Doing Family Therapy Ch4.pdf

CHAPTER 4 In the Beginning Great Expectations a family for the first time is always so awkward. It’s easy M eeting for you to worry about what may happen: “Will the family start arguing?”; “Will they expect me to tell them how to fix their child’s encopresis in the first session?”; “What if the te...

CHAPTER 4 In the Beginning Great Expectations a family for the first time is always so awkward. It’s easy M eeting for you to worry about what may happen: “Will the family start arguing?”; “Will they expect me to tell them how to fix their child’s encopresis in the first session?”; “What if the teenager refuses to talk or stomps out?” On top of that, you’re already feeling a bit frazzled because your car decided to break down in the middle of the interstate, and then the director has just come around again, not too subtly reminding everyone how billing income is down and that, by the way, your performance evaluation is coming up next month. Ugh. But from the family’s side of the room, they have anxieties of their own: “Will I be liked?”; “Will the kids misbehave and embarrass us?”; “Will I have to talk about my abortion?”; “Is Meg going to bring up that one time I got drunk and hit her?”; “Is this guy going to think that this is all my fault?” Yes, beginnings are always difficult for everyone, and even if you’re a seasoned clinician, it’s easy to feel a flutter of anxiety when a new family first walks into the office. And as mentioned earlier, the clients of today are much different from those of 10 or 20 years ago. Through websites, television, and social media, clients are more knowledgeable about the therapy process; with online therapy shopping and telemedicine options, they have more choices and clearer expectations. With insurance restrictions, agency caps on sessions due to waiting lists, and 49 50 D O I N G F A M I LY T H E R A P Y the instant gratification of technology, they and you are often seeking quick results. And for those who have no experience with therapy or exposure to it, my experience and earlier research (Phillips, 1985) suggest that families expect to come for only one or two sessions. As we mentioned in Chapter 1, they often view therapy, especially if they have never been in therapy before, as being similar to their experience with their family doctor—walk in, describe the problem, walk out 20 minutes later with a diagnosis and a treatment plan (aka prescription), and maybe come back if the treatment isn’t working. So like it or not, there’s pressure to hit the ground running in this first session. You can’t afford to spend most of the session filling out paperwork or nodding your head and simply listening. Families have expectations: They want to feel and think differently at the end of the first session; they want to leave with something. By the time those butterflies have subsided on both sides of the room, you and the family need to begin to share a vision of what is wrong, what can be changed, and feel and believe that this therapy stuff might actually work. In this chapter, we present a map for defining the goals, tasks, and tools of that critical first session. And in the following chapter, we look at the process: how to actually conduct the first session and pull these elements together to create a successful beginning and firm foundation. FIRST-SESSION GOALS Allen and Terry come in with their two sons, Daniel, age 12, and Brian, 10. The boys are constantly at each other’s throats, says dad, are doing poorly in school, and to cap it all off Daniel was recently caught breaking into a neighbor’s house with a couple of his friends. Both parents agree that the boys haven’t gotten along since Brian was old enough to crawl, but things have been especially difficult over the last 6 months. They had tried therapy once before, a few months back, but only went one time. All the therapist did, they said, was to ask a bunch of questions; he gave no suggestions and only seemed interested in scheduling another appointment. They thought it was a waste of time. Here you have your presenting problems: poor school performance, sibling fighting, Daniel acting out. Your mind is probably already racing ahead—formulating, based on your theory—possible hypotheses and questions to ask. But before we get ahead of ourselves, what do we need to accomplish in that first session to make it a successful one? Here are our goals: In the Beginning: Great Expectations 51       Build rapport. Decide how you need to be. Create new/deeper conversations. Assess the problem and the family. Change the emotional climate in the room. Offer a new view of the problem and a preliminary treatment plan.  Assign homework. Let’s take a look at these goals one by one. Build Rapport You can ask all the smart questions in the world, but it won’t matter if Allen and Terry think you don’t understand, don’t care about how they feel, or think that you are incompetent. Rapport is the matter of cultivating the relationship, conveying competence and trust, and being sensitive to the family’s needs and fears as you gently lead them in and out of their anxiety. Without rapport, without an emotional connection to you, your clients will be too frightened and will refuse to move. They’ll shut down or not come back. Creating rapport is creating safety. Without it, there is no therapy. So how do you build rapport? Some simple techniques follow. Courtesy Address everyone by name, invite them to sit down, apologize if you were a few minutes late. Listen to what each person says, give each one a chance to speak, and show you’re listening by not interrupting and by making eye contact. Matching Body Posture, Voice Tone, Language, and Perceptual System You can mirror the body posture of the person talking: crossing legs, leaning forward. You can also match the tone: the energy of the 6-yearold, the quiet hunched-over sound of the teen. If the father throws in cuss words, throw in a couple yourself; if the mother is a scientist, talk about research findings. Use the skills of neurolinguistic programming and talk the language of each person’s perceptual system: “Allen, how do you see the problem?”; “Terry, how do you feel about what Brian just said?”; “Daniel, how do you handle it when your dad blows up at you?” 52 D O I N G F A M I LY T H E R A P Y Being Conscious of Dress Your clothing reflects an impression, like it or not. You want to appear professional, even if you are doing telemedicine, but not cause your clients to feel uncomfortable or out of place. That doesn’t mean you need to wear construction boots when seeing the dad who is a carpenter, but you also don’t want to wear the three-piece power suit unless there is a particular reason that you want to appear more authoritative. Sometimes you do (hence, the white coats of doctors), to meet client expectations, but at times you dress to bolster your self-confidence. The important point is to be mindful—don’t throw on whatever you find in your closet just because you forgot to do the laundry. Being Sensitive to Differences In recent years much has been written about culture and its impact on clinical practice. All of us know that the clients’ racial, ethnic, religious, and cultural backgrounds shape their expectations of therapy, family structure and family values, the roles of parents and their children, and the ways that decisions are made and priorities are set. Familiarizing yourself with these cultural differences is an important foundation for your work. But you don’t need an encyclopedic knowledge of various cultural values as much as a respectful attitude. This means raising differences rather than dismissing them, showing inquisitiveness and interest in their uniqueness. You can demonstrate this simply by asking questions: “You mentioned that you are Hindu [or Muslim or Jewish or born-again Christian]—can you tell me how your religious beliefs shape your family values?”; “Every family is different—what are some of the values or beliefs that you feel make your family unique and special?”; “Because I am not Chinese myself, I wonder if you can tell me how your heritage has influenced your family values.” Families appreciate the opportunity to discuss their particular view of life. By asking and listening carefully, you are showing respect for their views and a willingness to incorporate them into your working partnership. Actively Listening You show that you understand not by saying, “I understand,” which can often sound formulaic, but instead by sincerely inviting clients to explain more to help you understand—“I understand what you said, but I’m not sure what you meant. Can you tell me more . . . ?” You acknowledge the emotions underlying their statements: “Allen, it must In the Beginning: Great Expectations 53 be frustrating for you”; “Terry, you sound really worried about Daniel”; “Daniel, I bet you feel like your folks are always on your back.” Actively listening is probably the most basic and powerful means of building rapport: the fact that the individual feels heard. This is what the good family physician does when she asks what’s wrong and takes the time to sincerely listen to what you have to say. Clarifying and Setting Expectations I’ve met parents who drop their 8- or 10-year-old child off at the front door of the agency for a first appointment. When I ask the child where the parents are, she says that they are sitting out in the car listening to the radio, or they needed to go to the grocery store and will be out front in an hour to pick her up. Similarly, I’ve met husbands who imagine that you will excuse them after a few minutes and have an intimate “girl talk” with their wives to help them to be less nervous about sex, mothers who ask if you can hypnotize their daughters so they will be less obsessed about their boyfriends, or parents who expect that by the end of the first session you’ll write a letter to the school principal recommending that their daughter be readmitted. Some family’s expectations are realistic (they will need to come a few times together as a family; you’ll help them communicate better), others are not (you’ll talk with the IP, whether it is the acting-out kid, the drinking dad, or the don’t-care teen and straighten him out; you’ll tell the couple whether or not they should go ahead and get divorced); but as mentioned earlier they come with some expectations of therapy, even if they are vague or uncertain. Because faulty expectations are one of the sources of client resistance, you want to quickly understand and clarify what those expectations are so you are on the same page from the start. One way of uncovering is to ask about any past therapy experiences. Terry and Allen said they thought their last experience with therapy wasn’t helpful because the clinician only asked questions and gave no feedback. Krishni says she has been in and out of therapy for most of her adult life, the last round for 3 years. Alicia says she did family therapy with her parents when she was a teen and the parents were divorcing; she doesn’t remember much of what they talked about but remembers feeling dumb and put on the spot by the counselor’s questions. Terry’s and Allen’s impressions of their last therapist are invaluable: You know exactly what you need to do in the first session to establish rapport and keep them from quickly dropping out—not just ask 54 D O I N G F A M I LY T H E R A P Y questions but instead provide some feedback. Similarly, if your agency has a 10-session cap on treatment, Krishni may understandably have a difficult time understanding how effective this type of treatment may be. Even though Alicia is no longer a teen and may respond differently to therapy now as an adult, her negative experience has lingered in her mind and tells you that you don’t want to repeat it by putting her on the spot with your questions. Knowing about these past experiences gives you something to bounce off of—you know what to replicate or avoid and you can talk about how your style is similar or different. And of course, you can simply ask. You ask Sara if she has ever been in therapy before; she says no, and so you go ahead and explain your clinical orientation and overall approach. Or Nate says that what most attracted him to your profile was that it said you had a mind– body approach but isn’t exactly sure what that means; you go ahead and explain what it is you exactly do, what you focus on, and how you connect it to his presenting problem. Think of clarifying expectations at two levels: In the first session you are clarifying in broad strokes, a macrolevel—defining overall goals, clinical orientation, time limits, and so on, in a deliberately conscious way. You tell Allen and Terry that their past experience sounded frustrating for both of them, and you plan on giving them some feedback by the end of the session; you explain to Krishni the rationale for the time-limited treatment, and perhaps cite research supporting its effectiveness. But you are also clarifying expectations on a microlevel as the process unfolds in the opening sessions: Alicia finds that through your active listening and by the way you ask questions that she doesn’t feel interrogated or put on the spot but instead feels safe; Terry and Allen come to know your clinical style and personality by your tone and attitude and what you focus on, and from these interactions decide whether you are competent and considerate and can take the risk of trusting you and leaning into the relationship. Decide How You Need to Be By deliberately employing these various techniques for building rapport, you are creating for the family a solid foundation of connection, an environment of safety that is so essential for moving forward. But ideally, you also want to take this rapport building one step further and decide how you need to be with each person in the room. What does this mean? That you assess the emotional state of each of the family members and tailor your approach to them rather than In the Beginning: Great Expectations 55 adopting a one-size-fits-all one. If dad, for example, is angry and silent, you want to help him calm him down and get him talking, and so you explicitly say that you understand and accept that he is angry rather than pushing against it; if he seems dismissive of you, say, because of your age, you may want to increase your power by talking about your successful experience with problems such as his. Similarly, if mom seems anxious, you want to help her relax, and so you may talk about your frustrations as a parent or try joking with her a bit to reduce the tension, while with a teenager who sees you as another authority figure and seems intimidated, you may consciously slouch down in your seat and adopt a more laid-back pose. These deliberate adjustments in your presentation help change the relationship and session environment on the immediate microlevel; consider this as session first aid. But there’s another level to this: Therapy at some basic level is being the ideal parent or partner, giving people what they didn’t get or needed most—sensitivity, support, encouragement, safety, and appreciation. One of your goals in this first session is determining exactly that—what do you need to do, what do you need to avoid doing. This is not about your changing your personality to suit each person, not about being insincere or dishonest, not about getting clients to like you, but instead about being sensitive to their sensitivities, to their emotional wounds so you don’t inadvertently rewound them and cause resistance or dropping out. How do you uncover these sensitivities quickly in the first sessions? By listening and watching for transference cues: Daniel says that his father is always picking at him or you see his father, Allen, being critical of Daniel in the session. Or Terry mentions that her mother to this day seems to show little interest in her life, and she has always felt unimportant and neglected by her. Or Alicia mentions that her former therapist’s putting-her-on-the-spot questions reminded her of her parents, who did the same all the time and caused her to feel constantly micromanaged and interrogated. You now know in a span of a sentence or two how you need to be with Daniel, Terry, and Alicia: Not sound critical to Daniel and instead be supportive; actively listen, acknowledge, and show interest in Terry’s thoughts and emotions to counter her wounds of feeling unimportant and neglected; be careful about flooding Alicia with too many questions so she doesn’t feel interrogated, and explain the intention behind your questions so she doesn’t automatically interpret them as micromanaging. Hearing how family members describe past and present relationships tells you what wounds and wounding to avoid and how to best resonate with clients and avoid creating resistance. And as mentioned 56 D O I N G F A M I LY T H E R A P Y in Chapter 2, what you’re looking for and generally finding are not 20 issues but a handful—feeling criticized, micromanaged, dismissed, not heard, neglected; not being appreciated. By identifying what each individual is most sensitive to, deliberately avoiding stepping on those wounds, and providing what the person needs most, you not only help the person feel safe and able to start the treatment process, but you are creating those corrective emotional experiences that help heal. But wait, there’s more: There’s one more level of information that you can use to know how to be: noticing and responding to parallel statements in the moment. Although transference cues give you the broad-brush, macrolevel view of the relationship landscape—how you need to be overall in the relationship with a particular family member and what to avoid and do within a session—parallel statements return us to the microlevel, helping you know how to respond to what is happening in the present as it unfolds. The concept of parallel process originates from psychodynamic perspectives and is closely connected to our discussion of content versus process. Think back to any conversation you’ve recently had. On one level was the content—the topic you were talking about. But at another level, running like background software on your computer, was a simultaneous unfolding of an emotional process: Out of all the things you could have said next in your conversation, why did you say what you did? Interesting question. Perhaps the other person’s last comment stirred a memory from your past and so you find yourself bringing it up, or her tone of voice had an edge of criticism and stirred a different reaction—you found yourself choosing your words more carefully, shutting down, or getting defensive. The point here is that what may seem on the surface to be the normal give-and-take of conversation, what unfolds is not arbitrary nor simply content driven. Rather what unfolds next is always a reaction to what came before even when we are not fully aware of it. And this same back-and-forth process is particularly distilled in therapy. So Allen is talking about his brother and says, “He never listened to me,” or Terry says, “Allen never really understands how I feel.” Yes, we know we need to be careful moving forward so that Allen feels listened to, that Terry feels we understand how she feels. But looking closely at what Allen or Terry is saying on the microlevel, we wonder why Allen or Terry, out of all they each could say, are saying this? Perhaps, and it is only a perhaps, Allen or Terry was triggered by something we said that stirred some emotional reaction that was incorporated into their statement. The question for you to ask yourself is: “Am I doing something right now that causes Allen to feel I am not In the Beginning: Great Expectations 57 listening?”; “Am I doing something now that gives Terry the impression that I don’t understand her?” You don’t need to obsess about this, nor do you need to assume that your relationship has gone off course, but you may deliberately want to adjust your response. You hear Allen or Terry’s comment and make sure you are actively active listening to what Allen is saying; you do the same with Terry or ask follow-up questions about her feelings, so that she truly feels heard at the moment—you have nothing to lose by doing so. And if you notice that there is a larger pattern unfolding in which such comments are more frequent, it’s time to talk about that possible larger pattern: “I’ve noticed in our last few sessions that you’ve been saying that your brother and others in your family never really listened to you; do you feel that I do that sometimes?” “Terry, I’ve noticed that you’ve brought up again that you feel that Allen doesn’t understand you; I’m wondering if you feel that sometimes I do the same.” You matter-of-factly craft your question so they are not triggered and defensive. You may get a yes or no answer. If yes, you know what to do next; if a solid no, you can move forward. But regardless of their answer, you are taking an active step in fixing potential problems in the clinical relationship, doing now what Allen’s brother is not doing with Allen or Allen is not doing with Terry. You are deliberately being sensitive to possible rewounding, modeling for clients how to do the same, and repairing and creating a corrective emotional experience. Create New/Deeper Conversations There is nothing that could be more exasperating for a family than to spend 15 minutes filling out forms, and then another 35 minutes answering question after question, some of which seem to them unrelated to the problem (“So how do you get along as a couple?”; “Any complications during pregnancy?”), only to have the therapist suddenly look at his or her watch and say, “Wow, looks like we ran out of time. Let’s continue this next week. How about the same time?” This was the experience of Terry and Allen: As soon as they hit the hallway, they’re thinking, “Continue what? Wasting my time?!” No surprise when they don’t show up the next week. To say you need to create new, deeper conversations means you are starting treatment in that first session. We all learn about assessment and treatment—Act 1, Act 2—one following from the other. Even though this order seems to make logical sense, it’s better to think of treatment as not coming after assessment as much as running alongside it, such as building rapport throughout the session or deciding 58 D O I N G F A M I LY T H E R A P Y how you need to be. But so is asking Allen to say something positive to Daniel in the session: not only are you beginning treatment by having Allen offer Daniel something Daniel needs, you are at the same time assessing—seeing how willing Allen is to follow your suggestions, how difficult or not it is for him to treat his son differently, and whether switching from nagging to praise has an impact and changes his son’s reactions. Similarly, by giving a family a homework assignment, you are not only continuing treatment in the home by asking them to approach old problems in new ways, but you are also simultaneously finding out what clinical options work or don’t work with this particular family, much like your doctor does when she learns from you that the drug she prescribed isn’t working. Your starting point is focusing on the basics. You determine who has the problem and what it is: Terry is worried about Brian, Allen is mad at Daniel, Daniel is upset about school. You block the dysfunctional patterns: If the parents complain that the boys are fighting too much at home, you don’t allow the boys to argue for long in the office, nor have the parents repeat over and over again their ineffective way of handling it. You ask questions about what’s missing: “Terry, you mentioned ‘things’ in the past—what kinds of ‘things’ are you talking about?”; “Allen, you’re understandably focusing a lot on Daniel—can you tell me something about Brian?” You carefully track the process by asking Allen and Terry to describe how they each handle Daniel and point out how easily they disagree. You go where they are not by being bold, by having the courage to ask the hard questions and challenge their well-worn stories and assumptions, by moving into areas that in everyday conversation they probably think about but are afraid to bring up: “Do you feel that your differing parenting styles are affecting your relationship as a couple?”; “Are you afraid that Daniel will continue to struggle as an adult?” You seek to create an experience by asking Allen to sit next to Daniel and express to him his worried feelings about the break-in. Throughout it all, you demonstrate honesty and leadership to help everyone feel safe so that your silences are not mistaken for consent. And if you do this, the family learns that therapy is not about laying a problem on your lap and waiting for a solution, but an active process where all of you work together as a team, with you in the lead, to solve problems. By creating these deeper conversations, you begin to change the story that each holds on to, and you create the vision of what can be, countering their fear that things will always remain the same. They begin to see change unfolding before them. In the Beginning: Great Expectations 59 Assess the Problem and the Family Deeper conversations are the beginnings of treatment and the medium for assessment. In the course of family therapy you will shift back and forth between (1) time spent in sessions finding out about something you need to better understand the problem and develop or fine-tune a treatment plan (for example, a child’s school history, why the parents got divorced, the grandmother’s problems with depression, how well the behavioral chart worked last week) and (2) time spent within the session helping the family reach its goals: providing information about the problem, helping them learn and practice new skills (for example, Allen listening to Daniel instead of criticizing, an older daughter staying out of the fights between the parents); gaining new insights (for example, helping the mother see how she is treating her oldest daughter more like an adult friend than a teenager); and providing a safe environment so that the couple can discuss issues important to them (for example, deconstructing the weekend’s big fight or the couple’s sexual problems). Most of what you do, especially in the middle stages of therapy, will be of the latter type—helping the family reach its goals—whereas most of the information gathering takes place in this beginning stage. However, deciding what you need to know and finding it out can seem overwhelming. The specific information you need to assess the presenting problem will depend on your clinical orientation and treatment map for that problem, but next are some generic but key questions to ask yourself about any family and their implications for treatment. What Keeps This Family from Solving These Problems on Their Own? One of our goals is not only to help solve the problems the family members present but also, and more important, to help them learn to solve their problems on their own. Asking how they get stuck solving their own problems at the beginning keeps this goal on the front burner, and your tools for assessing this are the several that we’ve already discussed: Sorting what are individual learning problems—skills that individuals or families lack—and problems about learning—those situations where emotions override their skills; comparing and contrasting what they present and describe against our self-differentiated, adult model to determine where their faulty problem-solving process interferes with their success. 60 D O I N G F A M I LY T H E R A P Y A logical starting point is looking at skills that families have or need. Eight-year-old John was recently diagnosed with ADHD and placed on medication, but the physician suggested the parents see you for help with everyday management, and the parents admit that all this is new territory for them. And so you follow your treatment map for ADHD and talk about setting a clear structure and routines at home, about defining expectations in advance, such as talking with John before going into Walmart about how he needs to behave once inside, about proactively coordinating homework assignments with his teachers in case John gets scattered and doesn’t remember what he needs to do, and so on. Sometimes you find that families have a solid base of skills but realize that these skills need to be tweaked: Susan’s clear structure and expectations work fine with her 7-year-old but don’t carry over as well with her 13-year-old who is more independent and easily feels micromanaged; Jake’s combination of Alcoholics Anonymous (AA) meetings and increased exercise has helped him maintain his recovery, but you suggest that increasing the number of weekly meetings, as well as scheduling regular check-ins with his sponsor, may help him build a more solid foundation for his recovery. Once you’ve evaluated skills, you can turn to assessing problems about learning, about the impact of emotional wounds, about stuckpoints and faulty processes, and again clients may quickly let you know what you need to know. Fasil says he feels proud of his parenting, but admits that when his 14-year-old daughter begins to roll her eyes when he asks her to do a simple chore, he becomes enraged; Sonya says upfront that she tends to be laid back about the children’s schoolwork and grades, but when her son gets frustrated and just digs in his heels and stops trying, her frustration hits the roof; Matt admits that he has always had trouble with any confrontation, or that he knows he is self-critical. Here you drill down to sort out the source of these emotional triggers: You find out, for example, that Fasil grew up in an Iranian family where children’s obedience was expected and where there was no tolerance for any defiance; Sonya says that she has always worried about her brother who was the “quitter” in the family and now is struggling as an adult; Matt’s father was addicted to alcohol and remembers that he was frightening when he was drunk. Fasil is trying to reconcile different family and ethnic cultures; Sonya is understandably pained by the struggles her brother is having and probably fears that the same may happen to her daughter; Matt learned to cope with his father by walking on eggshells, being the “good” child, and tended, as children In the Beginning: Great Expectations 61 do, to blame himself rather than his dad for problems and eruptions that arose, which continues to this day. You share your thoughts and see if they resonate with the clients. But sometimes sorting out where and why families get stuck solving their problems is not so clear. Is Harry, for example, struggling with his teenage daughter because (1) he doesn’t know how to effectively shift his parenting and communication style to accommodate the changing needs of his teen or (2) no, he has the skills, but when his daughter gets explosive, Harry, who has a history of being in abusive relationships, gets emotionally triggered and battles with her more as an adult than as a parent? Similarly, are Allen and Terry having trouble getting their children to bed because (1) they don’t understand the importance of routines or (2) when Terry is out of town on business, the children whine, push Allen to let them stay up later, and he gives in? Skills, emotions, and old wounds, or both? Again, you don’t have to know the answer, but you ask yourself the question and then ask them: “So, Harry, you both argued yesterday about what your daughter was going to wear to school. I’m wondering why. Does this happen every morning? Do you feel, Harry, that you should have a say about what your daughter wears to school, or was yesterday different? How? Why do you think this issue turned into a big argument? Why is this one issue particularly important to you?” Or “It sounds like you both agree that the kids should have a set bedtime, but, Allen, it sounds like when you are home with them on your own, they begin to give you a hard time and push to stay up later. I’m wondering why. Do you maybe feel that bedtimes don’t need to be so set, or is it something else—that their whining rattles you and you give in, or that when Terry is away you don’t have to be so strict, or that overall are confrontations difficult for you?” You can even say, “I’m asking these questions, because I’m trying to figure out what triggers this problem and where you get stuck.” Now you wait and see what they say next. If it turns out to be about parenting skills, you can provide some education and give specific steps to put new behaviors in place. If it is more about emotional triggers, take the time to unravel them: What does Harry begin to feel and think when his daughter gets angry; is it triggering his old childhood wounds? What about the whining rattles Allen so much—does he think about rules and routines differently when his wife is not there, or are strong emotions and any confrontation one of his stuckpoints, his Achilles’ heel, that keep him from being more “adult”? Your orientation and treatment maps help you decide what paths to explore and what questions to ask; the answers come from the family. 62 D O I N G F A M I LY T H E R A P Y How Well Can the Family Members Communicate with One Another? While a communication breakdown can lead to a breakdown in problem solving, you also want to stop and look at the family’s overall communication skills and styles. Obviously, lots of screaming is not good, nor is shutting down, turning away, stomping out, or pointing and waving fingers. Can the individuals regulate their emotions—realize when they are escalating and have ways of calming themselves down? Can they circle back once they are calm and have productive conversations that help each other understand how they felt, why they were upset, and come to some resolution? Your job is to assess by watching, asking, educating, and teaching skills—letting everyone speak, not interrupting, making “I” statements, talking about feelings rather than facts, and so on—and by politely pointing out to the family members when the conversation is going nowhere and turning into a power struggle, by pulling them out of the muck of facts and getting the conversation back on the track of problem solving. By changing the process as it unfolds, you are changing the content, and as you change both you are helping them solve the problem right there and teaching them how to more effectively communicate and solve problems. This facilitating of good communication in the first session is often a priority: a sign of your leadership and the first step in treatment. What Is the Family’s Emotional Range? This is another case of looking for what’s missing. The ability to express a wide range of emotions is like having a full scale of notes upon which we create the melodies of our lives. For many of us, however, our range is limited, and some of us are truly one-note Johnnies (for example, I’m sad, I get angry; I’m frustrated, I get angry; I feel lonely, I get angry). Our emotional flexibility is shaped by social and cultural norms (men don’t cry, women aren’t supposed to get angry) and by the models we absorbed in our childhoods within the family. Often emotions are suppressed or distorted through drugs or alcohol, acted out (for example, spending too much money, having affairs), or shrouded in an ever-present cloud of anxiety. Having a limited emotional range, like a limited verbal vocabulary, can cause others to misinterpret you or not understand what your inner world is like. In a family session, you may see emotional range spread out among the various family members—for example, dad only gets mad, In the Beginning: Great Expectations 63 mom always cries, Jake is disruptive in class, or Emily gets depressed— where each relies on his or her own comfortable emotion, and only together is the family able to complete the emotional scale. Often one person’s designated emotion serves as a vicarious outlet for one or more of the others: Mom’s easy tears express vicariously for dad his inexpressible deep sadness, Jake’s open hostility toward his father allows his mother to vicariously express her rage toward him as well, or the children’s intense sibling rivalry dramatizes the parents’ subtle but real marital tensions. The need for and dependence on these indirect emotional outlets can be strong and difficult to give up. Even when the consequences are negative (Jake and his father have an awful relationship), the person needing the emotional outlet will subtly reinforce them, locking the family members into unhealthy patterns. Simply asking who feels what or observing the process will tell you what’s missing in each person’s emotional life and in what ways the emotional range of each needs to expand. Your next step may then be to close off the vicarious outlets (Jake and dad avoid fighting) to enable the others to experience and label their emotions directly. All this wading into new emotions can raise everyone’s anxiety, including your own. As new emotions begin to bubble up, the family’s reaction will be to ignore, criticize, or analyze them to death. What these new emotional sprouts need most are recognition, space, and nurturance by you. Let the others know that it’s okay, that they don’t need to be afraid of mom’s outburst or dad’s tears. Model good listening, waiting, compassion, and positive feedback for taking the risk; allow the process to unfold. By once again demonstrating the simple courage of moving against your grain, you help the family see what new experiences can emerge. Are There Cracks in the Family Structure? As we mentioned in the last chapter, one of the ways your family doctor assesses your presenting problem is by comparing your signs and symptoms against a healthy norm. She checks your urine and finds out that your pH is higher than it should be, or takes your blood pressure and finds that it is 30 points above the normal range. By having a healthy range to measure against, the doctor has a starting point for diagnosis and treatment. You are doing the same on the individual level when you compare the individual family members against Bowen’s differentiated self, but you can extend this concept to the entire family unit by comparing what you see in the room against a healthy family structure. For a 64 D O I N G F A M I LY T H E R A P Y simple and effective resource, we can turn to structural family therapy models (Minuchin, 1974). Here’s our model of a healthy family: P P C C The parents are represented by P and the children by C. There is a hierarchy, in that the parents are on top having more power and control, the children are on the bottom having less, and the solid line in between indicates that there is a clear boundary between the adult and child worlds. The solid line between the parents indicates that they have a solid adult relationship and that they are on the same page in terms of parenting. Even though their styles may be different, they agree to expectations, consequences, and so on in managing the children. And if the family structure consists of a single parent, the same hierarchy is still in place. Finally, the solid lines between the children mean that even with age differences and some amount of sibling rivalry, they can get along and can support each other. But here are a few less healthy variations: P P C C The dotted lines between the parents indicate that they are not working together as a team, are on different pages regarding parenting, and in extreme cases are polarized, in that one parent who is strict causes the other parent to compensate by being overly lenient. This situation can occur in intact families, but also between divorced parents. What happens in these situations is that the children are constantly testing because expectations are not clear or are playing one parent against the other to get their way. What needs to be fixed to bring them in line with a healthier model? The parents need to work together as a team, even if they are divorced. P P C C In this scenario, the vertical line between the parents indicates that they are disengaged, and the move of one child to the parent’s side In the Beginning: Great Expectations 65 indicates a surrogate relationship. Here we could imagine one parent using a teen as a confidant and treating her more like an adult; the hierarchy is broken and the teen then feels entitled. Often, too, the other parent may have his form of solace or support—in an affair or an addiction, such as pornography, alcoholism, or workaholism. Again, what needs to be fixed? The walls in the parent relationship need to come down, and the child needs to be bumped back down to the child group. P P C C What we see here is that one parent is alone and in charge, and the other parent is joined below with the children. Essentially this onedown parent has no power, feels dismissed, and is treated as one of the children. Because the parent is being treated like a child, he feels like a child, and the children come to treat this parent as a peer. Sometimes the disempowered parent will be a ringleader for the children, leading periodic attacks against the other parent. Although the controlling parent has power, what the diagram clearly shows is that she is isolated and alone. What needs to be fixed? The other parent needs to move up and regain power, and both parents need to work together as a team and have a good adult relationship. C P P Finally, in some ways, this is a worst-case scenario. Here there is neither a parent nor parents on top but a child or usually a teen, who is emotionally and/or physically running the family. Sometimes this occurs because the teen is filling in for incapacitated parents—there may be severe illness or addiction that keeps the parents from fulfilling their roles. In the more dysfunctional version, the child acts out, sets the emotional tone, the parents feel helpless, and the teen feels entitled to do whatever he wants. What needs to be fixed? In either scenario, the child needs to be bumped down. If the child is filling in for the parents, often some sort of foster care situation needs to be created for the child to reduce her responsibility, or the parents need to get the outside support or treatment they need to fulfill their roles as caretakers; if the child is acting out and entitled, often the courts need to get involved to both put limits on the child and back up the parents. 66 D O I N G F A M I LY T H E R A P Y So, like your physician, you compare in the first session what the family presents against where they need to be. You take into consideration cultural and ethnic differences—a father’s or mother’s more dominant role, for example, or that they seem more child centered than what you would expect based on their values—but then look to uncover how their structure may fuel their presenting problems. And then you can ask questions to drill down to determine where the gaps lie. Here are questions to ask yourself and them; the comments in brackets and italics reflect the underlying rationale behind the question:  Even though their styles may be different, do both parents agree on rules and expectations for the children? Are there areas they disagree about? How do they handle them? [Are they presenting a united front, and if not, where and what are the effects, and why?]  Do they describe themselves as being polarized with one tending to be more lenient because the other is so strict and vice versa? [Not only are they able to work together as a team, but they are also aware of whether or not they can do that, showing self-awareness about the larger dynamic between them.]  Do the parents say they have no time for each other, are child- or work-centered, or seem disengaged from each other in the room? Are they motivated and able to make time to do things together as a couple? [What is the quality of everyday life? Is their couple relationship important enough to make it a priority? If not, why not?]  How do the parents feel the children are getting along with each other? How do the children feel they are getting along with each other? Are the children kind to each other, or do they bicker or jockey for parent attention? [Sometimes parents are overreacting to what may be more normal sibling rivalry. At other times, the siblings are honestly struggling with each other and feel they have no support from the parents or parent. How well the siblings interact not only lets you know if one child is feeling more neglected or one child is more favored, but also is a barometer of the overall state of the parents and the family.]  Do one parent and the children gang up against the other parent? [The structural problem, where one parent is unempowered and sides with the children against the other parent.]  Is there one child who is driving the session process, and the parents seem unable to contain her? [Is one child entitled, or are the parents struggling to manage their everyday lives.] In the Beginning: Great Expectations 67 What Is the Family’s Theory about the Cause of Their Problems? Just as families have some expectations of the therapy process, they usually have a theory about the cause of the problem they face, even when they say at first that they have no idea: it’s biological (“He had a lot of high fevers when he was a baby, and I think it caused brain damage”) or genetic (“He’s just like my uncle who acted the same way”); it’s because someone else doesn’t like the family (“The school’s got it in for us”); it’s the result of some past trauma (“Our house burned down last year”), past karma or God’s punishment (“I’m being punished for having an abortion when I was a teenager”), poor parenting (“She lived with her father who never had any rules”); or something else. We all instinctively create some explanation for our problems, rather than live with the uncertainty of having none. Finding out in the first session the family’s theory or theories about the problem is important, because they tell you where the family believes the solutions lie. Terry’s belief that the boys are doing poorly in school because the teachers don’t like them is a very different theory about the problem than if she thinks it is because she doesn’t spend enough time helping them with their homework or if she feels they have an undiagnosed learning disability. From your perspective as a family therapist, your challenge is to expand the definition of the problem to include the involvement of the entire family, offer new ideas to reshape their theory, and experientially connect the problem as they see it to the patterns within the family. Knowing their theory gives you the starting point for linking their ideas with your own. Finally, we can combine the concepts of family structure, expectations, and theories to describe some of the most common family presentations. Here they are, along with their characteristics, your clinical goals, and, to be effective, the traps you want to avoid (what not to do) in order not to replicate the dysfunctional patterns. THE “FIX-MY-CHILD” PARENTS Characteristics: Parents present a united picture of the identified child as struggling with individual problems that are impacting the family. Parent expectations: Because they see the child as the source of their problems, as well as the family’s, they expect you to work with the child individually and “fix” her. Goals: Help the parents see how they are part of the problem and the solution. Engage them by initially talking to them in the language 68 D O I N G F A M I LY T H E R A P Y of the child’s problem (for example, “What do you do when Frank gives you a hard time?”); assess the child; help parents see the child’s behavior in a new light (for example, educate them about ADHD) or as the outcome of a larger family process (it seems like Frank feels constantly criticized); empower parents to be change agents within the family. What not to do: Do only individual therapy with the child beyond the initial assessment. THE ENMESHED VERSUS DISENGAGED PARENTS Characteristics: In these families, one parent is overly involved with the children, is supportive, and has difficulty creating structure or setting limits—that is, the parent is enmeshed. The other parent seems distant and aloof, may be a heavy-handed disciplinarian, and struggles to be supportive—that is, this parent is disengaged and distant; the parents are often polarized. Parent expectations: If the enmeshed parent comes in without the partner, he wants your help managing the children when the other parent is not there or uninvolved. If the parents come in together, they argue, the enmeshed parent wanting you to convince the other to be less strict, the distant parent wanting you to tell the other to be firmer. Goals: Bring both parents into the therapy process. Help them see how it’s not the other parent who is the problem, but their differences and polarization. Work toward improving their relationship and creating a united front. Change the roles: Help the distant parent support the other in setting boundaries, encourage the strict parent to be more nurturing. What not to do: Re-create the family structure and polarization in therapy—that is, ignore the distant parent, re-create the disciplinarian’s role in the session as the limit setter of the children, and leave the other parent unempowered, or side with one parent rather than helping them both work together as a team. THE OVERWHELMED SINGLE PARENT Characteristics: Chaotic family, little structure or consistency, often the parent has a history of abuse. The parent believes that the children have individual problems or are simply out of control, and doesn’t know what to do. Parent expectations: Look to you to assess and treat the children and/or create structure, enforce rules, and reduce chaos. In the Beginning: Great Expectations 69 Goals: Rather than taking over, you want to empower the parent through skill building and support. Help the parent divide problems into more manageable segments, and help reduce environmental stressors so the parent is less overwhelmed. What not to do: Take over and rescue the parent. This can create unreasonable dependency on you, and you can become overwhelmed yourself. THE TRANSITIONAL FAMILY Characteristics: Essentially a combination of the dynamics of the enmeshed/disengaged parents and the overwhelmed single parent. The disciplinarian leaves the family, and the remaining parent struggles to create structure; one of the children—the oldest, the one who identified with the disciplinarian—steps up to replace the missing parent but has broken through the hierarchy. She then feels entitled, is emotionally running the family, and may even be abusive toward the remaining parent. Parent expectations: Have you rein in the entitled child. Goals: Develop limit-setting and structure-setting skills in the parent so he can take charge and the entitled child can step down; facilitate grief over the lost parent; help the entitled child find a new, healthier role within the family. What not to do: Replace the missing parent’s role in disciplining the children. THE CRISIS FAMILY Characteristics: The family easily feels victimized by life events, takes a reactive stance to problems, and often has an “us versus the world” mind-set. Parent expectations: Help them manage the current crisis. Goals: Because they are usually distrustful of the outside world or have learned to use others in a manipulative way, you want to initially build trust by encouraging the family to contact you when in crisis; because they often have a black-and-white perspective (“Either we’re in a crisis or we have no problems”), you want to help them learn to recognize the early signs of problems and help them to be proactive and address budding problems before they reach a crisis point. What not to do: The dangers here are that you work harder than the family, that you create dependency by maintaining the on-call rescuer 70 D O I N G F A M I LY T H E R A P Y role for crises; your reactive role replicates the family’s reactive role and you wind up feeling in crisis yourself. THE REFERRED/NO-PROBLEM FAMILY Characteristics: Another agency defines the problem, mandates therapy; the family is openly angry or passive-aggressive. They feel they have no problem or that a situation was blown out of proportion; they often feel victimized by the larger system. Parent expectations: To agree with them that the problem isn’t a problem and therapy is not necessary. Goals: Be clear about your role, that it is separate from the concerned agency, that therapy is a means to a larger end that the community is concerned about; have the referral source clarify concerns; explore treatment options and consequences; find a problem and/or goal that the family is willing to work on. What not to do: Be the enforcer for the referring agency. You will find some variations on these common presentations, and we talk about some of them later in more detail. The theme they all share is the expectation that you will fill in some hole in the structure or take charge and manage a problem—do what they cannot—rather than your helping them learn how to do this themselves. By quickly defining the family’s expectations and theories, reshaping them, and being aware of what you need to do to avoid replicating the problem, you can then support the family members in learning the skills they need to be more successful in managing their life together. What Are the Individuals’ Stuckpoints and Mental Health Issues That Keep Family Members from Being “Adult”? Although family therapy is not individual therapy, families are made up of individuals, and as we discussed in the last chapter, you always want to assess individual coping styles and obstacles that may get in the way of moving forward as a family. Here you want to look at obvious faulty coping styles and stuckpoints: Terry struggles with regulating her emotions, Allen with managing conflict; their individual struggles impact their ability to parent and problem solve, and not only help create the couple’s and family’s emotional climate, but likely seep into their outside relationships, such as work, as well. In addition you want to also look at individuals through a more formal clinical lens and be alert to clear mental health issues that may be undiagnosed or In the Beginning: Great Expectations 71 untreated, such as struggles with addiction, severe depression or anxiety, ADHD, bipolar disorder, eating disorders, posttraumatic stress disorder (PTSD), and severe obsessive– compulsive disorder (OCD). As we discuss in the next chapter, it is important to assess and decide whether further evaluation is needed by a specialist, whether individual treatment is necessary, whether these individual problems supersede the focus on the family and need to be addressed before moving forward, or whether these individual issues can be incorporated into the overall family treatment. What Are the Family’s Strengths? With so much of the focus on problems and dysfunction, it’s easy to overlook your other partner in healing, namely, the family’s strengths. When we think of strengths, we often think of the obvious—they are economically stable, show insight and compassion, have external supports—the hold-the-line grandmother, the concerned teacher, the church group that is more like an extended family. But often the simplest and most potent sign of strength is that the family comes to see you: They are willing, albeit in varying degrees, to sit together in your office and talk to a stranger about their worries that their children will struggle as they did or that their childhoods will somehow haunt those of their children. They sit with the hope that things can be better. Not surprisingly, they often cannot articulate or define these strengths. The tunnel vision owing to their problems and depression and the expectation of your judgment get in the way. But you can see what they cannot, you can articulate their strengths, and this is one of your jobs, to underscore what they are doing well, to draw out those stories of resiliency, define the good intentions beneath the not-sogood behaviors, and commend them for their willingness to reach out for help. By affirming them, you are building on the small but decisive step that they have taken. These seven questions are some of the key areas you can explore in that first session; other questions or variations may arise from your theoretical approach. Taken all together they form a foundation for developing and confirming your initial hypothesis and setting treatment goals. While this information may seem like a lot to gather, much of what you need to know about these questions will come from simple observation and listening; what is left, you can ask about directly. What you want to avoid is getting swallowed up by the family’s content, and for that you need both a frame for viewing the dynamics and leadership 72 D O I N G F A M I LY T H E R A P Y in shaping the process. With practice and growing confidence, your ability to cover this ground will become easier. Change the Emotional Climate in the Room If building rapport sets a foundation of safety, then creating deeper conversations and asking specific assessment questions begin the treatment process by providing the family members with new information about one another and the therapy process, and in turn, changes their perspectives and moods. But it is useful to have as a goal that of intentionally changing the emotional climate—creating those new experiences, unlocking new emotions—so that they truly feel different when they walk out from when they walked in—and in turn feel connected to you and the therapy. It helps to think of therapy, especially in these early sessions, as performance. As we discussed in earlier chapters, you cannot avoid creating an impression about both you as a therapist and about the therapy you do. To think of therapy as performance is to be conscious, deliberate, and proactive in shaping that impression. You are already doing it as you consciously build rapport. Now as you progress through that first session, you have opportunities to further shape the process and change the emotional climate. Here are some of the common climate-changing techniques you can think about ahead and proactively use within the session. Noting and Responding to Transference Cues We’ve already talked about how to use transference cues to know how to be and what not to do: Don’t treat Daniel like his critical dad but instead treat Daniel in the session the way Allen struggles to be—be more compassionate, more actively listening; be gentle and understanding toward a mom who never feels understood or supported by a partner; give positive attention to that “lost child” quiet sibling who says little in the session and always feels upstaged by his acting-out sib. You listen for cues, you observe, you choose how to be so you don’t intentionally trigger old wounds and replicate dysfunctional patterns. Tapping into Softer Emotions through Content One of the simplest but effective ways of changing the climate in the room is by uncovering softer