Part 1: Why It’s Important (Katie Gordon, Ph.D.)
Simply put, it’s important to include family members in the treatment of children and adolescents because it leads to better mental health outcomes. Parents are often valuable resources in therapy, and their active involvement in the treatment process can go a long way to reduce their child’s suffering and mental health problems. Multisystemic therapy (MST) for adolescent conduct disorder is a clear example of the potentially powerful and positive impact family members can have on clinical outcomes. In one particularly impressive MST study, Schaeffer and Borduin (2005) followed up adolescent felons who were randomly assigned to either MST or individual therapy 14 years prior. They found that those who received MST were 4 times less likely to be re-arrested, 2.5 times less likely to be arrested for a violent crime, and averaged ~62 less incarcerated days per year than those who received individual therapy.
In a review article on the status of treatments with family components (e.g., parental psychoeducation, parent training), Diamond and Josephson (2005) presented evidence that including parents in treatment for other childhood/adolescent mental health problems, including substance-use related problems, anxiety disorders (particularly if one or both parents have anxiety also) and attention-deficit/hyperactivity disorder (ADHD) tends to lead to better outcomes than treatments that do not include parents (note: parental involvement does not appear to affect core symptoms of ADHD, but reduces associated behavior problems) . Since the 2005 review, more evidence has emerged that a specific type of family-based treatment (FBT) is superior to supportive individual therapy for bulimia nervosa in adolescents (le Grange, Crosby, Rathouz, & Leventhal, 2007), findings that are in line with those that Mike Anestis presented on FBT for adolescents with anorexia nervosa earlier this week. Involving family in the treatment of adults is beyond the scope of this article, but it is worth mentioning that there is empirical support for manual-based family treatments for adults with substance use disorders (e.g., Fals-Stewar & O’Farrell, 2003), bipolar disorder (Rea et al., 2003), and schizophrenia (Pharoah et al., 2006).
Despite the evidence that including family members in treatment can be very beneficial, some clinicians may still feel reluctant, and parents may fear that they will be blamed if they participate. This may be due, in part, to historical or even folk explanations of mental disorders. For example, beliefs that certain mental illnesses are caused by having an absentee father (e.g., having “dad issues”) or an uncaring mother (e.g., “the refrigerator mother” or “the schizophrenogenic mother”) may linger in the minds of parents and even clinicians, despite a lack of evidence to support these theories. Part 2 of this article highlights the importance of directly addressing these types of issues by assuring parents that the purpose of their involvement is not to place blame, but rather, to enlist them as essential, helpful collaborators in their child’s treatment. It may be particularly important to assure parents of this early on, given evidence that parental therapeutic alliance predicts retention rates and outcomes in therapy for children and adolescents (e.g., Shelef et al., 2005). A second, perhaps more common, reason clinicians may feel reluctant to include families in therapy might be that they feel unsure about having the appropriate skills and/or feel intimidated about being “outnumbered” by clients in the therapy room. The purpose of Part 2 of this article is to normalize these feelings of uncertainty, and to outline some practical tips for including family members in treatment.
As a family therapist for 25 years, I can’t imagine any conceptualization of child or adolescent psychological problems that does not include careful examination of the family process. The assessment of family dynamics throughout treatment allows for deeper understanding of the presenting problem, and the factors that maintain it. With this in mind, I hope that these hints will be helpful to clinicians working with children, adolescents and their families.
1. Start early by asking family members to attend the initial assessment session. Set up a 1.5-2 hour meeting for an initial assessment, not counting any paperwork you’ll have them fill out. I usually set up an initial session fee that is somewhat less than two hours but more than the one hour standard fee. Introduce yourself to each member of the family in the waiting room, making a bit of small talk. Depending on the age of the child(ren), I also make sure to have some toys or games ready for them as well, as it can help with engaging the client and building rapport. Notice the affect, attitudes, and body language of all member of the family. I try to gather basic information, such as the child’s age, presenting problems, and the family member names prior to the first session. This is done through a 10-minute phone consultation when the clients first seek out your professional services. Although a good office manager can save you the trouble of this conversation, I believe it is highly beneficial to actually speak to the family and establish some initial rapport and connection. You may also be able to determine whether this is a case that you are qualified to accept. I have referred prospective clients out at this point due to my lack of expertise with their particular problems, insurance issues, and/or some other issue.
2. Appreciate the differences between assessment and treatment. The first few sessions are primarily assessment, and therefore clinicians need to avoid jumping in to the rescue of the family. This is the time to observe, ask questions, and detail how the family functions. The family dynamics will quickly appear without much prompting. For example, if there is a toddler who is playing while the clinician is speaking with the parents, you can observe who redirects the child, the patience levels, and the type of words and physical actions used during interactions with the child. With older children and adolescents, you can observe where they sit, how close to either parent they are, how active they are in conversation, how affectionate, along with mood and communication patterns. If clinicians interrupt and direct too tightly at this point, you could miss important observations into the family’s true form and style.
3. Set the rules up immediately. After you introduce yourself and explain a little bit about how you work and your philosophy, encourage them to ask any questions they may have at that point. This is the time to disclose a bit more about your experience as a therapist. Did you work in schools? Hospitals? What brought you into the counseling profession? If you have any sense of humor (hopefully) this is the time to be wise, gentle, and humorous. If you have no sense of humor, then perhaps a political science major may have been more appropriate. I usually state at this time that I was a childrearing expert at one time-- immediately after graduate school and prior to the births of my three children. I want them to know that I am a parent and have experienced the full effects of having a job, being in a relationship, and raising children who were all not perfect every moment of every day (except my co-author). This builds an alliance of immeasurable importance with the parents because they feel that they will be understood rather than judged.
Explain how therapy works and in general what they can expect. I usually say that I will meet with the child/adolescent alone some to most of the time, go through confidentiality, and leave some time at the end of each session for parents to join us. As some occasions warrant – we may spend a whole session together as a family.
4. Practice helps a family therapist more than anything. If you are an intern or student, or a newly supervised licensee, then seek out as much family work as you can. Avoid that feeling in the pit of your stomach that you may be outnumbered or overwhelmed in session. Embrace the unknown - understanding that expertise is the result of hundreds of hours of practice. Find a supervisor who likes systemic and family therapy and get their assistance. Read a Satir or Minuchin book or article. I am reminded that when I did workshops in my thirties with these esteemed family therapy pioneers, I went immediately back into my practice and attempted one of Satir’s techniques with a very dysfunctional family. It was a total flop except for the insight I gained about myself as a young family therapist. Of course, I missed the point that these famous family therapists had years of experience in conducting family therapy!
5. After assessment is complete, and the clinician has established a respectful and workable relationship with the family it is time to actually do what they are paying you to do… provide treatment. Of course, treatment recommendations depend on your observations and conclusions regarding family and individual diagnosis(es). Clinicians may find it helpful to devote a part of a session to review their opinions with the family, outline treatment protocols, and get consent for treatment. The consenting family is a less problematic family. Some disorders (e.g., anxiety disorders) may require less family involvement than others (e.g., oppositional-defiant disorder, which typically has a greater impact on the entire family’s functioning). At times, sibling conflict may be so important that I’ll decide to have a separate meeting with the siblings.
6. With regards to treatment considerations, families typically have developed a series of rigid responses to disciplinary situations without really understanding that there are other ways to interact. Many clinicians use the react vs. response techniques to educate families. I basically tell parents that any strategic and planned response is superior to simply reacting, so it’s imperative to discuss how to handle conflict. During this period of introducing new patterns of responses, clinicians are likely to find different degrees of unwillingness or inability to make changes. We often think the clients are being resistant and treat it as such. However, most failure at this point is due to parental insecurity and the results of years of habitualized reactions. The gentle, supportive, and educational approach is usually more successful, and may keep the client engaged at a time when they want to give up. Most importantly- go slowly and pick only one behavior to change at a time. This may be as simple as disengagement, time-out, or rehearsed verbalizations such as “I’m too upset now to decide what to do, let me go chill for 15 minutes, and we’ll meet back here to finish our discussion.” Remind parents that change is difficult, but simply making the attempt sends a message of support and love to their children.
A most valuable therapeutic technique in family therapy is positive practice. This is when the client and/or their family role play the new response to repetitious conflicts first in the clinician’s office then at home. Remember-- it is highly unlikely for an individual to apply a new technique in the middle of the apex of a stressful moment when they have reacted to it in the same way for months or years. Our brains just don’t function that way. The more they rehearse the responses in times of calm the greater the likelihood of success when they really need it. This also builds up rapport and teamwork within the family.
7. To paraphrase Virginia Satir, “There is only one argument that ever exists- and that is whose definition of what is going on is going to be accepted”. Family therapists the world over have found such wisdom in this simple proclamation which has profound effects on how we view psychotherapeutic treatment. We clinicians often get drawn into conflicts with families about who is right--they actually present their arguments to us and ask us to make a decision after all the evidence is presented! I usually comment that I forgot to wear my robes this day, and therefore I cannot judge effectively. Unless it’s allowing children to play with matches or play in traffic, I try to encourage parent-oriented solutions.
As a result, family therapists often teach communication skills as a vital part of therapy. Remember, parents have almost no training in parenting, and the communications skills that feel natural to many clinicians do not feel natural at all for some families. The basics of communication skills training include: using “I feel...” rather than “you…” statements, timing the discussion of problems right (e.g., not while watching TV or in the middle of the night), and how we to divide time between listening and speaking. It also may help to highlight the goal of effective communication-- do we want to be right or be happy (and resolve the problem)? There are many effective communication programs available. A couple that I prefer are Defiant Children, Second Edition: A Clinician's Manual for Assessment and Parent Training and The Parent's Handbook: Systematic Training for Effective Parenting .
It is also essential to teach parents to listen to children and adolescents during non-crisis times. Sometimes, direct interaction between parents and children only occurs when something is going wrong. Of course, this is upside down. The more we listen to our children in non-conflict situations, the better the communication is during the conflict situations. Perhaps the most efficacious time for practicing good communication is during therapy, because there is a supportive, experienced person to assist them and because most people, even children, know that therapy is a time for sharing important thoughts and feelings. I often joke that it’s my sofa that does everything- as soon as their bottom hits the cushion they start emoting! Outside of the office the best times to communicate with children is away from distractions and for short periods of 5- 15 minutes. I believe short walks are also effective times for communication because, symbolically, both people are walking in the same direction, towards the same goal. Communicating while walking can also reduce the amount of eye contact and body language being negatively interpreted by the other person (which can lead to conflict).
8. There are some common problems which tend to derail effective treatment if the clinician does not respond effectively:
- Adolescents (ages 15-19) do not always want their parents involved in treatment. They may feel that their confidentiality and trust in the clinician is compromised, because they feel that the clinician sides with parents during conflicts. In this situation, referring the parents to another clinician for parent skills training may be appropriate. It is particularly convenient if they see a clinician in the same practice, or you have established a good working relationship with the clinician, so that you can work together to treat the family. Every once in a while a family session can be more effective with the two clinicians conducting co-therapy.
- Parents may expect quick results and improvements despite presenting with serious problems. This is best dealt with by reminding parents that these problems didn’t develop overnight, and therefore cannot be solved easily. Also, remind parents of the treatment plan and highlight the small improvements that they may not have noticed or remember. Also, if too much time has passed with little or no positive results, it’s prudent to meet with the family, and admit that the current treatment plan does not seem to be effective. Developing additional or alternate plans is advised in this situation. This may include increasing the number of sessions per week, referral for further psychological testing, a medication consult, etc.
- One or more individuals may take over the session and diminish the clinicians’ ability to direct traffic effectively. This may include excessive arguing, aggression, and threats or physical attacks towards each other. This almost always occurs because the clinician tries to get the family to use a level of communication that they are not ready or skilled enough to use. An experienced family therapist practices smaller and less emotionally-laden topics before moving onto the big issues. It is also necessary to carefully consider the mood of the client or their family on that particular day. If the clinician reads significant disturbance or aggression, it may be better to speak with that person individually and ask them if they are okay with a family session that day.
Humor and empathy are usually effective in discharging anger. No one can truly be angry with someone who clearly understands and articulates their perspective. Often, it is the job of the family therapist to rephrase a family member’s statement in a way that is less threatening and more accurate. Asking permission to do this and asking if you spoke correctly allows the client to still feel in control. If a conflict starts to accelerate I may say “ Oops, I’m sorry I forgot to wear my striped referee’s jersey today” or “Folks, if you wait about an hour then you can argue for free once you go home- it’s too expensive to fight here.” Sometimes you might just have to insist that one or all the parties take a time out in another room or outside. Many times, I have had an adolescent or parent storm out of session and come back on their own within five minutes, because they really want to be a part of treatment.
- Seldom, a parent, due to his or her own issues (e.g., a diagnosable mental disorder), is unable to improve much of their skill set, and does not contribute in a positive way to their child’s treatment. A clinician may then employ “damage control,” and try to teach the son or daughter how to responsibly and functionally get their needs met in their lives, even if that parent is unable to assist them.
- In some situations, a clinician may feel that a family or one of its members display such callous and obstructive behaviors that it is necessary to discharge them from treatment. Make the discharge in compliance with the ethics of your license and/or practice, making sure to provide them with referrals for treatment elsewhere (it’s best not to refer them to colleagues that you like!).
In conclusion, family therapy can be a vital and effective assessment and treatment modality that requires a certain set of skills. There are a number of workshops, books, classes, and supervision experiences that can assist you in acquiring these skills once you have determined the value of family therapy as it fits into your practice.
If you are interested in learning more about integrating family into the treatment of children and adolescents, we recommend the following products, all of which are available through the Psychotherapy Brown Bag online store:
Les Gordon, M.A., has been a Licensed Marriage & Family Therapist and an educator for over 25 years, and currently has a private practice in Coral Springs, Florida.
Katie Gordon, Ph.D. is an Assistant Professor of Psychology at North Dakota State University. She received a year of training in family-based treatments for eating disorders at the University of Chicago.