Oftentimes, families enter therapy by way of one child--the identified patient. In this scenario, parents often expect their child to participate in therapy alone, which goes against the foundation of systemic treatment. Inviting families to, and working with them in, therapy has been the topic of this three article series.
In parts one and two, you learned how to engage every member of the family, stay mindful of your triggers, support children's voices in therapy, and partner with parents and colleagues. Now, in part three, I focus on your ongoing tasks in systemic treatment, which will lead to the final guideline for working with children in family therapy (guideline number six).
Assessment as Intervention
Many of your most important tasks in family therapy require vigilance and consistent use. For example, joining, assessing ages and stages (see guideline #3), utilizing resources, as well as noticing and highlighting change are therapist responsibilities that do not end.
Assessment, in general, is also an ongoing task. It is woven into joining, intervention, and therapeutic conversations. As you follow your curiosity about clients, you learn more about them. The new information will likely tie into ideas that are relevant to therapy, whether the family is in the beginning, middle, or end stages of treatment. Ongoing assessment is what brings context and reveals larger themes relevant to the therapeutic process.
In addition, assessing the problem, the goal, and family patterns on an ongoing basis will help you stay out of content and work within the larger dynamics of the family.
Assessing the problem
In part two of this series, I mentioned that before beginning therapy, parents have often tried other avenues to solve the problem. Ask about these efforts.
What have been the attempted solutions?
What did these attempted solutions yield?
Ask these same questions as parents and children employ new strategies in their work with you. Make evaluation an ongoing task.
In addition, assess:
What is the history of the problem? (including frequency, severity, etc.)
What are the exceptions? (i.e., when is the problem not a problem, or not present?)
What is every individual family member's definition of the problem?
What patterns are noticeable in the family system?
patterns of response to the problem
What do family members believe about the identified child?
Is the problem the problem, or is the child the problem? In other words, have family members tied the problem to the child's identity?
As is clear from these questions, assessment is itself intervention. As you learn information, you have the opportunity to address it in ways that generate hope, clarity, and connection for the family.
Rather than being a checklist of techniques you do in the therapy room, systemic treatment is a process of interacting with the family. In order to engage in the process, adopt questions as your craft and remember that language is both revelatory and mobilizing (for both you and the family). Language is our best tool.
Systemic interventions require observation, listening, trust, and flexibility, because they are often formulated in the moment--in response to what is happening. The spontaneity of this therapeutic dialogue allows both you and the family to manage and integrate the differences between family members.
Systemic interventions that can be used on an ongoing basis in therapy include:
The circular question. Circular questions are used to help define the problem, understand interactional sequences, assist family members in comparing and contrasting each other's behavior, and they are used as interventions. Circular intervention questions ask one member of the family to comment on the relationship between two others. (Fleuridas, Nelson, & Rosenthal, 1986).
Externalization. Externalization is a Narrative Therapy technique that localizes the problem outside the person, and then, oftentimes, personifies the problem. The behavior has a life of its own and has defeated the child as well as the family (White, 1984). Once the problem has been externalized, and the family has adopted this new view of the problem, work to change family members' orientation to the problem from one of defeat, anger, avoidance, etc., to curiosity (White, 1984). Family members become investigators on a quest to understand the problem, including its whereabouts, habits, goals, among other characteristics.
Reframing. Expand the family's view of problem behavior by reframing. Simon and AliceVeter-Zemitzsch (1985) discuss three different types of reframes: highlight the problem, relabel a role to change it, and positive reframing.
Further, context and meaning reframes re-interpret family members' set beliefs about a behavior, by offering alternatives. For example, for context reframing, ask yourself:
What else could the behavior mean?
When is it/could it be a resource rather than a problem?
For content reframing, the behavior stays the same, but the meaning changes. For example:
The art teacher calls the parents because their daughter's artwork has taken a "dark turn."
A content reframe re-interprets the child's "disturbing paintings" as "her only safe way of expressing her emotions." The reframe moves the behavior from "concerning" to "healthy."
Once behaviors are reframed, and family members' beliefs about behaviors begin to shift, engage the family in concrete behavioral change. When the behavior's power weakens for the family, through circular questioning, externalizing, and reframing, family members begin to regain their power (or their sense of having power over the problem). They are then ready to use their newfound teamwork and understanding to create change.
Which brings me to . . .
Guideline #6: Once family and environmental problems are addressed, behavioral problems will diminish (Sells, 1998).
Successful systemic treatment relies on your belief that it is most effective to work with and within systems, rather than with individuals.
Your initial instinct about whether to divide families into individual sessions or meet with them as a family unit may reveal your belief about systemic work. However, it's not that simple. Therapists can meet with entire families and work as if they were working with individuals. Therapists can meet with individuals and work systemically.
So, systems work is not so much about who is in the room, as it is about how you are working. Are you placing the individual client within his/her systems (in your mind's eye) and intervening accordingly? Are you assuming the problem isn’t native to the child, and rather, is created and maintained in patterns of interaction?
Systemic work, as mentioned in part one, requires and promotes the belief that problems do not reside within individuals; they are created and maintained in interaction.
Family therapy is a complex process of putting problems in context, expanding those contexts, mobilizing resources, creating connection, all while genuinely empathizing and joining with family members. It's no easy task. On the other hand, there is nothing like knowing you've made a difference for a family's intergenerational patterns. Your work, in combination with the family's work, will change their genogram for generations!
Do you invite the entire family to therapy when a child is the identified patient? Why, or why not?
Fleuridas, C., Nelson, T. S., & Rosenthal, D. M. (1986). The evolution of circular questions: Training family therapists. Journal of Marital and Family Therapy, 12(2), 113-127.
Simon, D. J, & Veter-Zemitzsch, A. (1985). Strategies for the resistant adolescent. In M. K. Zabel, TEACHING: Behaviorally Disordered Youth (pp. 17-22). Retrieved from https://files.eric.ed.gov/fulltext/ED264706.pdf#page=23