Simms, S., Benjamin, J., & Patel, P. (2026). The history, contemporary status, and future of ESFT (Companion Chapter to Ecosystemic Structural Family Therapy: A Trauma-Informed, Strength-Based Model for Treating Families). Phila Family Books.
The History, Contemporary Status, and Future of ESFT
Six critical events are vital to the creation, development, and future of ecosystemic structural family therapy (ESFT). The first directs our attention to a pivotal moment in the early launching of cybernetics. This new field of study served as the first block in foundation for the development of systemic thinking on which ESFT rests. The next critical event brings the reader to the Macy Conferences, held across the Unites States, which sparked the growth of cybernetics as we know it today. This critical event marks how cybernetic principles added additional building blocks to family therapy’s foundation. The third critical event involves structural family therapy’s formative years at the Wiltwyck School for Boys and how this effort sets the foundational blocks for ESFT. The fourth critical event is structural family therapy’s formal development and worldwide dissemination at and through the Philadelphia Child Guidance Clinic. This event illustrates how the Philadelphia Child Guidance Clinic set the stage for the launch of ESFT. The fifth critical event is when the Commonwealth of Pennsylvania developed and administered an intensive in-home family therapy program implemented across its 67 counties. ESFT emerged from this event and differentiated itself from structural family therapy. There have been more than 30 years of clinical application and practice-based research through Pennsylvania’s and then Delaware’s Family-Based Mental Health Services. The next critical event involves ESFT’s more recent developments, its efforts to move from a practice-based to an evidenced-informed systemic family therapy model, currently applied across a broad continuum of care, serving a diverse population of children, youth, adults, and families. Finally, ESFT’s future lies in its potential to guide therapists to thoughtfully respond to known and unanticipated challenges imposed by the unfolding changes of modern society and our broad social ecology’s press on vulnerable children, youth, adults, and families and us, the professionals across the world.
Critical Event 1: The Founding of Cybernetics
In 1943, a research group at the Massachusetts Institute of Technology studying machines and behavior and another at the University of Chicago studying theoretical neurophysiology caused a stir by publishing two seemingly unrelated papers on a common groundbreaking topic. These theory-focused researchers boldly asserted that feedback loops govern and regulate mechanical and living systems so that they may accomplish purposeful actions (Rosenblueth et al., 1943; McCulloch & Pitts, 1943). These papers and the ensuing debates paved the way for the founding of cybernetics. Rooted in an ancient Greek term referring to the helmsman of a ship, cybernetics is the study of circular processes managed by a series of inputs and outputs. It directs the observer away from examining an object—that is, asking, “What is this thing?”—and toward conducting an interactional inquiry by asking, “What does it do?” (Ashby, 1957, pg. 1).
Automobile manufacturers often offer a cruise control option. A driver enters an open expanse of the expressway and sets the cruise control for 65 miles per hour. The vehicle runs at a steady speed for several miles. As it climbs a steep hill, the speedometer signals the cruise control device that the vehicle is slowing. This input triggers an output: The device signals the accelerator to increase the amount of gas delivered to the engine. This output returns the vehicle to the set speed. After the vehicle crests the hill and begins a steep descent, the vehicle quickly gains speed. The speedometer offers the cruise control device a new input: It should reduce the flow of gas. This input triggers another output: The reduced fuel slows the vehicle to resume its original speed. Consistent with cybernetic principles advanced by Rosenblueth and colleagues (1943), this electrical system is governed and regulated by feedback, through inputs and outputs, to accomplish a purposeful action.
The human body seeks to maintain a core body temperature of 98.6 degrees Fahrenheit. As the environmental temperature rises, the body’s internal sensors note this input and generate an output triggering the hypothalamus to activate the sweat glands to cool the body. As the body cools, these same sensors signal to the hypothalamus to stop sweating. As was described by McCulloch and Pitts (1943), feedback governs and regulates this biological system to accomplish an important purposeful action.
These researchers were the first to articulate the key organizing principle underlying the interactions perspective, which includes ESFT. They inspired the founders of systemic family therapy to upset the apple cart of the dominate theoretical perspective of the day, psychoanalysis. They advanced the bold and compelling notion that all active, purposeful human behavior occurs in a circular process governed by a system of internal and external feedback. Rather than exclusively homing in on the internal life of the individual and symptomology expressed through an expert-derived diagnosis (What brain-related event is afflicting this individual?), the therapist identifies and attends to the interactions perspective (How is this symptom related to the individual’s adaptation and functioning?). ESFT is rooted in the founding of cybernetics and is built and relies on cybernetic principles.
Critical Event 2: The Founding of Systems Theory
Between 1946 and 1953, the Josiah Macy Jr. Foundation sponsored an initial series of transdisciplinary conferences across the United States commonly referred to as the Macy Conferences. Thinkers and researchers from a host of fields of study tethered broadly to engineering, medicine, the sciences, and the social sciences convened “to lay the groundwork for the new science of cybernetics” (Pias, 2016). The participants repeatedly considered then widely applied a cybernetic diagram demonstrating how inputs and outputs influence and control a recurring circular feedback loop to a diverse set of examples in biology, engineering, medicine, and technology.
Building on the momentum generated by these meetings, additional Macy Conferences such as the Cybernetics Conferences, held between 1946 to 1953, and the Group Processes Conferences, from 1954 to 1960, were organized around relating cybernetics to the living world. The participants focused on and used the term recursiveness to capture this complex process with a simple descriptor. This effort advanced the idea that all living creatures, from amoebas to humans, indefinitely operate through observable, recurring, predictable, circular procedures, or operations. This endeavor triggered the exponential expansion of systems theory and laid additional foundational building blocks for the interactions perspective.
Critical Event 3: A Founding Contribution to Family Therapy
One attendee, Gregory Bateson, a cultural anthropologist, inspired by his immersion in the Macy Conferences, assembled a California-based team. Their shared purpose began to upset the dominant theoretical apple cart—psychanalysis—by applying cybernetic ideas through terms like recursiveness to the mental health challenges of the day.
Initially identified as the Bateson group (Hayley, 1976), this multidisciplinary group played a momentous role in early advancement of family therapy. Their first groundbreaking research effort generated compelling observational data illustrating a cybernetic process applied to a compelling mental health challenge: how symptoms associated with schizophrenia seemed to either emerge from or resolve based on communication and regulatory processes occurring between family members, not on the internal workings of the brain and mind (Bateson et al., 1956). Their widely cited paper captured the attention of a growing cadre of clinical therapists and researchers around the world.
Building on this very early family-therapy-focused research effort, Watzlawick and colleagues (1967), as an off shoot of the Bateson group under the Mental Research Institute published Pragmatics of Human Communication: A Study of Interactional Patterns, Pathologies, and Paradoxes. Relying on evidence generated from their practice-based clinical research, they motivated a growing number of mental health professionals to consider a groundbreaking idea that symptomatic behavior is an adaptive response to the demands of a situation rather than a disease of the mind. They used their evolving grasp on how interactional inputs and outputs serve to regulate and control behavior to experiment with novel treatment techniques. For example, by paradoxically prescribing the symptom, they helped clients discover that they could not only voluntarily produce the symptom but also eliminate it. In 1972, Gregory Bateson published Steps to an Ecology of Mind. This extensive collection of transcribed talks and published writings offered a comprehensive treatise for therapists examining the links between cybernetics, epistemology, systemic thinking, and the operational mechanisms underlying the process of change.
Underlying this complex work and challenging read is one key principle that runs throughout the book: Human beings perceive their world based on a unique system of perspectives and beliefs about themselves and their world. To change, the individual must see, consider, and compare other perspectives within their existing belief system. They must attune to and act on those circular inputs and outputs (Bateson, 1972, pg. vii). This principle profoundly influenced systemic family therapy approaches like ESFT. Then Watzlawick and colleagues (1974), through their work at the Mental Research Institute’s Brief Therapy Center, built on Bateson’s work by publishing Change: Principles of Problem Formation and Problem Resolution. They convincingly demonstrated how not only the client’s but also the therapist’s circular inputs and outputs uniquely contribute to either stabilizing or changing symptomatic behavior.
Next, they framed problem formation as an interpersonal process characterized as a mishandling. One type of mishandling is when action is necessary but not taken—for example, monitoring a child as they suffer from caregiver neglect. Another type of mishandling is when action is taken when it should not be. Sending a family member for treatment when they deny there is a problem is a common example. The third type of mishandling is when action is taken at the wrong level. An example would be referring a woman experiencing domestic violence to individual psychotherapy. They asserted that the therapist must understand problem formation and resolution through a systemic lens to effectively facilitate change.
Critical Event 4: Founding Structural Family Therapy
One of those scientist practitioners inspired by the Bateson and Mental Research Institute groups’ efforts was Salvador Minuchin. In 1960, he secured a staff position at the Wiltwyck School for Boys, an institution founded in 1936 for African American “delinquent” boys from disadvantaged, disorganized families in greater New York City. First serving as the intake psychiatrist from 1960 to 1962, Wiltwyck repeatedly observed residential treatment related successes cascade into postdischarge regressions. As the director of the family research unit from 1962 to 1965 (Minuchin, 1965), Minuchin, with colleagues Edgar Auerswald, Shirley Elbert, Bernard Gurney, Charles King, Braulio Montalvo, Clara Rabinowtiz, Bernice Rosman, and Florence Schumer, secured a National Institute of Mental Health grant to empirically investigate a family-focused understanding of and treatment for “juvenile delinquency” (Minuchin et al., 1964).
The Wiltwyck group’s first professional publication (Watzlawick et al., 1967) described their innovative approach for generating a family diagnosis and organizing a family-based treatment. They explained how their accruing clinical observations coalesced into a clinical, cybernetics-based research hypothesis linking the breakdown in parental control, guidance, and nurturance to the male child’s retreat to the sibling subsystem to get their needs met. This caregiver–child relational cutoff led to the male child’s tragic drift into “delinquency.”
Next, the Wiltwyck group illustrated their groundbreaking family therapy approach to “delinquency” using their research hypothesis to implement two procedures, three organizational phases, and four treatment-based tasks. The first procedure directed the clinical team to focus on both the parent and sibling subgroups, bringing to the fore their unique relational dynamics. The second organized the clinical team to strategically direct the parents to pay attention to and connect with the sibling subgroup. The clinical team implemented these family-based treatment procedures across three broad treatment phases. The first phase was the team’s entry and induction into the family. The second was the team’s therapeutic work with the family system. The final phase was the therapy team’s disengagement from the family to solidify the family’s autonomy. It was noted, almost as an aside, that the team also used case management to respond to “problems of existence” that confounded their work with these underprivileged and stressed families. Each family session was conducted through four tasks. The first brought together the child in placement, their family, the child’s milieu-based therapist, and a family therapist. The next task separated the family into two groups. The family therapist collaborated with the parents. The children’s milieu-based therapist worked with the sibling group. The third task reassembled the family and therapists. The fourth task was a postsession team debriefing and discussion. The Wiltwyck group reported using this approach as a diagnostic tool with 60 families and a treatment approach with seven families for 25–31 sessions. They offered a detailed case study as practice-based evidence to support the efficacy of this approach.
The Wiltwyck group’s second published report (Watzlawick, et al., 1974) described the development and use of two standardized family assessment tools designed to assist in family diagnosis and to measure treatment related family-based change. The first tool was the Wiltwyck Family Task developed by Minuchin, Elbert, and Gurney. Its purpose was to create a standardized approach for observing and describing a family’s interactional process as it related to their process-based research hypothesis. The family was placed in a room with a one-way mirror and an audio tape recorder. They were asked six questions. The first two questions involved planning a meal together and how to spend $10. The third question asked the family members to assign role and function-type labels to one another, such as “Who is the bossiest?” The fourth asked the family members to describe their likes and dislikes about one another. The fifth requested that the family describe the start, course, and resolution of a family fight. The sixth asked the family to work together to build a replica of a provided wooden model.
The other tool was the Wiltwyck Family Interaction Appreciation Test, developed by Elbert, Rosman, Minuchin, and Guerney (Elbert et al. 1964). Ten cards each portrayed an artist rendering of a family scenario determined by the research hypothesis reflecting themes like parental control, guidance, nurturance, and conflict. The family therapist asked the family to work together to tell a story depicted by the card. Each administration was audio recorded then analyzed through a coding system designed to categorize and rate family verbal interactions. Both standardized family diagnostic tools generated information about how family members perceive one another, their assigned roles, and family processes related to variables such as parental control, guidance, and nurturance (Minuchin et al., 1964). Again, the report offered a detailed case study generating practice-based evidence supporting the efficacy of these tools.
Both early structural family therapy and ESFT rely on broad principles such as entering the family with a relational hypothesis, the use of assessment tools to flush out and test a family structural organizational hypotheses linked to the presenting child-based concerns, deliberately organizing every session around a set of specified family-focused procedures and using the therapy to enact interactional tasks designed to help caregivers connect with their children (Parmanand & Benoit, 2015). But there is more to ESFT than using broad, global, family-focused principles and assessment tools.
Critical Event 5: The Development, Expansion, and Dissemination of Structural Family Therapy
With Montalvo and Rosman in tow, Minuchin left the Wiltwyck School for Boys in 1965 to direct the Philadelphia Child Guidance Clinic. Founded in 1926 as the third of 42 federally funded child guidance clinics situated in major urban areas across the United States, the clinic was an established, well-regarded Philadelphia pediatric mental health institution. Like most facilities of that day, it housed a multidisciplinary staff committed to serving the mental health needs of inner-city youth through a psychoanalytic treatment approach. A psychiatrist worked individually with the child. A social worker worked with the caregivers. Although it is seemingly obvious, the new leadership team was destined, like the Bateson and Mental Research Institute groups, to again upset the psychoanalytic apple cart. As they settled into their new offices at 17th and Bainbridge in South Philadelphia, the clinic’s new leadership team assiduously worked to finalize their last report for their grant-funded Wiltwyck research project.
Using the impending 1967 publication of Families of the Slums: An Exploration of Their Structure and Treatment as a springboard, Minuchin assertively came out of the leadership gate advancing the idea that the clinic must reorganize around a theoretically coherent, clinically relevant, research-informed, family-centered treatment approach. The goal was to not only create a practice-based clinical setting for the development and advancement of a new form of family therapy but also create a training center for this approach. This, of course, immediately challenged the status quo (Fishman & Rosman, 1986).
Minuchin and Structural Family Therapy
From 1965 to 1974, through a series of lectures conducted across the United States and Europe, reinforced by a growing number of professional publications (Minuchin, 1974), Minuchin used the clinic to facilitate and promote its own recursive process: developing a new model of family therapy based on systems theory, experimenting with related treatment techniques, and creating a family therapy training center. In 1965, Minuchin described “conflict-resolution family therapy” with multiproblem families (Minuchin, 1965) and, with Barcai in 1969, advanced a related technique called therapeutically induced family crisis, in which naturally occurring family conflict was seen as a therapeutic opportunity. Rather than trying to quell it, the family therapist relied on it to push for specific structural organizational shifts in family functioning designed to help caregivers precipitate a desired change in child behavior (Minuchin & Barcai, 1969). Minuchin looked beyond the clinic’s longtime commitment to multiproblem families to expand its focus. Not only did Minuchin turn the clinic’s attention to a wider range of families, such as those presenting with idiosyncratic problems related to stressful life events, but he also sought nonclinical families to understand how they worked. These efforts and more led to the 1974 groundbreaking publication of Families and Family Therapy. With chapter 1 titled “Structural Family Therapy,” Minuchin launched the clinic’s signature family therapy model.
Structural family therapy offered mental health professionals a growing set of guiding principles, specific assessment tools, and treatment techniques designed to help them see, understand, and respond to the client’s symptomatic presentation as an expression of a contextual problem grounded in family process. The therapist enters every therapeutic encounter with the notion that individuals are not only connected to and affected by their families but also connected to their larger social context. Assessment tools like a structural map visually illustrate the family as an open system with connections between and under the influence of one another and their outside world. These tools concretely depict how mutually influencing subsystems in and out of the family influence the reduction, maintenance, or exacerbation of the client’s presenting problems.
Going against the grain of psychiatry’s deficit perspective, the therapist uses structural family therapy to help families access their untapped potential and capacity to grow, develop, and progress through a developmental life cycle by reorganizing how they relate to one another and the world around them. Because assessment and treatment are a recursive process, the assessment tools also help the therapist to delineate goals for the therapy. They always join with the family to motivate them to restructure in ways where they relate in a deliberate, intentional, prescribed way as a means for influencing the identified patient’s behavior. These therapeutic efforts inspire the family to independently promote the adaptation, growth, and development of every family member, especially the symptom bearer (Minuchin, 1974). Structural family therapy shines an enduring spotlight on Minuchin’s contribution and indelibly marks the clinic’s prominent place in the history of systemic family therapy.
The account of early structural family therapy showcases Minuchin’s goal-driven administrative leadership, clinical acumen, and unwavering commitment to developing a systemic family systems model supported by practice-based research and training. As sometime ESFT historians, however, we must remain theoretically tethered by asking you to consider the development and growth of structural family therapy not just as related to the impressive effort of one committed professional but also through a relational contextual lens.
Landau (2024) recently directed our attention to the Xhosa and Zulu term ubuntu. She noted, “Ubuntu refers to behaving well toward others or acting in ways that benefit the community. A person who behaves in these ways has ubuntu. He or she is a full person.” Minuchin inspired the clinic’s staff to embrace and implement their own version of the ancient notion.
Faculty, Staff, and Trainee Contributions to Structural Family Therapy
Through Minuchin’s repeated contacts with the Bateson and Mental Research Institute groups, he inspired Jay Haley to move to Philadelphia in 1967 to direct the clinic’s Family Therapy Research Program. Although faculty like Minuchin and Haley repeatedly garnered attention though national professional presentations and publications, other members of the institute, less visible to outsiders, sculpted and shaped many facets of structural family therapy that we know today. Soon after Hayley’s arrival, he and Montalvo connected to write and receive a grant creating the Institute of Family Counseling (Hayley, 1976; Lappin, 2018). Their audacious goal was to serve the poor by identifying, recruiting, and training respected members of the community as family therapists. They canvased neighborhoods to inquire, “Who in your neighborhood do you believe could help your child?” The stand-out members of the community including Barbara Bryant, Gerald Hawthorne, Barbara Penn, Edna Smalls, and Peter Urquhart were recruited to join Hayley, Minuchin, Montalvo, Jerome Ford, Lydia Lynan-Gervacio, Cloé Madanes, Carter Umberger, Rae Wiener, and Marianne Walters to learn, master, and practice structural family therapy (Haley, 1976; Lappin, 2018).
The institute advanced and demonstrated two unsettling professional positions. The first asserted that life informed by experiences accrued within a shared social context, as exhibited by their recruits, are just as effective as if not more so than the acquisition of advanced professional degrees supplemented by insight-oriented individual psychotherapy for preparing psychotherapists. Not surprisingly, every member of the institute—faculty and therapist alike—went on to influence the growth and development of structural family therapy. Here are a few examples. Minuchin used the phrase, “joining the family,” 17 times throughout Families and Family Therapy (Minuchin, 1974).Although some readers likely ascribe this well-known, frequently used term and technique to Minuchin, it was the members of the institute who brought it to the fore and first applied it to structural family therapy. Jerome Ford articulately described a process regarding how local people “joined in the community” to not only survive but, more importantly, adapt and thrive. The institute’s trainees then used their community-based experiences to demonstrate repeatedly how to use their personal resources to build effective therapeutic relationships (Brian Ford, personal communication, March, 2018). Hayley used both the Institute of Family Counseling and the Institute of Teachers of Family Therapy as sources for advancing the second unsettling position around psychotherapy training procedures that profoundly affected not only structural family therapy (Hayley, 1976) but other systemic family therapy models. One new training procedure correctly anticipated the contemporary research finding that therapist self-assessment is biased toward unfounded overconfidence (Macdonald & Mellor-Clark, 2015). The institutes’ faculty and trainees shunned time-consuming content-oriented case discussions. They avoided wrestling with complex theoretical ideas through didactic training and case conferences in favor of teaching and learning family therapy as a set of discrete steps and skills through an interactive group effort. Trainees used videotaped recordings of their work to show their work but also to receive feedback to deliberately practice refining or learning a new skill. Finally, the treatment’s outcome was assessed by the trainees by bringing back clients and families to directly inquire about whether and what changes they produced. These are just two behind-the-scenes examples of how the two institutes’ faculty and trainees put their long-lasting but unsung mark on structural family therapy.
Nine years after arriving in Philadelphia, Minuchin created and led a dedicated clinic-based team who resoundingly shared in accomplishing two major goals. First, structural family therapy gained worldwide recognition as a preeminent model of family therapy. Second, the clinic also garnered an international reputation as the go-to site for family therapy training. In 1974, the Children’s Hospital of Philadelphia and the clinic relocated to a newly constructed modern complex in Southwest Philadelphia. This shared shining new complex preceded more monumental gains (Lappin, 2018): a projects on psychosomatic illness in children, another on family therapy of drug abuse and addiction, and the Family Therapy Training Center.
The Psychosomatic Illness in Children Project
Minuchin, Rosman, and Lester Baker, a pediatrician at the Children’s Hospital of Philadelphia, submitted and received a National Institute of Mental Health grant and another from the National Institutes of Health to study the treatment of psychosomatic illness in hospitalized children through the hospital’s clinical research center. Settling into their new offices in this University City enclave, the clinical research team with extensive assistance from Ron Liebman, Leroy Milman, and Tom Todd took structural family therapy to its next stage of development and recognition.
This practice-based research borrowed and expanded on assessment and treatment methods from the Wiltwyck research program. These assessment procedures took structural family therapy to a new level. They emphasized four family transactional characteristics: enmeshment, overprotectiveness, rigidity, and a lack of conflict resolution. The child’s propensity to express symptoms physically through diabetes, asthma, or anorexia coalesced with one or more of these family transactional characteristics to create a life-altering, life-threatening clinical presentation. The child’s wranglings with normal developmental challenges and the family’s responses to these normal and expected developmental events served as the precipitating onset event (Walsh, 2016).
From an open-systems perspective, the four family transactional characteristics functioned to maintain the symptoms. The therapists weaved traditional treatment techniques like relaxation skills in with family-focused change strategies, including reframing and in-session enactments to explore and create new interactional patterns to generate desired treatment outcomes (Lund et al., 2002; Minuchin et al., 1975, 1978). For example, Minuchin and Liebman brought the hospitalized youth suffering from anorexia nervosa and their caregivers together for a family lunch session. This enactment allowed the family to exhibit one or more of the identified family characteristics. Attending to the pattern helped the therapist help the caregivers practice restructuring their family relationships (Rosman et al., 1975). The outcome data was impressive. Life-altering, life-threatening conditions that once defied traditional treatment approaches now appeared responsive to this evolving structural family therapy.
Addiction and Families Program
Seeking a system-oriented, practice-based research context, Duncan (Duke) Stanton relocated to Philadelphia in 1972. Building on his military experience in Vietnam, training with Virginia Satir and Ray Bardill, a study of Haley’s publications, and clinical work with people with addiction, Stanton secured a position at the clinic to finalize a research design and apply for a National Institute for Drug Addiction grant to underwrite the Addicts and Families Program. He collaborated with Tom Todd to finalize a proposed randomized clinical trial with four treatment conditions: individual therapy, family movie intervention, unpaid family therapy, and paid family therapy. The grant was funded in 1974, and Stanton hired Todd as the clinical supervisor. They assembled an initial team of professionals, including Gerald Hawthorne, David Heard, Sam Kirshner, Jerry Kleinman, David Mowatt, Alexander Scott, and paraprofessionals, including Paul Riley, Sam Scott, and Peter Urquhart. At its peak, this research program employed a 70-person staff, and the treatment continued for three years (1974–1977) and the posttreatment follow-up through 1981.
The Addicts and Families Program approached drug addiction from a family systems perspective. Addiction was seen as embedded in a family pattern that maintains the addict’s drug use but also family stability, especially regulating physical proximity and emotional closeness between the person with addiction and their caregivers. When the person with addiction abstained, conflict between caregivers increased. When the person with addiction relapsed, the caregivers reunited to focus on the addiction. From a developmental perspective, drug use helped the person with addiction maintain distance from yet remain connected to their family. The clinical team employed structural–strategic treatment principles driven by an atheoretical shared purpose to creatively do what it takes (T. Todd, personal communication, February, 2024) to accomplish their treatment goals. The family therapists used structural family therapy fundamentals, enacting new patterns and techniques like joining, boundary making, and restructuring. They made use of strategic elements like concrete treatment goals such as caregiver-enforced requirements for the addict to remain drug free, employed, and live independently and implementing between-session therapeutic activities like detoxing at home.
The outcome data clearly demonstrated that short-term structural–strategic family therapy with adult males addicted to opiates could be highly effective in reducing drug abuse. Compared with the three other treatment conditions, the paid family therapy condition showed superior results. A higher death rate occurred among the person with addiction not participating in the family therapy condition. Not only did the Addicts and Families Program further advance structural–strategic family therapy, but it also serves to demonstrate additional points: Family therapy was applicable not only to children and youth but to adult clients as well (Tuck et al., 2023). The empirical outcome data generated through a randomized clinical trial convincingly showed the effectiveness of this approach. Finally, training that was focused not only on adherence to and competence in implementing the model but also on an esprit de corps (think, ubuntu) commitment to achieving a desired outcome appeared critical to generating success.
The Family Therapy Training Center
With the clinic’s transition to its new location, the Institute of Family Counseling and the Institute of Teachers of Family Therapy were subsumed under the newly created Family Therapy Training Center. It housed a psychiatry training fellowship, a psychology predoctoral and postdoctoral training program, a social work training program, a nurses training program, and a faculty-based training program targeting outside agencies and organizations. This training context not only drew trainees from the greater Philadelphia area but also from around the world. Trainers built on Montalvo’s and Haley’s approaches, including direct observation through live supervision and teaching therapy as a set of discrete steps and skills learned by doing through an interactive group effort. Again, the trainees used videotaped recordings of their work to show, tell, and receive feedback regarding what they were doing in therapy. As the center secured more training contracts, the senior faculty traveled far and wide advancing the practice structural family therapy.
Marion Lindblad Joins the Clinic
In 1969, fresh off her participation in the civil rights movement as a Freedom Rider, Marion Lindblad was entering Temple University as a doctoral student interested in studying imaginativeness in disadvantaged preschool children. A former professor at the University of Minnesota suggested that she contact Patricia Minuchin, a Temple University professor specializing in child development. Lindblad approached Professor Minuchin for advice and consultation. Sometime later, Patricia invited Lindblad to dinner to discuss her research. When Lindblad knocked on the door, Salvador—Patricia’s husband—greeted her.
As Pat finalized the dinner preparations, Salvador, not surprisingly, initiated the joining process. He learned that, for the past two years, Lindblad had worked as a psychologist at the Irving Schwartz Institute for Children and Youth in Philadelphia. Aware of its psychoanalytic approach to “disturbed” children, he boldly asserted that Lindblad’s professional training and research would be better served by employment at the clinic. In short order, she applied for and secured a psychologist position. She regularly received system-focused supervision, attended family therapy seminars, and worked directly with Salvador Minuchin and other senior faculty. She became privy to the inner workings of the clinic’s programs, including the Institute of Family Counseling, the Institute of Teachers of Family Therapy, the Psychosomatic Illness in Children Project, and the Addicts and Families Program. Moving up the ladder, she was promoted to assistant director, then director of Clinical Outpatient Services at the clinic’s West Branch location. She completed her dissertation in 1977. Not surprisingly and, just as Salvador portended, her dissertation, A Study in the Relationships Between Family Interaction Patterns and Imaginativeness in Disadvantaged Children, linked the development of an individual characteristic, imaginativeness, to family process.
Although she was deeply inculcated in the practice of structural family therapy and the ethos of the clinic, Lindblad experienced her work at the clinic in ways that inspired her to start thinking beyond the immediate boundaries of structural family therapy. For example, the clinic launched a much-needed day treatment program serving chronically truant children. The goal was to bridge the gap between mental health and education under one roof. Although this effort clearly resonated with its mission to serve these vulnerable children around a long-time community concern, it immediately encountered major challenges. Referrals from the school system and the community were scant, absenteeism was high, and the dropout rate unacceptable. To make matters worse, as Salvador Minuchin sought community-based connections to advance the program, he encountered scorching criticism and profound resistance. To add insult to injury, the light of day periodically revealed broken windows at the South Philadelphia facility.
Minuchin understandably backed away and asked Harry Aponte to take the lead in solving this challenge. Through repeated efforts to “join in the community” as “someone who looked like someone from the community” (H. Aponte, personal communication, January, 2024), Aponte’s keen system-focused observations uncovered a blind spot. The clinic’s leadership team had failed to join with a key member of the community’s leadership team. Aponte combined his growing mastery of structural family therapy with the deeply held notion that life informed experiences accrued within a shared social context are key ingredients for relationship building, he immersed himself into the community and discovered that Jim Lester was a key community leader and also the cornerstone for achieving success. Aponte repeatedly sought and eventually earned Lester’s support. As a result, referrals increased, and children reliably attended, actively participated, and thrived. Their families became involved in supporting and celebrating the children’s success. Although Lindblad was deeply influenced by and grounded in structural family therapy, her exposure to experiences like this and others directed her attention to the impact of the broader social ecology on individuals, families, and organizations. In 1979, Lindblad and her husband transitioned to Cincinnati, Ohio. In Ohio she furthered her thinking about the relationship among individuals, families, and their broader ecosystem in this new context.
Cultivating ESFT
Settling into her new hometown, Lindblad-Goldberg quickly channeled her energy into a new professional project. In 1980, she proposed and was granted space but no financial support to create and run the Family Therapy Training Center at the University of Cincinnati School of Medicine. Determined to build a systemic, low-cost, community-based, practice-focused training site for psychiatry residents and other professionals interested in learning family therapy, Lindblad rolled up her sleeves and got to work. She initiated two important steps. First, she sought referrals from demographics in need of services: minority, low-income, single parent, female-headed families presenting a severely symptomatic youth. Then, she organized this clinical service and training program around current professional efforts regarding the recursive relationship between expanding and refining structural family therapy with system-focused empirical research. She relied on empirical data generated from her ongoing collaboration with Joyce Dukes through Single Parents Project at the clinic, funded by grants from the US Department of Health, Education, and Welfare; the OMDS; and the Administration on Children, Youth, and Families. She used these data to guide therapists in training to see, understand, and respond to the referred child or youth client and their caregivers through a culturally attuned, competence-based, ecology-focused lens (Lindblad-Goldberg, 1985).
This approach informed trainees about a major clinically relevant difference between clinic-referred and nonclinic-referred families. The clinic-referred families demonstrated stressful home environments and engaged in an unbalanced give-and-take relationship that pushed away and alienated members of their social networks more than the nonclinical families did. Lindblad used this research-guided training experience to inform and expand the theoretical boundaries of structural family therapy. This broad ecology-focused structural approach generated professional enthusiasm and clinical success, which opened doors for a growing number of psychiatry fellows and community-based therapists to seek training in ecostructural therapy (Lindblad-Goldberg & Dukes, 1985).
Launching ESFT
In 1986, following her husband’s professional transition back to Philadelphia and entering the shadow of Salvador Minuchin’s retirement from the clinic, Lindblad accepted an offer to direct the clinic’s training center. Building on its legacy of expanding “the knowledge in the processes of training and change” (Fishman and Rosman, 1986) she once again hit the ground running. First, she nurtured the training center’s longtime tradition of offering system-focused training at the local, national, and international levels. As one of the faculty, Andy Fussner, stated, “The center flew me to Germany every two months to consult with and teach family therapy to a very passionate group of trainees” (A. Fussner, personal communication, 2014). Second, she established and recruited for a postgraduate training program in marriage and family therapy approved by the Commission on Accreditation for Marriage and Family Therapy Education. Third, she responded affirmatively to the Commonwealth of Pennsylvania’s request to develop and implement an intensive family therapy program for children and youth diagnosed with severe emotional disturbance and at-risk of out-of-home placement (Jones & Lindblad-Goldberg, 2002, 2008).
It was this third project that precipitated the development and implementation of ESFT. Lindblad worked with Karen Snider at the Department of Public Welfare, Ford Thompson at the Office of Mental Health, Constance Dellmuth and Patricia Serra at the Bureau of Children’s Services in 1988 to launch family-based mental health services programs across Pennsylvania’s 67 counties (Lindblad-Goldberg et al., 1998). With Martha Dore and Lenora Stern, Lindblad organized a multidisciplinary team that included training center faculty member Andy Fussner, Gordon Hodas, Ann Itzkowitz, Wayne Jones, Ruth Sefarbi, and Ioloe Walbridge; professional consultants from around the nation; family-based mental health services program directors; and professional parents from a statewide parent advocacy network to launch ESFT through family-based mental health services.
This effort was described in Creating Competence from Chaos: A Comprehensive Guide to Home Based Services (Lindblad-Goldberg et al., 1998). Through this publication, with the help of her assembled leadership team, the training center faculty, and members from her broader professional ecosystem, Lindblad formally introduced and described ESFT. This publication articulated four fundamental features of the model. ESFT rests on the theoretical underpinnings of cybernetic principles and structural family therapy. It also incorporates the efforts from the clinic and training center faculty to highlight both the critical role of ecosystems play in family life (Auerswald, 1968; 1972;Minuchin, 1970, 1974) and ecostructural approaches designed to collaboratively link family with resources in the broad social ecology like school and child welfare (Aponte, 1974). It also captures and advances recent theoretical and research efforts directing family therapists to attend to the impact of informal (Lindblad-Goldberg et al., 1998) and formal (Bronfenbrenner, 1975) social systems on child well-being and family life. It articulates how ESFT uses treatment trends advocated by consumers and funders to serve high-risk clients through a collaborative relationship in the least restrictive setting. Finally, the publication describes how early pre- and posttreatment research documented the effectiveness of ESFT applied through family-based mental health services, including the reduced out-of-home placement rate of referred children and youth. If you would like a detailed description of the theoretical and clinical foundations of ESFT beyond what we discuss in the rest of the book, you will benefit from studying Jones and Lindblad-Golberg (2002) and Lindblad-Golberg and Northey (2013).
In the 2000s, the University of Pennsylvania’s School of Medicine tragically shuttered the storied clinic’s doors and absorbed its clinical services into their Department of Child and Adolescent Psychiatry at the Children’s Hospital of Philadelphia. With the faculty in tow, Lindblad relocated the training center to Friends Hospital in Northeast Philadelphia and renamed it the Philadelphia Child and Family Therapy Training Center (PCFTTC). Building on her experiences at the clinic and the Family Therapy Center in Cincinnati, she remained relentlessly committed to advancing the growth and development of ESFT. Her first mission was to effectively serve vulnerable members and families in the community with a no-cost mental health clinic centered on the practice of systemic family therapy, especially ESFT. The second mission was to use PCFTTC as a practice-based setting to train postgraduate trainees in systemic family therapy with an emphasis on ESFT. Finally, through Pennsylvania’s Office of Mental Health and Substance Abuse Service’s Children’s Bureau, she collaborated with Pat Johnston and the Family-Based Mental Health Training Institute at the Western Psychiatric Institute and the University of Pittsburgh Medical Center and later with Wayne Jones and the Center for Family-Based Training to further advance the growth, development, and effectiveness of ESFT applied through family-based mental health services across Pennsylvania and Delaware. In Fall of 2019, Lindblad retired to assume the director emeritus position at PCFTTC. She appointed Steve Simms as director, and he appointed Pinky (Mehta) Patel as associate director.
In March of 2020, the COVID-19 pandemic and resulting stay-at-home orders halted face-to-face in-home therapy for youth served by Pennsylvania’s and Delaware’s ESFT family-based mental health services programs. Relying on ESFT’s foundational connection to the cybernetic principle of seeing crisis as a developmental opportunity for a system-based change, the three family-based mental health services training centers created the Consortium for the Advancement of Ecosystemic Structural Family Therapy. As of writing the present book, this collaboration has yielded five initiatives designed to sustain and advance the certification of therapists trained in ESFT:
- Help stakeholders navigate the pandemic-imposed challenges to the practice of ESFT.
- Create and implement ESFT family-based mental health services logic model and an ESFT logic model.
- Develop and implement measurement-based training on knowledge assessment, collaboration scale, and enactment scales.
- Analyze and publish the psychometric properties of the Modified Family Assessment Form as an evidence-based assessment for measuring family functioning.
- Analyze and publish quasiexperimental research findings of the treatment outcomes for youth and families engaging in ESFT family-based mental health services in partnership with state-managed care organizations.
The first initiative is a crisis-induced effort to assist relevant stakeholders in competently navigating the unwanted pandemic-imposed challenges to the practice of ESFT through family-based mental health services. Stakeholder attention was directed to three key supervision or training interventions: in the face of adversity, promote and secure an unremitting commitment to systemic thinking through ESFT; adhere to ESFT in all practice settings, including the less-familiar telehealth option; and use expert-guided deliberate practice to prepare the therapist to adhere to and competently apply key ESFT principles under new, unfamiliar, and challenging conditions like telehealth (Rousmanieere et al., 2017; Simms et al., 2021).
The second initiative is to create and implement the logic model for ESFT family-based mental health services and a general ESFT logic model. The purpose of the general ESFT logic model is to threefold: to succinctly describe how ESFT is intended to work along the broad continuum of mental health care; to pointedly illustrate to the user ESFT’s inputs, activities, interventions, outputs, and outcomes; and to define ESFT’s treatment objectives and goals to clearly demonstrate alignment with systems theory.
The third initiative is to create, implement, and sustain a measurement-based approach to supervision, training, and competency assessment (knowledge assessment, collaboration scale, and enactment scales; Bobek et al., 2025). The knowledge assessment, a 70-item multiple-choice criterion reference instrument, organized around seven factors reflecting key aspects of the ESFT model (characteristics of target population, family dynamic and family structure, core concepts and principles, therapeutic and professional relationships, family assessment, ESFT’s theory of change, and ESFT’s treatment goals and methods). The goal is to objectively identify the trainee’s ESFT knowledge-based strengths and areas requiring further instruction and study. A study of its psychometric properties is under way.
In the Therapeutic Collaboration Coding (Ribeiro et al., 2013; Simms et al., 2021), the rater views live or recorded sessions and codes the frequency of observed interventions for four factors yielding two ratios: supporting to challenging markers and validation to invalidation markers. These ratios are used to evaluate how balanced the collaboration is from the therapist. By focusing on the in-session markers, the supervisor and trainer help the trainee appreciate how in-session client–therapist exchanges affect bigger treatment-plan-related outcomes.
The Family Therapy Enactment Scale, Revised version 6.30.2025. It is based on the original scale and research by Allen-Eckert and colleagues (2001). The purpose is to assist the therapist in initiating, sustaining, and bringing structured assessments and change enactments to a successful conclusion that are consistent with the adherent and competent practice of ESFT. Adherent delivery is achieved through four phases: preparation, initiation, facilitation, and making meaning. Competent delivery is determined by the overall score and by it being productive and meaningful for the family.
The fourth initiative is to analyze and publish the psychometric properties of the Modified Family Assessment Form (MFAF) as an evidence-based assessment for measuring family functioning. Simms and colleagues (2025) studied the psychometric properties of the form using data archived from 614 children and youth receiving ESFT family-based mental health services. The results revealed a three-factor structure (caregiver–child relationship, cocaregiver relationship, executive functioning) consistent with ESFT, established good internal consistency, construct validity, and reliability. It also appeared sensitive to differences between pre- and posttreatment results on the MFAF’s three factors.
The final initiative is to analyze and publish quasiexperimental research findings of the treatment outcomes for youth and families engaging in ESFT family-based mental health services and in partnership with state-managed care organizations. Three recently published studies using archived data offer growing evidence regarding the efficacy of ESFT family-based mental health services. Byers and colleagues (2021) examined archival data (288 clients and 378 caregivers) exploring the relationship between caregiver adversity and treatment outcomes in ESFT within family-based mental health services. Their findings indicated that caregiver childhood adversity did not predict treatment outcomes, whereas current adversity was negatively associated with the client’s length of stay at the facility and their level of care after discharge. These results suggest that ESFT is effective regardless of a caregiver’s past adversity but that addressing the current caregiver’s stressors is essential to optimize treatment outcomes.
Herschell and colleagues (2024) completed an analysis of children and youth archived data (N = 25,016) and revealed that engagement in ESFT family-based mental health services was associated with a significant reduction in out-of-home placement and increased community-based care both during treatment and up to six months after discharge. Use rates for out-of-home services, especially inpatient psychiatric care, declined over time, with inpatient admissions dropping notably from 12% prior to treatment to less than 5% six months after discharge, whereas the rates for residential placement remained consistent before and after services. These findings demonstrate that ESFT via family-based mental health services effectively reduces the need for restrictive placements and sustains positive outcomes following the completion of treatment.
Jones and colleagues (2024) examined the relationship among the length of stay in family-based mental health services, admission and discharge ratings on the Child Assessment of Needs and Strengths, and rates of out-of-home placement for youth (N = 2,164) receiving ESFT via family-based mental health services. The results revealed that youth participating in the intended length of stay (6–8 months) demonstrated significantly higher posttreatment strengths and reduced needs on the assessment and lower postdischarge rates of out-of-home placement than did youth with both shorter and longer stays.
To summarize, ESFT builds on basic structural family therapy principles, assessment tools, and treatment techniques designed to help the therapist see, understand, and respond to the client’s symptomatic presentation as an expression of a contextual problem grounded in family process. Relying on its deep roots in cybernetics and going beyond structural family therapy, ESFT directs the therapist to connect the mutually influencing links among the presenting clinical concerns; the complex inner workings of the client; their family life; informal social networks such as their extended family, friendship network, and neighborhoods; formal networks like school, work, police, social services, and government; and invisible but influential forces like culture, racism, and oppression. The client and their family and are affected by these complex connections in ways that promote individual and family resilience or vulnerability. ESFT organizes the therapist to adopt a strength-based, competence-focused, collaborative perspective that shares decision-making with the client and their family to advance the treatment through a least-restrictive, community-focused environment. Finally, supervisors and trainers should consider ESFT as a training model too. The therapist applies the mutually influencing links to themselves and their relationship with their supervisor, trainer, and practice setting.
Critical Event 6: Using ESFT to Help Therapists Survive and Thrive
The resolute mental health professional always finds ways to contend with solvable and unsolvable challenges. Although we could put our heads together and generate a lengthy and compelling list of those challenges, our experience training thousands of therapists supported by recent research generates three points for us to consider. First, caseloads are excessive, which leads to emotional exhaustion (Griffiths et al., 2024). Second, acuity rates are alarmingly high. Across the globe, over a million people annually die by suicide (Cramer & Kapusta, 2017; Giddens et al., 2014). The third point is the press from the community, reimbursors, regulators, and government to “fix” the “problem” as soon as possible for the least amount of money (Griffiths et al., 2019). Expectations from clients, families, and organizations for a quick fix are not only unrealistic but unsustainable. Although ESFT will not in and of itself solve these challenges, it helps us look in the mirror every day and enthusiastically and confidently reflect, “I did an excellent job today.” The professional makes this happen by creating and enacting (Carr, 2019).
Systemic Work in a “Fix It” World
As professionals responsible for monitoring and promoting the safety and mental health of children, youth, and adults, we regularly face and navigate life-altering and life-threatening clinical challenges (Park et al., 2025). The systemic perspective guides us to see, understand, and effectively respond to these worrisome mental health treatment challenges through the mutually influencing links among the client, their family, and their broader social ecology. The surgeon general’s 2021 report to the country, Protecting Youth Mental Health, resoundingly echoes and lends growing support for this compelling support for this position (Office of the Surgeon General 2021). Despite an interest in and commitment to a systemic approach, we may feel pressure to focus on the individual. The solution is both complicated and straightforward.
It is the therapist’s ethical responsibility to approach each case from a theoretically coherent, clinically relevant, and evidence-informed perspective (Simms et al., 2020). Simply put, what is the right thing to do? If your answer is to work systemically, this is what you are obligated to do. ESFT offers a guide for navigating the many compelling forces encountered in your own social ecology by wrangling with questions like “Am I trapped in a negative interactional pattern with my supervisor and this agency, and does this challenge me to alter and compromise my clinical approach?”
Creating and Sustaining a Systemic Perspective in a “Fix It” World
Supervisors, program directors, and administrators leading organizations monitoring and promoting the safety and mental health of children, youth, and adults walk a trying tightrope. How do we create and sustain an organization committed to systemic practice in a professional climate that emphasizes deficits and expert treatment focused on reducing or eliminating the individual’s symptoms. Recruiting, training, and retaining employees interested in and committed to systemic practice is a core challenge of this situation. We must orient, train, and support every employee to think systemically and to use their unique professional role and function to advance a theoretically coherent, clinically relevant, evidence-informed, system-focused treatment model like ESFT (McClure et al., 2024). The collection, analysis, and reporting of outcome data designed to inform relevant stakeholders on first- and second-order treatment outcomes is another challenge, as is using those data to assess and steer our clinical, supervision, and training efforts. We must also adapt to regulators and funders who likely expect a more behavioral, first-order approach to treatment while creatively finding ways to adhere to and advance our commitment to a systemic focus and second-order change.
Contributing to the International Community
The systemic family therapy movement began in isolated pockets of the United States, but over the last 70 years, it has spread throughout the world. Although the challenges of daily practice likely organize us to focus on the local challenge at hand, once again, the ESFT practitioner is compelled to go to the high ground to see and “acknowledge the interconnectedness of individuals, families, communities, and societies and incorporate family therapy as a vehicle for accessing resilience and healing” (Andolfi et al., 2023, p. 7-11). Although most of us will not travel abroad to advance this mission, our local challenges and efforts are always connected to the international ecosystem.
Poverty, climate change, community violence, political oppression, and war are propelling families to immigrate to secure short-term and permanent solutions. As the future unfolds, it is likely that many readers have or will encounter clients and families affected by or connected to this growing international movement of people. We encourage you to begin with the Assisi Manifesto (Andolfi, et al., 2023). It offers a thoughtful systemic guide that helps every reader prepare to work with families of every culture. It includes the following principles:
- Avoid the use of diagnostic language, medications, and hospitalization as a quick first-order fix for the problems of living.
- Include the voices of children and youth into the problem-solving process.
- Rely on a multigenerational approach to helping all families navigate the challenges of modern life.
- Promote and protect the basic human rights of all people, especially members from our most vulnerable communities and populations.
- Create family therapy training efforts that not only teach theory and techniques but also offer deliberate practice.
Beginning with Bateson, followed by Kerr and Bowen, and continuing into the present, systems theory provides a framework for understanding families as interconnected dynamic systems rather than isolated individuals (Carr, 2015). Within this perspective, the family is viewed as a living, biological system where each member’s actions and emotions affect the others, and the family continually adapts to internal and external influences (Priest, 2023). Systems theory highlights that families exist within broader social, cultural, and environmental contexts—such as communities, laws, politics, and religion—that shape the balance between risk and protective factors and the influence overall family functioning. The key elements of systems theory include the system, boundaries, patterns, stability, change, complexity, and the application of research to practice (Carr, 2015).
ESFT is grounded in systems theory. It recognizes that meaningful change in a family happens through systemic transformation in the context of the ecosystem rather than isolated interventions. Therapists using ESFT focus on family patterns and relationships, as well as the broader sociocultural environment (social ecology) that influences them. This model prioritizes second-order change—deeper, structural shifts in how the family functions—while also employing first-order, immediate behavior adjustments when necessary. ESFT therapists use interventions such as reframing, enacting, joining, and anchoring, informed by family assessment tools and observation, to build strong therapeutic alliances, shift family beliefs, behaviors, and emotional connections, and empower families to achieve positive outcomes through their own autonomy and adaptability.
As Marian Lindblad-Goldberg stated, “families are their own best resource for change” (Lindblad-Goldberg et al., 1998, p. 26). Therapists are experts in therapeutic models, but each family is the expert on their own journey. Therapy is most effective when it empowers families to create lasting change.
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