Sarah’s arrest came as a complete shock to her parents, Edward and Ellen. True, the 15-year-old had experienced difficulties for many years. Adopted when she was 2, she showed oppositional behaviors when she was 6, was placed in a special section at her school for kids with behavioral problems when she was 10, and had a long history of different counselors and psychologists. Since starting high school, she’d begun running with the wrong crowd and started smoking dope. Still, with all the therapy through the years focused on helping her learn to control her anger, Edward and Ellen thought the worst was behind them. They certainly didn’t expect a cop at the door saying that their daughter had been caught riding in a car with a group of teens who’d robbed an electronics store. This was the “last straw” for her parents, who were now considering whether to send her to a residential treatment facility.
When Sarah and her parents came to the first session, they were tense and upset. At one point, Edward stood, moved toward Sarah, and in a quiet, but seething voice said, “We’re done. I see no way out—you’re out.” He turned to me and in the same subdued, angry tone said, “We’ve already talked with a residential treatment program, and we decided that if this didn’t work, we’d send her. We want your help in deciding which one is best.”
In the first moments with this family, I felt caught between Edward’s request, Sarah’s desire to be heard, and the strong feelings in the room. Like many therapists, I want to take action to immediately to calm volatile emotions and try to make a difference. But what could I do here?
Finding a Clinical Road Map
Over the years, I’ve found that I’ve needed a solid, research-backed clinical model, which would guide me in sessions and keep me grounded during conflicted family interactions, and be flexible enough to allow me to draw on my intuition, creativity, and sense of the client.
The one I use, based on 30 years of research on the most effective interventions with delinquent and violent juveniles and their families, is Functional Family Therapy (FFT). Like other models, it provides a framework for conceptualizing the case, focusing attention on significant aspects of the client’s dilemma, relational family patterns, and history, and more important, a kind of “clinical GPS” system. It not only shows a way through rough, unmarked territory, but allows you to update decision points and recalibrate the therapy to fit changing circumstances and unexpected developments.
The core notion of FFT is that there’s a beginning, a middle, and an end to the therapeutic change process, which correlates with three distinctly defined phases of treatment: engagement/motivation, behavior change, and generalization. Each has specific goals and requires specific therapeutic skills.
I knew I needed to act quickly to get this family engaged and motivated before the session ran away without me. The clinical GPS that FFT provides told me that the first thing I needed to do to achieve the primary goal of phase 1—engagement and motivation—was to use the event in the room to reduce negativity and blame, and create a family focus. Also, I had to do it in a way that “matched” the family’s style.
The event wasn’t hard to find, so I said: “I’ve been told that all of you were very reluctant to come today, and—as you’ve reiterated—that you’re considering having Sarah live somewhere else. My guess is that what just happened is a reflection of your struggle. I respect and appreciate your honesty, but I need your assistance. Can you help me understand what goes on between the three of you that ends up with this level of discouragement?”
The initial question represented an important core principle of FFT: presenting problems are relational. The goal of the question was to pull them out of an emotional pattern that put the blame on Sarah and shift the focus to the entire family.
Sarah was the first to respond. “What a stupid question! Can’t you see, this is what I have to deal with every day?” she said belligerently. Ellen sighed and turned away again, while Edward said to me, “Now you can see why we can’t take it anymore—she’s so disrespectful.”
“It was a stupid question,” I quickly responded to Sarah. “And it comes from not really knowing how things work in this family. I may never completely understand your feelings or the struggle your parents have in trying to protect you, but what I do know is that the anger you feel gets misunderstood as your unwillingness to try, to listen, and to be respectful. My guess is that what looks to be anger is really fear—fear of losing them.” Before her parents could respond, I turned to them, saying, “And it’s probably not a lot different for the two of you. The anger behind the decision to send her away is less about wanting her gone than about the fear that you won’t be able to protect her and help her in the way your heart tells you that you should.” Again, talking fast before anyone could speak, “That’s why I’m so curious about what happens here.”
Reframing—A Therapeutic Martial Art
This kind of intervention is called a “relational reframing,” a term coined by my colleague Jim Alexander and me. This dynamic form of reframing is really the “judo” of this therapy. As in judo, the therapist “moves toward,” using the powerful emotional momentum already present in the room, to shift the direction of therapy and promote new ways for clients to see themselves and their problems.
Just like judo, reframing happens through a series of interactions, not a single intervention. With Sarah and her family, I tried several different ways in the conversation to redirect their anger toward the theme of the hurt behind the anger. For example, later, when Sarah’s father said he’d exploded with anger about a situation, Sarah gave a sharp, loud, derisive laugh. She then said heatedly that when her father, or anybody else, yelled at her, “It just makes me crazy!”
Reframing again, I suggested that Sarah’s apparently disrespectful laugh was a form of assertiveness—a requirement on the street, where she and her peers thought of themselves as tough. I thus reframed her aggressive response to her father as difficulty hearing her father as a parent, rather than as a challenging peer. Then I said to Sarah that I heard her defiance and volatile anger as pain and frustration, because her father didn’t know how to reach her except by yelling.
At that, Sarah began to cry and, through her tears, said that she’d lost her parents once (her biological parents), and she wasn’t going to lose anyone else. Sobbing, she said she knew her parents saw her as a bad kid, but inside, she was a girl with a heart.
By framing the parents’ behavior as the expression of loss, bafflement, and hurt, as well as a heartfelt desire to protect their daughter, I gave myself room to suggest that while their motives and intentions were noble, their reactions to Sarah weren’t always helpful. In other words, I could help them acknowledge their part in the problem, frame it in a way that wouldn’t make them defensive, and start to build a family alliance. This, in turn, would create a safe environment, in which all could talk about difficult issues without reverting to mutual accusations.
Encouraging and Expanding New Behaviors
Behavioral approaches to families like Sarah’s usually focus entirely on communication, problem-solving, negotiating, conflict management, and parenting, but I began by teaching the family how to interrupt escalating interactions that typically occurred when Sarah came home in the evenings. I noted that the family could prevent or interrupt escalations by first negotiating limits to when and how long Sarah would be out on the street, and then learning how to manage conflict when she came home.
The specific agreement negotiated by a family is much less important than helping them follow a process that develops and builds negotiation competence. At this point in the behavior change phase of FFT, I’m not mediating between family members or helping them forge acceptable agreements to solve specific problems, but coaching them in how to competently negotiate their own agreements.
In the three behavior change sessions with this family, focusing on their most salient presenting issue (escalation of anger around Sarah’s return home), they practiced the negotiation and conflict-management strategies I’d taught them. The goal was to help them tailor these skills to multiple situations as they came up. During the sixth session, we focused on the many ways in which the strong emotion generated by their volcanic reactions was likely to pull them back into old patterns. I reframed their discouragement when additional struggles came up—like Sarah’s continued drug use—and helped them generalize what they’d learned.
Seeing the Results of FFT
By now, the practice of negotiating issues together had helped the family internalize a sense of themselves as part of an alliance: Sarah was no longer regarded as a source of their difficulties: her problems were their problems, and vice versa. With this new, expanded sense of themselves as an integrated family unit, a team—along with their generalizable skills at working through problems together—they could become more proactive at addressing other issues in new ways. For example, I initiated a conversation about Sarah’s school and learning difficulties, and the parents, on their own, sought out the resources of the mental health center to seek a psychiatric consultation. The new psychiatrist diagnosed Sarah with an attention deficit problem—definitively ruling out bipolar disorder—and prescribed a medication, which Sarah willingly took. In addition, through the same mental health center, the family identified a specialized learning environment for Sarah with smaller class sizes, where she enrolled. The fact that the family found and made use of these resources on their own represented a milestone for them and indicated that the goals of the generalization phase had been accomplished.
After six months, Sarah was successfully meeting the requirements of the special school program, coming home close to the expected time, and taking her medication as prescribed. Better still, despite ongoing challenges, her parents hadn’t threatened to have her removed from the home: they’d become a united family, fully committed to one another.
This blog is excerpted from "From Conflict to Alliance" by Thomas Sexton. The full version is available in the May/June 2011 issue, Achieving Clinical Excellence: Do We Need a New Model?
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Illustration © Sally Wern Comport
Tags: adhd children | Children | Children & Adolescents | children in therapy | children/adolescents | family | family therapists | family therapy | family therapy techniques | healthy relationships | medicating children | oppositional children | raising kids | rapport | therapeutic alliance | Thomas Sexton