Family-Centered Treatment With Struggling Young Adults

A Clinician’s Guide to the Transition From Adolescence to Autonomy

Brad Sachs

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781136484803
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Family-Centered Treatment With Struggling Young Adults is an indispensible guidebook to the unique set of problems and opportunities that families face when young adults are experiencing difficulty pulling anchor and setting sail. Renowned clinician Brad Sachs, PhD, provides both a conceptual framework for understanding the reasons behind the increasing number of young adults who are unable to achieve psychological and financial self-reliance and a treatment framework that will enable practitioners to help these young adults and their families to get unstuck and experience age/stage-appropriate growth and development. In Family-Centered Treatment With Struggling Young Adults, clinicians will gain an in-depth understanding of the complex psychological challenges that parents and young adults face as the latter forges a path towards success and self-reliance. Moreoever, they'll come away from the book having learned an innovative approach to sponsoring family engagement ant the launching stage—one that reduces tension, resolves conflicts, and promotes evolution and differentiation on both generations' parts.

Chapter 1

Fluid Family Therapy

Music begins the moment you listen.

Jean Monahan

Several years ago, I treated a family with two sons, one of whom was an adolescent and one of whom was a young adult, both of them living at home with their parents. The treatment extended over the course of almost a year and addressed a wide range of worrisome behaviors that included underachievement, scrapes with the law, and drug and alcohol abuse. Although most sessions included all four family members, there was plenty of variability within sessions—sometimes I met with the sons together or individually; sometimes I met with the parents without their sons. I also scheduled some individual sessions with each son from time to time, a few parent-only strategy sessions, and one meeting that included the maternal grandparents, who lived less than an hour away and had always had a close relationship with their grandsons.

The treatment produced good results, and by the time we decided to finish up, things at home weren't perfect, but they were a good deal more stable than when the family had first consulted with me. At what was planned to be our final session before taking a mutually agreed upon hiatus, I asked the parents what they had found most helpful about the work that we had done together.

The mom responded by telling me that she was pleased with what we had accomplished, but she had been doing some reading about adolescence and suggested that if they ran into problems again, perhaps they ought to try family therapy.

I was completely taken aback by her comment. “What exactly do you think we've been doing?” was the question that I was tempted to ask her. How could they not have known that they had indeed been participating in actual family therapy with an experienced family therapist? But I bit my tongue and agreed with them that that might, indeed, be worth pursuing down the road, if necessary.

After they left, I imagined that, based on the reading that she had done, she must have envisioned family therapy as treatment that entailed the entire family spending every minute of every session together with the therapist. But because there had been plenty of coming and going in our work together—conjoint sessions, individual sessions, split sessions—it could not, according to her criterion, truly be classified as family therapy.

In addition to throwing me for a loop, however, this mother's comment was revealing, because it suggests that the name for the work that we are doing doesn't really matter. What ultimately matters is the actual work that we are doing— however we name it—and, more importantly, how well we are doing it.

The name that I have come up with for the clinical approach that I will be describing in this book is Fluid Family Therapy (FFT), and I suppose in some ways it's a response to this mother's comment. Adopting a systemic outlook in therapeutic work doesn't have much to do with how many people are sitting in the consultation room. You can be thinking and working systemically with only one, motivated family member sitting in your office, and you can be thinking and working in a linear way with an entire extended family sitting in your clinic, hospital, or office (my first family therapy supervisor, the ingenious Phyllis Stern, referred to this as “individual therapy with an audience”).

What follows are the basic tenets of Fluid Family Therapy, but the emphasis is on the fluid part of this moniker. I want to emphasize that I am not presenting a concrete, manualized treatment method that can be easily replicated and applied with relevance and specificity to every family that consults with you; nor can I offer a tightly edited list of crisp, definitive clinical aperçus. Families, from my perspective, are human enterprises that are simply too complicated to understand in their entirety—they are complex organisms, not simple mechanisms. We who treat families are constantly confronted with confusion and contradiction—it is indeed the very nature of our work.

Instead, I have tried to present a flexible framework for treatment that is highly versatile, depending on the presenting problem and the identified patient, and one that is likely to induce the family to get unstuck and follow the paths that their best efforts and instincts creatively forge for them. The range of struggling young adults we will come across is vast—we will be taking care of young men and women who suffer from serious mental illness; who are emerging from the foster care system without any family or societal safety net in place; who have autism-spectrum disorders; who are homeless; who are returning from military service, possibly with injuries; who are recent immigrants; who have succumbed to cults; who are wrestling with sexual orientation challenges; who have grown up impoverished and disadvantaged; whose parents are divorced; who are being launched by grandparents rather than their parents; who are up against medical challenges and disabilities. It would require thousands of pages of inquiry to address all of these situations with an adequate level of analysis.

But because of the power of systemic thinking, family therapy has the potential to be an enormously supple and versatile clinical approach when working with any family at the launching stage of the life cycle, and the more that we maintain our fluidity as clinicians, the more likely we are to trigger growth and healing, no matter what the basis of the family's struggles may be.

ORIGINS

The general treatment approach that I will be laying out in the coming chapters emerges most saliently from Family Systems Theory, which hypothesizes that problems and symptoms are best understood not as existing within an individual, but within the web of relationships between individuals, and that they are sustained and maintained by predictable, but ultimately changeable, patterns of behavior among family members. We refer to the treatment framework as Fluid Family Therapy because both its origins and its strategies are fluid.

Regarding its origins, Fluid Family Therapy draws from the following sources:

• Structural Family Therapy, as proposed by Minuchin (1974), has taught me to look carefully at the ways in which a family organizes itself—its boundaries, its hierarchy, its alignments—and to find ways to intervene that improve the family's organization such that it is more adaptable in the face of change.

• Strategic Family Therapy, as proposed by Haley (1985) and Madanes (1981), has taught me to explore the function that certain symptoms perform within the family system and the importance of understanding the role of the symptom before attempting to ameliorate it.

• Narrative Family Therapy, as proposed by White and Epston (1990), has taught me that it is not generally the dilemmas and problems themselves that afflict us but the maladaptive ways in which we think and talk about those dilemmas and problems that can be most deleterious.

• Bowen Theory, as proposed by Bowen (1978), has taught me to look at the family through the lens of its intergenerational heritage and to emphasize healthy differentiation as opposed to geographical separation or emotional cutoff.

• Contextual Family Therapy, as proposed by Boszormenyi-Nagy (1987), has taught me to attend closely to the family loyalties, both functional and dysfunctional, that illuminate and define every individual's journey toward self-reliance.

• Attachment Theory, as proposed by Bowlby (1969), has taught me to reinforce the concept of interdependence, the reality that the path toward independence is always anchored in the ability to maintain close emotional connections throughout the life span.

• Motivational Theory, based on the work of Deci (1996), has taught me to understand the intricate connection between autonomy and the capacity to develop self-mobilized and self-motivated initiatives.

• The work of Helm Stierlin (1981) has taught me to understand why healthy separation between parent and child during late adolescence and early adulthood is sometimes imperiled or runs aground.

• The work of D. W. Winnicott (1952) has taught me to be closely attuned to the “empathic ruptures” that are a natural occurrence in individual and family therapy and to use these painful impasses as ways to enhance self-awareness and spur personal and relational growth.

• The work of Monica McGoldrick (2011) has taught me to respect the complexity of the family life cycle and the ways in which each member's developmental trajectory intersects with and influences those of others.

• The work of Froma Walsh (2002) has encouraged me to apprehend the complex multiplicity of family life in a diverse and changing world.

Like most seasoned clinicians, I have also incorporated techniques borrowed from numerous other theorists, practitioners, and schools, including those associated with cognitive-behavioral therapy, mindfulness, and Eastern thought (acupuncture, meditation, yoga, etc.).

FAMILY SYSTEMS

When I was growing up and my brothers and I got sick, my mother would remind us that it will take some time to get the cold “out of your system.” While that may be an applicable metaphor when it comes to mild infectious diseases, the reality is that nothing ever “gets out” of the family system—issues, themes, conflicts, and entanglements remain there forever, echoing through the generations in various forms and guises. Our job as family therapists is not to disinfect the family system but to illuminate it so that the family can see it more clearly and then make the necessary alterations and find the appropriate antidotes in response to this illumination.

FFT recognizes the uniqueness of each family and does not have as its objective a particular solution to a family problem or a particular definition of healthy family functioning. Its goal is to help families understand themselves better, augment their realization of and access to their own resources, and enable them to use those resources to get themselves unstuck and moving forward. This is accomplished not through engaging in a lockstep, irreversible sequence of assessments and interventions but through the therapist's creative and courageous encounter with the family, his capacity to take the family's psychological pulse, to enter into their darkness and light a single match, to help them slow down and simply have a good look at, and give a careful listen to, each other.

While dramatic transformations and epiphanies may, at times, take place, FFT is designed to foster steady, nuanced shifts in the family's functioning, ones that are more likely to take root and endure over time rather than those that will breathtakingly flare up and then disappointingly disappear. The therapist does this, at least initially, by injecting something new and different into the warm bloodstream of the family through pointing out the recurring patterns of their behavior and how the patterns might be changed to everyone's advantage.

The priority is not whether change occurs but whether change can be maintained — and, especially, whether it can be maintained outside of therapy, like a hothouse flower that can also thrive when transplanted into an outdoor garden. This kind of sustained and expanded change is likely to take place only if the family system has changed along with the individuals comprising the system.

In this regard, the goal of FFT is to make the therapist, and therapy itself, obsolete; to empower the family with the capacity to perceive and resolve their difficulties on their own (I like to keep the wonderful Ray Charles song, “I Don't Need No Doctor” in my head: “The doctor say I need rest, but all I need is her tenderness, He put me on the critical list, when all I need is her sweet kiss.”)

In FFT, problems in treatment can be anticipated, but it is recognized that they cannot be avoided. Defiance and resistance among family members are not seen as problems or obstacles but instead as invitations to the therapist to become better acquainted with who they are and how they behave. We want to acknowledge and address the power of the family as a whole, or the power of one or more of its members, to defeat us as well as to defeat anyone else who tries to facilitate change, and to see this power not as a headache or a hindrance but as royal entrée into the experience of what it must be like to live with them.

FFT is a patient and deliberate intervention as well. While it is practical and doesn't waste time, it also recognizes that families have limits to what they are able to accomplish and that they are entitled to rest and restore themselves on certain developmental plateaus for periods of time, if they would like, before resuming their march up the continuous mountain of growth. FFT recognizes the wisdom of the family and respects their intuitions regarding how much recalibration of their closeness with or separation from each other can be tolerated. It appreciates that self-defeating behavior may serve a purpose, communicate something important, or protect against even more destructive behaviors.

Patience on the part of the therapist is particularly important, because the emotional skin of individuals and families is always thinner, more tender and vulnerable, at a developmental juncture, and so the likelihood of oversensitivity on the part of one or more family members is magnified. There is an emotional nakedness that we all expose when we welcome someone into the family or experience the loneliness of a farewell. Confusion, compressed thinking, prickly reactivity—all of these are associated with the need to change, and all of them need to be respected and very tenderly palpated.

Our patients are often going into murky, hidden places deep within themselves and yet simultaneously may be available for more open and intimate contact with others than ever before. So there is tremendous room for growth but also tremendous room for clinical error if we push too hard or move too quickly.

Every family is afraid to face certain truths because they are afraid of what these truths will say about them, both to themselves and to others. Our job as clinicians is to help them confront these truths and, as Dorothy and her friends do when Toto pulls the curtain hiding the Wizard of Oz, to realize that these truths are not quite as intimidating and fearsome as the family imagined.

When a confrontation with the family's reality becomes necessary, the therapist does not proceed heedlessly but remains mindful of the vulnerabilities of the family and its members and constantly monitors the level of trust that has been established with them. There is a necessary roughness that may be required to galvanize them but unnecessary roughness deserves a penalty, and the family will be certain to inflict this penalty, in one form or another, on the therapist for this infraction.

FFT gently but firmly guides the family toward a rational assessment of their situation and some prospective changes that might improve it but includes an acknowledgment of what remains irrational and difficult for them, and perhaps even for the therapist, to understand.

It is also useful, in this regard, to make the distinction between curing and healing when treating the family. The reality is that not every illness will be cured, but with the right care, the patient—in this case, the family—can still heal, often in psychological, spiritual ways. The identified problem brings the family members into closer contact with themselves and with each other, and this increase in connectedness expands their sense of well-being, even though the problem itself may not be completely resolved.

Finally, FFT acknowledges that people grow and change in many ways without having to be in therapy. There are many events and endeavors that catalyze human development, and the family should be discouraged from believing that clinical intervention is their only route toward safety or sanity.

Despite the aforementioned premises, it should be acknowledged that psychological intervention can never have the precision and predictability of other clinical interventions. In other words, we don't always know why what we do works when it does, in fact, work. I was listening to the National Public Radio program “Car Talk” one morning, and a caller commented that she noticed that she always got better gas mileage after going in for an oil change and wanted to know how oil changes improve gas mileage.

The hosts hypothesized that the better mileage had nothing to do with the oil change, but instead had to do with the fact that the technician probably checked and inflated her tires when she went in for an oil change. So while it was logical for her to assume that it was the oil change that led to the increased gas mileage, it was actually because of what accompanied the oil change—optimally inflated tires—rather than the oil change itself that she experienced improved automotive performance.

We may believe that our effectiveness lies in the inventive clinical strategies that we employ or the theoretically sound framework within which we operate, but it is likely that it is what accompanies our strategies and framework—our warmth, our kindness, our optimism, our faith, our endurance—that accounts for improvements in the family's “performance.”

THE FLUID FAMILY THERAPIST

The therapist conducting Fluid Family Therapy must maintain a versatility of roles. At times he observes the family from a distance, getting a read on their functioning and their interactional patterns. At times he pulls up beside the family as if in a sidecar and travels along their bumpy roads with them. At times he tries to muddy the overly placid surface of the family lake and induce imbalances in the family's functioning so that they have the opportunity to rebalance themselves in a more constructive way, and at times he empathizes with their struggles and normalizes their problems.

One way or another, though, the Fluid Family therapist becomes an intimate part of the family system. FFT is not seen as counteractant being administered from a distance but as a healing encounter that involves and changes the therapist in the same way that it involves and changes the family. Charles Fishman (1988) refers to this as maintaining a “Janus-like” position in which the clinician remains both inside and outside of the family, simultaneously influenced by, yet not overwhelmed by, the family's pressures—both actor and director.

With this in mind, the Fluid Family therapist keeps numerous therapeutic arrows in her quiver. A Japanese warrior once said, “Never have a favorite weapon,” and that is good advice for the clinician as well—relying too heavily or too consistently on one approach can close us off to the potential he...

Table of contents

• Front Cover
• Family-Centered Treatment With Struggling Young Adults
• Previous Books by Dr. Brad Sachs
• Title Page
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• Introduction
• 1 Fluid Family Therapy
• Interlude: The Six Categories of Struggling Young Adults
• 2 Family Loss at the Launching Stage
• 3 Beginning Treatment at the Launching Stage
• 4 Family Assessment at the Launching Stage
• 5 Family Dynamics at the Launching Stage
• Interlude: LGBTQ Issues
• 6 Getting Unstuck at the Launching Stage
• 7 Consulting with Parents at the Launching Stage
• 8 Consulting with Young Adults
• Interlude: Digital Media
• 9 Marital Issues at the Launching Stage
• 10 Money Matters at the Launching Stage
• Interlude: Countertransference
• Conclusion
• Bibliography
• Index