Setting the Course for Family centered Treatment
by F. Dave Williams, MSW, LCSW

As a counselor who works with children and adolescents, I have found that the more a family is empowered with education and support at the onset of counseling (upon intake), the less resistance the therapist faces during the various phases of treatment. This article describes some techniques for setting the course for family centered treatment.

Not everyone seeking counseling knows what family centered treatment is; nor are they aware of how family centered treatment will unfold in terms of the counseling process. During the initial interview, it is common for parents to describe their child’s behavior within the context of the child’s relationships with others (friends, parents, siblings, teachers, coaches etc.). Therefore, it is critical in that first meeting to educate both the parents and the child as to how family dynamics can impact a child’s behavior, which highlights the true need for family centered treatment. Parents learn how family dynamics can present difficult challenges for their child. They also learn that, within the same family dynamics, many resources and strengths exist, which can be cultivated to better leverage positive changes. This education for parents and other family members is invaluable because it sets the therapeutic tone and allows members of the family to understand their critical role in promoting the change process.

Frequently, it is important during the initial session to let parents know that the counselor may ask to see them without their child present and may also need to know more about their marriage, when appropriate. There may be a need to see all of the family members in different groupings, which could include siblings and even extended family members who are involved and/or residing in the home. It is important that counselors attempt to establish the nature and extent to which family dynamics are negatively influencing the child’s individual functioning and determine if there are any unknown stressors that could be damaging to the child if not addressed. The counselor should also seek out untapped resources that exist within the family system and work to identify and mobilize them for the family. Once these dynamics are assessed, a plan is developed in collaboration with the family.

Members of the family often need to be comforted early on and reminded that family centered treatment is most effective when members are committed to doing what works - not just what is comfortable for everyone. Many times, parents have to be convinced that their child’s behavior isn’t occurring in a vacuum and isn’t likely to be assessed, understood and changed in a vacuum.

The Story of Bill
The story of Bill illustrates a situation in which a child was brought for services and was initially opposed to the idea of family centered treatment. His parents were also resistant to becoming involved in their son’s counseling. Despite several attempts to initially educate them as to the need for a family centered approach, Bill and his family resisted.

Bill was a bright but guarded 12 year old who was failing at school, acting out at home, depressed and had recently made suicidal threats. During the first meeting with Bill, he reported that his father had been abusive both physically and emotionally toward him for many years. His mother was a victim of domestic violence at the hands of her husband and, unfortunately, Bill witnessed many of these violent episodes. Even though the physical violence had ended some years ago, Bill reported that, as long as he could remember, his parents were either fighting or ignoring each other. We developed a rapport around some of the more surface level issues like school work and peer relationships, but his depression, behavioral acting out and a growing feeling of hopelessness continued.

During individual work with Bill, he reported ongoing chaos in the home. After about three months, it seemed obvious that individual counseling wasn’t meeting Bill’s needs. Reluctantly, Bill agreed to participate in family counseling, which instigated reaching out to the parents and inviting them in. While they were initially resistant, they were open to new ideas given Bill’s continued decompensation despite a few months of counseling.

Over the course of continued individual work, many family counseling sessions and some attempts at marital counseling, a strong dysfunctional theme became obvious. Because of the trauma Bill witnessed and his resultant feeling of powerlessness, Bill developed a sophisticated set of behaviors: When he sensed a potential problem emerging between his parents, he acted out in an attempt to prevent a recurrence of the traumatic scenes he recalled from earlier in his childhood. This distraction tactic went unnoticed by his parents, who were lost in the complexities of their own individual and marital problems. The more his parents’ marriage destabilized, the more Bill would act out to attempt to compensate. Bill had developed this pattern over time as he witnessed many scenes of domestic violence during his formative years. Ultimately, the more he became entangled in his parent’s marital problems, the more he acted out, in proportion to the discord that existed between his parents. For the parents, Bill’s problematic behavior served as a distraction from their failing marriage and abusive relationship. Over time, Bill’s depression worsened from the stress of this balancing act.

With some time and counseling, the parents began to understand how their troubled marriage, as well as the violence in their home, had impacted Bill’s social, emotional and behavioral development over the years. Family work continued to target identified systems issues that contributed to Bill’s difficulties. It was agreed that individual counseling alone would not adequately address their son’s behavior because the origin of his behavior was directly tied to dynamics in the family system. The parents struggled with marriage counseling but found some relief in their own individual counseling, as each parent had many years of emotional baggage to examine.

Bill began to recognize some of these dysfunctional themes playing out in his own life (school performance, peer relationships and his overall depression). It was difficult for him to begin making better choices; however, as his parents began to change their dysfunctional behavior, he found it less painful to examine the true nature of his problems.

In counseling, he worked his way toward the realization that some of the only times he felt loved and important were when his parents were upset with him. He found himself consistently seeking the negative attention of his parents, his peers and his schoolteachers in order to feel accepted and included. As some of his behaviors stabilized, Bill developed better verbal skills and gained the confidence to express his needs and feelings in a more healthy way. In family work, Bill began expressing much of the anger he had been holding onto for years, which seemed to be the source of his ongoing depression. Bill found some relief in antidepressant medication, which provided additional support during this difficult segment of the healing process.

In her own counseling, Bill’s mother began to see that, under the stress of the chaos in the home, she had developed an unhealthy relationship with her son. In the aftermath of these crisis episodes, she would befriend Bill and share adult information with him, which later made it difficult for her to parent Bill when he was acting out. With the support of counseling, she was able to change this dynamic and learn how to lean on her adult support system, which opened doors for new parenting experiences with Bill.

Bill’s father struggled with his own mental health and, in his own counseling, worked to understand how his abusive childhood was playing out in his current family relationships. Bill’s father began learning how to control his anger and deal in a more healthy way with his own feelings of guilt related to the past.

Both parents have learned how to show affection and pay attention to Bill in a positive way, while also learning how to talk about the past in a way that leads to continued healing. For Bill’s family, the most difficult times come about when the regular stresses of life pull one or more of them back into old patterns of behavior. Family sessions are less frequent but occur when one of the family members feels they need a “tune up.” Bill’s conduct has improved both at home and in school. He remains in individual counseling where he works to better understand boundaries in relationships while also developing increased insight into his own self worth.

In this case, Bill’s behavior was clearly more accurately assessed thanks to the framework of a Family Centered Treatment model. Addressing Bill’s issues in individual counseling alone would not have led to uncovering, understanding and working toward the restructuring of family dynamics which were so central to the perpetuation of his problematic behaviors.| 

Dave Williams is a Licensed Clinical Social Worker who has been in the mental health field for 15 years. He has worked in residential care, hospital and outpatient settings. He received his Master’s Degree in Social Work from the University of Pennsylvania. He is a therapist with a private counseling practice, located in Bethlehem, PA, where he works with individuals, couples and families. Dave is also a Program Director for The Salvation Army, Allentown Corps, where he manages a women and children’s homeless shelter, a transitional housing program and homeless prevention services.