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Section 11
Structural Ecosystems Therapy for Caregivers, Part 1

Question 11 | Test | Table of Contents

A family-based therapy, Structural Ecosystems Therapy (SET), developed by Szapocznik and colleagues (Mitrani et al., 2000; Szapocznik et al., 1994) is one of the interventions being evaluated at the Miami REACH site. This intervention differs from the other interventions being evaluated within REACH in that it attempts to address the needs of the entire family within a conjoint context. It also focuses on transforming the process of family relationships as a mediator to improving caregiver support. The aim of the SET intervention is to improve the caregiver's interactions within her or his entire social ecosystem (family, community, health providers, etc.) to increase the extent to which the caregiver's emotional, social and instrumental needs are met and, in turn, improve psychological adjustment.  The specific intent of this paper is to demonstrate how the identification of family interactional patterns is a valuable clinical tool for implementing family-based interventions. Attention will be also be given to potential differences in interactional patterns between white American and Cuban American families. This paper will focus exclusively on patterns of interaction that occur within the family, and will not discuss the extra-familial, or ecosystemic, aspects of the intervention.

The application of SET within the Miami REACH project
As noted, SET is one of the interventions being evaluated at the Miami site of the REACH project. The participants (224 family caregivers of dementia patients, including 112 white American caregivers and 112 Cuban American caregivers) are randomly assigned to one of the three treatment conditions. The other intervention conditions include SET enhanced with a computer integrated telephone system (SET+CTIS), and a minimal contact telephone support control. The CTIS system serves to augment the family therapy intervention by facilitating the caregivers' ability to communicate with family members, friends, other caregivers and their therapist. The participants are recruited from two memory disorder clinics affiliated with the Department of Psychiatry and Behavioral Sciences, and from the community via newspaper and radio advertisement. In almost all cases, it is the primary caregiver who makes the initial call to the project.  All participants are required to meet the REACH inclusion/exclusion criteria, as well as the site-specific criteria. The care recipients are 60+ years of age and have a DSM4V diagnosis of dementia or a score of 23 or less on the Mini-Mental State Examination (MMSE; Folstein et al., 1975), and the presence of two IADE or one ADL impairments. Among other criteria, the primary caregivers are required to have been in the caregiver role for at least six months, live with the care recipient, and provide at least four hours of assistance per day. For the Miami site, at least one other family member must participate in the project. Other family members include actual or fictive family who provide emotional or instrumental support.

Overview of Structural Ecosystems Therapy (SET)
SET is a family-based intervention initially developed for the families of adolescent substance abusers, and adapted to enhance support for caregivers. SET is derived from a combination of two theoretical approaches: (1) the structural/systemic approach (Minuchin, 1974; Minuchin, et al., 1967; Szapocznik & COSSMHO, 1994; Szapocznik & Kurtines, 1989; Kurtines & Szapocznik, 1996) and (2) the ecosystemic approach (Bronfenbrener, 1979).  As a systemic approach, the SET model views the behavior of family members as interdependent and repetitive. In some instances the repetitive patterns of family interactions may be maladaptive or obsolete, leading to symptoms such as caregiver distress. Other family patterns of interaction may be particularly adaptive and relieve caregiver burden. SET is particularly appropriate for minority families because it recognizes the importance of culture as a contextual variable which can have a pronounced influence on family interactions.
The primary caregiver is the central figure in the SET intervention. This is the individual who is bearing the most practical day-to-day caregiving burden, and therefore is the most motivated to affect change in the family interactions that are related to caregiving. The primary caregiver is also typically the gatekeeper who controls access to the AD patient and her or his caregiving needs. Therefore, while other family members are typically distressed by the current family functioning, and certainly the aim of SET is to enhance the adaptation of the entire family to the caregiving situation, the primary caregiver is the initial entry point of the therapist into the family and usually remains the primary contact person throughout the intervention.

Generally, family interactional changes that are beneficial to the caregiver (e.g. by increasing available support) also benefit other family members (e.g. by improving their relationship with the caregiver, or by meeting their goals for improved caregiving). In fact, it is only through this mutual satisfaction that interactional changes can be maintained, since the absence of reinforcement on either side would cause the new interaction to be extinguished. There are cases (particularly among caregivers with borderline or narcissistic features) in which primary caregivers have unreasonable expectations of family support. In such cases, the therapist seeks to balance the caregiver's need for support while helping other family members to set limits on overwhelming demands from the caregiver.

In the initial sessions, the therapist usually meets with the caregiver alone or the caregiver and other family members, and gradually gathers the history of the family, AD and the caregiving experience. The goal of these initial sessions is to build rapport, establish therapeutic goals, and begin to assess the caregiver's family interactions. The therapist encourages family members to interact with each other in session to assess and transform interactions as they occur.

A central tenet of the SET approach is its emphasis on the processes of family interaction rather than on content. Process is comprised of how people interact, while content is the topic that they are interacting about. For instance, suppose a therapist learns from the caregiver that she and her daughter are in conflict regarding the AD patient's medication such that they have stopped speaking to each other. In this case, the content is the patient's medication, while the process is mother and daughter's inability to maintain communication in the face of disagreement. SET aims to transform the interactional processes (e.g. the inability to negotiate disagreement) that block the resolution of content concerns (medication management).

The therapist assesses interactions, determines which of these might be targeted in treatment and establishes a plan to transform interactions. This approach involves: (1) developing a clear understanding of the nature of supportive and problematic interactions, (2) understanding how these interactions are related to the family's current level of functioning, and (3) intervening in a very deliberate fashion to enhance supportive and reduce maladaptive interactions.
In the example given above, once the therapist has determined that there is a caring bond between mother and daughter, or at least between each of them and the AD patient, a planned set of interventions might include: (1) speaking individually with the women to engage and prepare them for a conjoint session, (2) strengthening their alliance by having them talk together about a common concern (e.g. the patient's agitation which is resulting in complaints from the day care center), (3) having the women work together on a practical problem-solving plan while helping them maintain their communication despite disagreement (e.g. by blocking escalating conflict or personal attacks), (4) following up on the plan in a subsequent session and congratulating mother and daughter on their teamwork, or exploring barriers that impeded progress (these might be practical, relational or intrapsychic barriers), and so on.

The assessment of interactional patterns is conducted along four dimensions of family functioning that are particularly related to caregiver functioning: structure (family roles), developmental stage, resonance (interpersonal boundaries), and conflict resolution.

The caregiving system, which consists of all individuals who play caregiving roles, must be organized to distribute caregiving responsibilities and for mutual support. Caregiver wellbeing is related to the caregiver's ability to serve, and be validated by the family, as a leader of the caregiving system. Caregiving structure involves family hierarchy, alliances and communication flow. In a family with effective structure, the caregiver is able to successfully distribute caregiving tasks, lead decision-making and collaborate with other family executives, and maintain alliances with other family members.
Culture can have an impact on caregiving structure. Cuban families often hold a hierarchical relational orientation (Szapocznik et al., 1978) and adhere to traditional gender roles. In Cuban families, older female caregivers may have particular difficulty in adopting some of the leadership roles of caregiving, especially vis-a-vis their care recipient husbands. Longstanding family roles can also have an impact on the ability of other family members, even those who are relatively acculturated, to accept the leadership of an older female caregiver.
- Mitrani, V.B.; Czaja, S. J.; Family-based therapy for dementia caregivers: clinical observations; Aging & Mental Health, Aug2000; Vol. 4 Issue 3

Personal Reflection Exercise #4
The preceding section contained information about Structural Ecosystems Therapy for caregivers.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Basak, C., Qin, S., & O'Connell, M. A. (2020). Differential effects of cognitive training modules in healthy aging and mild cognitive impairment: A comprehensive meta-analysis of randomized controlled trials. Psychology and Aging, 35(2), 220–249.

De Lucia, N., Grossi, D., Milan, G., & Trojano, L. (2020). The closing-in phenomenon in constructional tasks in dementia and mild cognitive impairment. Neuropsychology, 34(2), 168–175.

Di Nuovo, S., De Beni, R., Borella, E., Marková, H., Laczó, J., & Vyhnálek, M. (2020). Cognitive impairment in old age: Is the shift from healthy to pathological aging responsive to prevention? European Psychologist, 25(3), 174–185. 

What are three components of the SET intervention approach? To select and enter your answer go to Test

Section 12
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