Structural Family Therapy with Chinese Families in After-Violence Context

Abstract

This article aims to apply structural family therapy to working with family and intimate partner violence in after-violence context, where risks and safety issues have been addressed. This practice research study uses case analyses based on the work done with a Chinese couple and a Chinese family in Singapore, respectively. It identifies the salient therapeutic focus and healing processes in after-violence context with Chinese families. Reflections and feedback of social workers and clients during and after the conjoint sessions were included systematically. Practice implications to apply Structural family therapy in working with Chinese couples and families in after-violence are highlighted.

Introduction

Singapore is home to a predominantly Chinese population, making up 74% of the country's population (Singapore Department of Statistics, 2023). Singaporean Chinese families draw their fundamental values from Confucianism, which focuses on the collective self that emphasizes the benefit of the family, individual sacrifice, and respect for elders (Quek & Chen, 2017), as well as values of excellence and conformity (Sim et al., 2017), though they may be different in degree from the Chinese diaspora in other parts of the world (Chan, 2005). Unfortunately, Chinese families tend to keep problems to themselves to support and mutually protect the “family unit,” maintain harmony and hierarchical roles, save “face,” which are mostly unsaid “behavioural rules of a collectivist culture” (Ow & Katz, 1999, p. 620). Inevitably, family violence is one of the secrets within the family that has been considered as a distinct social problem for Chinese (Yick, 2001).

In Singapore, more people are lodging police reports on family violence since 2020. For instance, 5190 reports were filed in 2021, which is an increase from 5134 in 2020 (Hamzah, 2022). Most of these cases involved spousal violence, followed by violence against parents and then child abuse (Hamzah, 2022). This maybe connected to the COVID-19 pandemic lockdown, where there was worsened tension at home as victims were under more duress and had more difficulty in seeking help without the abusers knowing (Tan, 2021). There was a sharp 22% increase in the number of police reports filed monthly for offences related to family violence was reported (Lau, 2021), from 389 cases monthly before the lockdown to 476 cases during the COVID-19 pandemic lockdown. However, since the curb of the pandemic curbs lifted, the numbers continued to increase. There has been 2603 reports made from January to June 2022, compared to a total of 5190 reports filed in 2021 and 5134 in 2020, which may be due to greater awareness of family violence, leading to more people taking action or other reasons (Hamzah, 2022).

Since 1970s, major interventions for family and intimate partner violence (F/IPV) stemmed from the feminist idea, considering women are deemed powerless and oppressed (McPhail et al., 2007). The feminist model postulates that IPV is caused by power differentials that oppress women using physical, sexual, and economic control, as well as tactics of intimidation and isolation (McPhail et al., 2007). Subsequently, the understanding of F/IPV was further expanded to having different typologies of violence. Johnson (2006) delineated a typology of violence comprising situational couple violence and intimate terrorism, which provides a more nuanced framework for understanding IPV dynamics. Situational couple violence arises from conflicts and poor resolution skills, while intimate terrorism involves systematic control by one partner. Moreover, Kelly (1988) conceptualization of coercive control highlights its pervasive nature in intimate relationships, extending beyond physical violence. Coercive control encompasses various tactics aiming to induce fear and dependency. Kelly emphasizes understanding it as a condition influenced by broader contextual factors, not merely isolated behaviors. Understanding the nuanced dynamics of F/IPV, based on Johnson's typology and Kelly's conceptualization of coercive control, is essential for informing therapeutic approaches.

Appropriateness of Conjoint Therapy for F/IPV

The process of healing from violence does not necessarily mean leaving the relationship. It entails shifting psychological, emotional, and cognitive processes, as well as self-perceptions, in order to move forward with a renewed sense of self and agency (Neuman Allen & Wozniak, 2010). Many couples stay together and continue to manage role demands as spouses, as well as other demands such as parenting and managing finances after the violent occurrences (Maharaj, 2017). This is not uncommon in Asian context where preserving the family is given credence. Stith et al. (2012) believed that couples need a safe space to talk about the past violent interactions. Opposing needs make it difficult for the couple to navigate their relationship and employ newly learned skills as the woman is trying to accept her past experiences and heal while the man is eager to move beyond the shame of his past actions (Mayer, 2017). For many couples, addressing relationship conflicts can reduce incidents of violence (Roddy et al., 2018).

Conjoint therapy has been found to correct problems during the session (Maharaj, 2017; Vall et al., 2014) and offer support to each partner using family therapy interventions to promote changes in relationships (Harris, 2006). In a conjoint session, the couple's relational dynamics can play out organically and a discussion that may have escalated to violence at home is instead de-escalated with a professional in conjoint therapy (Karakurt et al., 2016).

Key Consideration for Conjoint Therapy for F/IPV

Safety is a major concern for those who are against using conjoint interventions to the F/IPV. The power differential, emphasized by the feminist perspective, may prevent the victimized partner to communicate their views openly. Disclosing information in the presence of their abuser can place them at an increased risk for retaliatory violence (Maharaj, 2017). Johnson's typology further amplifies this concern by delineating intimate terrorism heightening the risk of harm and rendering conjoint treatment inadvisable (Johnson, 2006). Additionally, Liz Kelly's research on coercive control underscores the broader range of abusive tactics beyond physical violence, exacerbating threats to victims’ safety (Chantler & McCarry, 2019). Conjoint therapy thus risks justifying harm and revictimization, implying victim responsibility and potentially normalizing violence (Harris, 2006; Maharaj, 2017; Vall, Paivinen et al., 2018), prompting ongoing concerns about the appropriateness of conjoint sessions.

Hence, scholars and practitioners highlighted three salient considerations when applying conjoint family therapy to F/IPV. The first pertains to the severity of violence. While some scholars and practitioners recommend that there should be no moderate or severe forms of violence present prior to commencing conjoint therapy (Harris, 2006), others recommend that the ongoing violence must be infrequent and mild (Vall et al., 2016). A useful definition and distinction for severity of violence could be “IPV that does not result in injury or fear” (Roddy et al., 2018, p. 294). The second pertains to the type of violence. Conjoint therapy is likely not suitable for cases falling under Johnson's typology of intimate terrorism or in the presence of coercive control, also poignantly outlined by Liz Kelly. In situational couple violence, these couples are suitable for conjoint therapy, if their level of risk is mild or moderate and not severe (Oka & Whiting, 2011; Roddy et al., 2018; Vall et al., 2016). The third consideration pertains to the discrepancy in reporting of violence (Stith & Mccollum, 2011). When the family or couple holds similar views about the prevalence and forms of violence, this is likely to produce positive outcomes (Vall, Paivinen et al., 2018). It seems that converging views on the violent behavior, past, present, and ongoing, denotes a readiness to engage in conjoint therapy and an acceptance of responsibility (Vall, Paivinen et al., 2018).

With the above salient considerations, we applied structural family therapy (SFT) to work with Chinese families after violence, as this model has been found to be relevant in addressing idiosyncratic cultural and contextual considerations of Chinese families (Ma et al., 2019; Sim, 2007). It has been found to more effective than individual level interventions based on medical or psychological views of the causes of domestic violence (Gelles & Maynard, 1987). This may be related to its potential for addressing power, boundaries, and transactions associated with family violence (Pender Baum & Pender, 2023). Structural family therapy believes that working with the individual was not enough in resolving relationship issues in after-violence situations, and that involving the entire family system is necessary to improving outcomes. The assumption is that family conflict is a connected to families’ patterns of interacting, and the goals of therapy are to interrupt the family's hierarchical structure, altering family dynamics and creating new ways of interacting and solving problems (Minuchin et al., 2021).

Background of PAVE and the Pilot Family Therapy Project

PAVE is one of the three specialist agencies dealing with family and interpersonal violence in Singapore. It has been applying the feminist lens in serving couples and families since its inception in 1999. Individual and group counseling sessions were conducted with both survivors and perpetrators of family violence to address the existing violence concerns. For survivors, the individual counseling platform serves to empower them while the program for perpetrators serves to make them accountable for their aggression. Besides addressing the violence concerns individually, PAVE recognizes that families concurrently have other needs, including the need for families to heal. In this pilot project, both Chinese families underwent individual and other services using a feminist lens to begin with. Prior to the commencement of family and couple work, using the three criteria stated above, the agency ascertained that the safety concerns were addressed and that there was no more recurrence of violence. In view of its applicability to Chinese families, and its emphasis on understanding and addressing power, boundaries, and transactions associated with family violence, we applied the use of SFT in this pilot project with consideration of local contexts and cultures (Ma et al., 2019; Sim, 2007).

Case Analyses

The first Chinese family, hereafter referred to as the Tan family, comprised a couple, aged 39 and 38 years old, and two young children, aged 8 and 5 years old. Mrs. Tan had sought help from PAVE as Mr. Tan had verbally abused her and used harsh physical discipline on both children. After speaking with all family members, the social worker gained a fuller understanding of the family's situation and ascertained that there was no concern of power and control. Mr. Tan also gained awareness of the impact of his past use of harsh physical punishment on the children and the father–son relationship via individual work. Before conjoint therapy started, Mrs. Tan considered a divorce as she felt there was no way to resolve the issues with Mr. Tan, and their children were constantly exposed to quarrels. However, she was willing to join this pilot project to work on their issues as a last resort. Seven couple sessions, each lasting 1.5 h on average, were provided over a six-month period from November 2021 to April 2022.

The second family, hereafter referred to as Wang family, consisted of a middle-aged couple who were 56 and 53, who had three sons aged 27, 23, and 19 years old, respectively. The youngest brother sought help due to the violence perpetrated by his second brother toward him. Before seeing them as a family, it was established that there was no further concerns of violence and the older brother who perpetrated violence had gained insights into his use of violence and took responsibility for his abusive behaviors through the individual work provided to him. Five sessions were provided for the whole family over five months from October 2021 to February 2022, in addition to the individual work with the perpetrator and victim, respectively.

The third author, trained and supervised in SFT, as well as an advocate of practice research, acted as consultant and coworker for the first and second author, who are social workers responsible of each case, respectively. Given the lockdown situation, the cotherapy team used ZOOM with the family for all sessions and connected the ZOOM session via Microsoft Teams for a group of 20 workers. Informed consent was obtained from all family members for the session to be videotaped as well as the participation of the PAVE team. Immediately after each conjoint session, family members were invited to evaluate and provide feedback for the session using the Session Rating Scale (SRS; Miller et al., 2000). The SRS is a four-item visual analog instrument to assess four key dimensions of effective therapeutic relationships dimensions: respect and understanding; relevance of goals and topics; client–worker fit; and overall alliance. Based on a total score of 40, any score lower than 36 overall would be a source of concern for the worker. Between sessions, the consultant, the worker concerned, as well as the entire PAVE would spend another three hours to debrief what transpired in the earlier session, discuss salient issues raised in the preceding conjoint session, and plan for the next session. These sessions were recorded and documented accordingly, with clients’ permission.

Therapy Focus and Process

From this pilot project, we found it useful to use SFT particularly focusing on three dimensions in after-violence circumstance: (1) shifting the family's focus that all family members can contribute to stopping the violence and the problem does not lie with an individual, (2) appreciating the family's developmental challenges and historical contexts, and (3) believing that families have strengths and are resilient.

In the case of Tan family, the couple constantly argued which often escalated to shouting matches in the presence of their two young children. The arguments, at times, revolved around trivial issues. In session 2, the couple recounted an argument because Mr. Tan refused to meet his wife's request for him to buy her a cup of bubble tea on his way home. Mr. Tan explained that he was not keen to do so as he was tired from work and wanted to be home early for dinner. On the other hand, Mrs. Tan could not understand his perspective and believed that it was a simple gesture to show his care for her. They were very fixed in their views, did not want to compromise and blamed each other. This isomorphic pattern of constant blaming each other was also evident in parenting their two young children. They insisted their way of parenting was better and were not able to work well together as parents together.

The illustration above highlights that families come to therapy with the certainty that the problem lies with the other individual. The workers thus focused on challenging their perspective and the way they interact with each other. When unproductive interactional dynamics were not addressed, their relationship could potentially become volatile and stressful, and might lapse back into the pattern of using violence, or divorce to resolve the impasses. Similarly, the Wang family came to therapy with the belief that the older brother had an anger management problem, while the younger one had an attitude problem as he behaved as he pleased. However, the problem did not just lie between the two brothers, as the use of critical comments and aggression were prevalent among various family members both currently and in the past, including Mr. Wang's parenting and disciplining method. Through the family sessions, it became apparent that the entire family needed to work on the violence issues, in lieu of focusing on one family member: Mrs. Wang:

They should learn how to control (the anger)

Consultant:

In your view, who in this family is the one who cannot control the anger most?

Mrs. Wang:

So many of us.

Consultant:

Who are they? Who's number 1?

Mrs. Wang:

Second brother

Consultant:

Number 2?

Mrs. Wang:

The rest same.

Consultant:

This is a very “rich” story. Mr. Wang said the two brothers don’t really talk, boil, and explode after a long time. Mrs Wang said the other part of the story is that the brothers cannot control their anger. Second brother is number one person who could not control his anger, but the others are not able to control as well, am I right?

Mrs. Wang:

Yes.

Consultant:

On the other hand, who can control anger best?

Mrs. Wang:

No one

Consultant:

So, if this is the case, what is this story about? Why does your family have such a low threshold of controlling anger, and not speaking to each other at the same time. Where did this come from?

Mr. Wang:

Maybe when the children were young, I don’t control them. I let them be, their character, behavior… I just observed. When they made major mistakes, I would punish them physically.

While attempting to change the interaction patterns within the family, it is crucial for workers to be cognizant of the family's developmental life stages and historical contexts. Every family comes with unique challenges and needs. A family with grown-up children, like the Wang family, has a different set of needs and boundaries as compared to a newly minted family with young children, like the Tan family. For the Tan family, a large part of the couple's stressors came from their parenting of children. In the sessions with the couple, the workers tried and failed to focus on the issues in the couple subsystem because the conversation in the sessions would often focus on their roles as a team of parents. This is understandable as their children were young and reliant on the parents and the bulk of the couple's responsibility at this juncture pertains to their parenting roles. Hence, it was important for them to achieve a level of teamwork as parents which is systemically linked to their relationship as a couple. For the Wang Family, the key issue was the lack of boundary in the family in the context of a family with adult children. To cite an example, the youngest brother and the victim in this case, though 19 years old, had been sleeping in his parents’ bedroom almost his entire life, controlling the master bedroom and doing things as he pleased. The issue of boundary was addressed partly through working on a family project to create a partitioned room for the youngest son, where the frustrations of other family members related to the privileges of the youngest son were dealt with directly.

Although the sessions came about because of the violence, workers should recognize and tap into the family's strengths and believe that families are resilient. As Aponte and Dicesare (2002) rightly pointed out, the strengths of the family and its members are considered building blocks of change in SFT. Structural family therapy is a therapy of hope and strength (Minuchin et al., 2021):

While there are many techniques that help bring out client strengths and resources, the most important aspect of this is the worker's belief that clients are (1) are connected to these strengths and resources, and (2) are able to utilize and implement them. With this belief, and expectancy, therapists help clients to believe in themselves and expect that they will be able to change their situations. (p. 281)

For these two families, the social work team helped them to recognize their strengths and constantly sought out opportunities to validate their strengths, while checking on the risks of violence. For the Tan family, despite all the stressors the couple faced currently and moving on, one of the main aims of the seven sessions was not to resolve all their outstanding conflicts and issues. Instead, the sessions aimed to help them to live with differences, or even negotiate conflicts without the use of violence, and for the couple to work better as a team to confront the developmental challenges ahead. For the Wang family, we saw a loving and lovely family that was apparently caring and sensitive toward one another, despite their “action-oriented” way of expressing love for each other, such as creating a project to carve out a room for their youngest family member within a short period of two months during the trying COVID period, when there was a high demand for workers and renovation prices were high for a family living in public housing. The social work team was shocked when Mr. Wang apologized to children in session 4, especially his second son (the perpetrator) for the use of harsh physical discipline in the past. His second son publicly forgave his father. This reflected the father's acceptance of responsibility for his past actions, acknowledgement of the impact on the children and the recognition of each other's past hurt. This also reminded us of the need to see the strengths of the family beyond the cultural wall, where Chinese fathers occupy a higher hierarchy in the family and would be unbecoming to apologize to his children.

Based on the SRS, the total average score for Tan Family was 38.3 while the total average score for Wang Family was 37.3. Both were above the cutoff of 36 out of 40 points. At the termination phase, the Tan couple provided written feedback spontaneously via WhatsApp to the key worker:

We have benefited tremendously from the sessions. We would not have come to where we are today, if not for the help given to us. I very much appreciate all the time and handholding from PAVE. It's not a goodbye but a new journey which we hope to be even better from now on.

The outcome of the Tan family corresponded with a pilot study by Scerri et al. (2017). Upon analyzing the transcripts of the men on programs, three core themes emerged in relation to the meaning of success: (a) cessation of violence and abuse; (b) enhanced awareness of self and others; and (c) improved relationships with better communication (Scerri et al., 2017). These related closely to the literature on “healing” that the presence of safety and support, being accorded respect and having their past experiences validated were crucial factors in helping survivors heal (Abrahams, 2007). After termination and at the point of writing of this article more than two years on, there is no further recurrence of violence reported in these two families. For the Tan couple, specifically, they recognized the impact of their conflicts on their children and what they could do to support each other. They resolved to communicate more and present a united front in parenting the children. At the termination session, Mrs. Tan reflected that she did not feel that alone now despite having more stressors, as she now could discuss with her husband. For the Wang family, the second son realized the hurt he had caused his younger brother and shared at termination stage about the importance of being “level-headed,” a term used by him to describe the need to restraint from using violence when dealing with conflicts. Although the two brothers were not ready to mend their relationship and preferred to live their separate lives under the same roof, the family had reported an increase in confidence for long-term safety and an overall improvement in family relationships.

Discussion

The findings of this case study identified the key focus and process with F/IPV in after-violence situation with Chinese families in an Asian context, where risks have been minimized, using a SFT lens. Many Asian couples and families wish to stay together after the violence stops and it is thus important to provide conjoint therapy with couples and families to deal with the aftermath of violence and ensure long-term safety. There is growing evidence that support the application of SFT with families experiencing F/IPV (Bimm, 1999; Gelles & Maynard, 1987; Pender Baum & Pender, 2023; Sammut Scerri et al., 2017; Trute, 1998). Structural Family Therapy challenges the family's pattern of interacting which help to ensure long-term safety as demonstrated in the two cases in this study. The ability to shift the family beyond the certainty that violence lies with an individual, appreciate the family's developmental life stage and historical contexts, and lastly, promote the families’ strengths and resilience are sine qua non in positive treatment outcomes, as evidence by observed and reported changes of the clients and workers in this pilot study, which requires further investigations.

The key concepts of SFT are useful to conceptualize and work with the way Chinese families interact. Hierarchy and roles are especially crucial in Chinese families as there is high respect expected for the elders (Ow & Katz, 1999; Quek & Chen, 2017). Hence, seeking forgiveness and healing do not come about easily for parents and older people in Chinese families as this would be seen as a loss of face and a challenge to their level of power, hierarchy, and identity. Furthermore, Chinese are socialized from young on the importance of emotional control and are seen as “more emotionally reserved, introverted” as compared to the Westerners (Tseng et al., 1985). According to Tseng et al. (1985), Chinese families value the collective whole and associate proper conduct of the individuals and family to save “face” of the family. These two families decided to break the secret of violence and sought help from a formal organization as the violence had threatened the sanctity of the “family unit.” This highlighted the possible challenges they meet and the courage they have beyond cultural mores, which social workers should be aware and appreciative of. This also speaks of the resilience and resources of Chinese families, which practitioners should respectfully recognize without being constrained by the cultural stereotypes that may constrict their work.

Safety is the primary concern when working with violence and hence, it is important to consider the salient issues described earlier prior to the commencement of conjoint therapy, particularly as promoted by the feminist perspective. As family therapy is not established to be an intervention to stop violence from happening, it is important to assess if conjoint sessions are appropriate for the couple and/or family, particularly the severity and type of violence, as well as the acknowledgement of violence. We thus believe it is important for social workers to use family practice with families experiencing F/IPV after the risk has been mitigated and there is acknowledgment of responsibility for the violence. For instance, Trute's (1998) proposed two phases when intervening with F/IPV cases; gender-specific intervention to stop the violence, followed by family therapy after the violence has stopped. This is aligned with our approach in working with the two families.

Nevertheless, it is crucial to keep safety in mind throughout the course of conjoint therapy and the possibility of recurrence cannot be ignored. Conjoint therapy is contraindicated if there has been recent violence, or if there is reason to believe violence may occur during the therapy. Other factors include the perpetrator's unwillingness to accept any responsibility for the use of violence, no acknowledgement that violence is a problem and lack of internal motivation for change.

Conversely, it is important to note that not all couples and families wish to mend their relationships as violence had resulted in grievous hurt and pain. In the case of the Wang family, the two brothers were not ready to reconcile their relationship further but agreed to coexist under the same roof in a safe manner with clear boundaries. Should couples decide to end the relationship, it is crucial to work on safe separation as separation and divorce pose considerable risk of violence (Capaldi et al., 2012). However, not much has been written in social work and family therapy literature on helping couples separate safely following the cessation of physical violence. Sammut Scerri et al. (2017) addressed this gap by providing recommendations to work with individuals to separate safely while keeping a clear relational focus in the process.

The importance of joining and building a relationship with the family cannot be overemphasized in addressing the violence use and subsequently in family interventions. Joining is more than a skill; it's a mindset of respect, empathy, curiosity, and commitment to healing (Minuchin et al., 2021). When a collaborative relationship with the family is established from start to finish, it allows the therapist to both support and challenge the family in evoking positive change (Minuchin et al., 2021).

Further research is also needed to evaluate the effectiveness of SFT in after-violence contexts with diverse cultural and ethnic communities. Longitudinal studies examining outcomes for families who received gender-specific intervention to stop the violence, followed by family therapy after the violence has stopped, will provide valuable insights into the impact of therapeutic interventions.

Conclusion

For a long time, F/IPV was the most common exclusion criteria for conjoint therapy. However, recent research is beginning to show that conjoint therapy can be an effective mode of treatment (Karakurt et al., 2016; Maharaj, 2017). Though there are always risks of violence recurring any time which workers should be mindful about, conjoint therapy offers a unique opportunity for couples and families to uncover major points of conflict and unhealthy interaction patterns, as well as create a better understanding and acceptance of one another. Structural Family Therapy is such conjoint therapy and there has been growing evidence that supports its application in F/IPV. There is a place for SFT in working with couples and families experiencing F/IPV, after safety and violence concerns have been dealt with.