Comments on Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively - May 2009 Psychotherapy Brown Bag featured article

Les M Gordon commented on 'Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively - May 2009 Psychotherapy Brown Bag featured article'

2009-05-06T03:26:58Z

Mike, thanks for the question. Resistance in psychotherapy is a huge topic- one that probably deserves many articles as there are multiple schools of thought. Some believe that resistance really doesn't exist and is simply a term designed by psychotherapists to clinically diagnose clients who don't follow or agree with all of their suggestions. Others feel that resistance is the key psychological symptom to follow closely in therapy and that understanding and treating resistance is paramount for successful outcomes.

My personal belief is closer to the first school of thought. It is the art of psychotherapy and the gift of persuasiveness that cuts through "resistant" clients. Certainly motivational interviewing is one very good technique, but there are so many others. This is based upon the clinician's own style and experience with similar situations. I personally use humor a lot in addressing resistance while some other experienced psychotherapists may carefully and thoughtfully use paradox. Even the statement "I'm very concerned that I'm not helping you enough at this point. Please tell me if there are ways in which I could assist you which would improve our sessions." demonstrates ownership of our part of the treatment process and also models how the client may take personal responsibility instead of playing the naming and blaming game. Hope this helps a bit.

LMG

Les M Gordon commented on 'Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively - May 2009 Psychotherapy Brown Bag featured article'

2009-05-06T03:02:15Z

Thanks for the comments and questions... Regarding time management- the amount of time depends upon the intensity and frequency of significant symptoms and unwanted behaviors. The more severe, obviously, the more time is needed and must be planned for in sessions. Personally, I always calculate that at least 25% more time is necessary when dealing with children and adolescents (especially adolescents). There are always more phone calls and time required regarding school and home behaviors. Also, parents require more support. I always schedule at least a 60 minute session and ask to see the parents for 5 minutes at the beginning and end of sessions unless I do a family therapy session which will be the entire time. Often, I schedule a session and one-half when something significant is happening. I find it's very counter-productive to feel that I'm rushing families at the end of sessions. Sometimes it can't be avoided and then I apologize and tell them I will call them later. I have just come to accept that endeavoring to do treatment effectively when dealing with this population requires more time. The payoff of working with children and adolescents is that you can keep your caseload up even when the economy is stressed (because parents feel their child's mental health is always a priority) versus the additional time required. Plus, I really love working with children. Importantly, the session must be FUN for the child and INTERESTING for the adolescent or they will not come to see you- so don't forget the play and game part of therapy.

LMG

Katie Gordon commented on 'Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively - May 2009 Psychotherapy Brown Bag featured article'

2009-05-05T01:44:53Z

Mike--Sorry if this is a double post, I wasn't sure it went through the first time. Feel free to delete if it is a repeat.

Another great question. I'll respond in terms of FBT for eating disorders. Fortunately, in my experience, it was pretty rare for a family to not be interested in FBT as a mode of treatment, especially after you assured them that you were not blaming them for their child's disorder. Many had tried individual therapy or multiple other ways of intervening before arriving at our clinic, so most expected and wanted FBT. My supervisor at U of C would start early building parental confidence by saying, "Who could possibly be better than you to help your child? No one knows your child better or cares more about your child getting better than you do."

That being said, in the rare cases where there was resistance to an FBT approach, my default position was to be empathic, but firmly insist that, because AN can be a life-threatening disorder, we need to do the treatment that has the best chance of being effective, and we need to start doing it immediately (this is after the assessment stage, so starting with FBT
usually in the 2nd or 3rd session). I am more firm on my stance about this than I might be with patients with other types of disorders (becauseof the relatively greater urgency) where I might spend more time with motivational interviewing before beginning treatment. That being said, I would still use the principles of motivational interviewing in my more directive approach. I would emphasize that ultimately it's their choice, that it's not easy to do FBT, that they do have the choice of seeking another type of treatment, or seeking treatment elsewhere. I would express sympathy for how difficult it must be for them and tell them that many parents feel that way, and that I would have a hard time if I were in their position. BUT I would balance that with doing my very best to present a compelling case as to why FBT was the best approach we have, and that I believe that they can do what it takes to help their child (e.g., my supervisor at U of C would build up their confidence by pointing out how well their other children were doing, and how good they were at keeping their child physically healthy prior to the onset of the disorder). In addition, I would emphasize that I am there to help and
support with the struggles--they'll be doing a lot of the hard work, but that I was fully committed to helping them get through it. If after all of this, they still did not want to be involved, I would probably make referrals to someone else, personally, because I wouldn't feel comfortable delivering another type of treatment for children/adolescents (with the possible exception of an older adolescent who was close to living on their own, e.g., ~18) with AN(that is my personal opinion and not necessarily that of U of C's).

When it comes to bulimia nervosa, to my knowledge, the frontline treatment is less clear at this time (e.g., cognitive-behavioral therapy or FBT for adolescents),so I would feel comfortable (and have) doing individual CBT therapy with an adolescent as the main mode of treatment if the parents would not engage. However, in these situations, I would do my best to form a rapport with parents, bringing them into sessions and the treatment plan as much as I possibly could. Specifically, I would do things like ask parents to eat meals with them or try to directly address parental-child interactions that appeared to trigger bulimic behavior (e.g., try to reduce parental blame through psychoeducation, help the patient to express
to the parent how they feel about something in a functional way).

Katie Gordon commented on 'Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively - May 2009 Psychotherapy Brown Bag featured article'

2009-05-04T20:58:35Z

Jill--great question. I'll let my dad answer that one for other disorders, but with regards to FBT for anorexia nervosa and bulimia nervosa, at the U of C, the default structure was 10 minutes alone with the child or adolescent at the beginning of the session. During this time, you get their weight and ask them about any issues that they feel are important to bring up with the family during the session. Then, the remainder of the session is usually spent with the whole family addressing the highest priority agenda items (i.e., the factors that appear to be most interfering with getting the patient in remission from the eating disorder and back on a normal developmental track). However, depending on the dynamics of the particular family, other structures may be more productive. For example, Eisler et al. (2000) found that in families where there were high levels of maternal criticism toward the patient, separated family therapy (where the therapist divides a session between separate meetings for the patient and the parents) was found to work better than conjoint family therapy (where the therapist meets with the patient and the family together). For families that were not high on levels of maternal criticism toward the patient, the treatments appeared to be equally effective.

In my experience, it was not uncommon for my FBT sessions to run over 50 minutes to a full hour (which I just saw in the Eisler et al., 2000 article was how long the conjoint family sessions tended to last, while the separated family sessions tended to last 45 minutes on average).

Mike Anestis commented on 'Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively - May 2009 Psychotherapy Brown Bag featured article'

2009-05-04T16:01:33Z

Katie and Les -

For a diagnosis like anorexia, where family-based treatment (FBT) is the most empirically supported option for adolescents and children, what do you do in the face of resistance from the family or client to the use of FBT?

Is it simply a matter of using motivational interviewing until opinions shift on treatment options, do you refer elsewhere, or do you turn to less well-supported treatment options?

Jill Holm-Denoma commented on 'Including family members in the treatment of children and adolescents: Why it is important and how to do it effectively - May 2009 Psychotherapy Brown Bag featured article'

2009-05-04T15:07:14Z

Thanks so much for this great article, and for clearly addressing many important components of family-based treatment! One thing I often struggle with in family therapy is how to manage time. Specifically, I'm not sure if I should see the family >1 time each week (e.g., if the parents want to be involved pretty regularly, do I meet just with the adolescent once per week and have an additional family session most weeks?) or cut the already short 50 minute session up into chunks (40 minutes with the adolescent, 10 with the entire family?), etc. Any wisdom you can provide on that issue woul dbe greatly appreciated!