeing if that process is
a pattern becomes important so the therapist can attempt to engage in some type of
pattern interruption. After the enactment in which Mara attempted to tell Morgan
that he needed to get his act together and Morgan told her she can’t control him,
the therapist asked, “Is that how it normally goes?” Morgan said that usually his
mother will keep going at him longer. The therapist inquired what happens then—
what structural therapists call tracking (Minuchin & Fishman, 1981). Eventually it
came out that Mara would give up trying to talk with Morgan and would wait until
Liam came home to deal with it. Later in the session, mother and son again had an
interchange, with Mara trying to reason with Morgan, threatening discipline, and
Morgan saying he would not listen to her. At this point, the therapist intervened
and said, “Thank you. That was a very nice sample of what happens between you.
It has been two times in this session that the same thing has happened. Mara tries
to intervene with Morgan, Morgan challenges that, and then Mara turns to Liam.”
Not only is this a statement of how the family functions, but it is also an interven-
tion. Families may not be cognizant of their covert interactions. By bringing them
to light, the therapist gets the family to think about the interchange and potentially
change how they react the next time an aspect of that pattern occurs.

Proximity. From very early on in the first session it was clear that mother and
son were enmeshed and father was on the outside. Liam was not only outside
the parental subsystem—coming in as a backup—but also outside in the spousal
subsystem. This led to the therapist developing several hypotheses of where the
session could go, including separating mother and son from their close proximity,
bringing closer father and son, and perhaps most importantly bringing closer hus-
band and wife. During one interchange where Mara was expressing her frustration
with Morgan’s poor performance in school and how she disliked having to ensure
what his homework was and whether he had done it, the therapist asked, “Mara,
I am very worried about you. You are always on alert around Morgan—what is
his homework, did he start it, did he complete it. Don’t you ever get a break from
that?” After she said, “No,” the therapist continued, “You are always on the front
line. When do you get R & R?” This focus on proximity led to an intervention to
move Mara away from always being involved with Morgan’s problematic symptoms
and to bring Liam closer.

Power. With an eye toward power relations, it became clear early into the first
session that Mara felt fairly powerless—both in her role as mother and wife—and
this left Liam and Morgan in more powerful positions. This led to a conceptualiza-
tion of increasing her position in the family where she was equal with Liam in the

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 36 Reiter

parental subsystem and more powerful in the subsystem with her son. The therapist
asked, “Mara, have you always felt powerless with Morgan?” She answered that
when he was an infant she didn’t. The therapist continued, “Where did you learn
in your family that you couldn’t challenge your husband?” This was a powerful
intervention that attempted to change the power dynamics in the spousal subsystem.

Possibilities. By using the case conceptualization guidelines, the therapist began

to introduce new possibilities to the family. This included shifting a narrative of a
problematic and disrespectful boy to one where the parents could feel more com-
petent and husband and wife could attempt to gain more connection and intimacy
with one another. Family members were encouraged to become healers for the
others. For instance, toward the end of the session the therapist stated, “Liam, I am
very concerned about your wife. She is so immersed in what Morgan is doing—at
home and at school—that is seems she might drown. What can you do to help
her?” This and the other interventions made in the session opened up possibilities
for family members to develop new roles and identities, which would lead to new
ways of interacting with one another.

CONCLUSION

This article presented a quick guide to develop a structural family therapy case
conceptualization. Using the 6 Ps—problem, process, pattern, proximity, power,
and possibilities—therapists can quickly understand what is occurring in a family
in order to develop a plan of action for treatment. Structural family therapy is much
more nuanced than was presented here. While the categories of the guide are uni-
versal, how the family functions within each is idiosyncratic. This is because each
family is unique. However, utilizing this quick guide to structural family therapy
case conceptualization allows the therapist an understanding of current family
functioning and pathways to how the family might change. While this structural
family therapy case conceptualization is generic and universal, how it is utilized
is idiosyncratic since it is the person of the therapist in which the understanding
and delivering of the model comes through.

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