Family Therapy 22 Year Old Boy Vignette Examples

Psychiatry (Edgmont). 2009 Jan; 6(one): 32–37.

Published online 2009 January.

Family Therapy with a Depressed Adolescent

Paulette M. Gillig, MD, PhD, Series Editor

Paulette M. Gillig, Professor of Psychiatry, Section of Psychiatry, Boonshoft Schoolhouse of Medicine, Wright State University, Dayton, Ohio;

Abstruse

Families can have a significant influence on a child'southward mental health. Family therapy is a handling modality that can be used alone or in combination with other treatment modalities. Family therapy strategies include psychodynamic, structural, strategic, and cognitive-behavioral schools. In this article the different schools are described and a instance of a depressed teenager is used to illustrate how each type of family therapy is implemented.

Keywords: family therapy, boyhood, low

Introduction

Family relationships can positively or negatively impact child development. This influence too occurs in the contrary manner: families influence the overall wellness of the child and the child influences the overall health of the family. This bidirectional influence is greater when the child has a psychiatric disorder.¹ When treating children, family unit interventions are commonly incorporated to a greater or lesser extent. In fact, child treatment has been referred to as de-facto family unit therapy.² A psychiatrist or therapist doing family therapy utilizes the connexion that exists between child and family unit with the goal of improving the overall functioning of the family. When a family functions better, the child functions better.^three

Family therapy is a grade of psychotherapy that directly involves all family unit members in improver to the "identified patient"—and explicitly attends to the interactions among all family members. If the focus is on the fix of relationships in which the person is intertwined, family work can be done regardless of who is initially involved.^iv Family unit therapy focuses on the relational and communication processes of families in order to piece of work through clinical problems, even though the child may be the only family unit member with overt psychiatric symptoms.⁴ This is because although i family member may be the "symptom bearer," the whole family is in distress. Interventions in family unit therapy are geared toward the family as a unit with the perspective that some private symptoms are products of relationship struggles within this unit. These individual symptoms are viewed as arising from and beingness complicated by the family arrangement matrix.^v Family therapy is considered more of an orientation than a specific type of therapy.

Introduction to the Case: A xv-Year-Old Male child and His Family

J was a xv-year-onetime boy who get-go encountered mental health treatment later on he admitted to his parents that he had thoughts of pain himself. He had been caught smoking cigarettes in his room at home by his stepfather and in the verbal altercation that followed J told his mother and stepfather that he "didn't care anymore and wanted to die." J'south stepfather became very angry and threw him out of the business firm for being disrespectful and untrustworthy. The mother then became enraged at her married man and told her husband that if he kicks out J, she is going, too.

J admitted to feeling depressed for several months prior to this episode. He wanted to be an actor and said that he did not see the betoken of studying or going to school. Although he did well academically in the 9th and tenth grade, his grades declined significantly in 11th course to the point that he was ineligible to participate in extracurricular activities like the drama order. He admitted to having difficulty fitting in and was associating with the kids who skipped class and took drugs. J'southward depressive symptoms included distressing mood, decreased motivation, decreased energy, decreased concentration, and sleep difficulty. After breaking up with his girlfriend, he cut himself superficially on his forearm with a razor and had fleeting thoughts of suicide.

The Influence of Family: The "Biopsychosocial Model"

The biopsychosocial model attempts to sympathise the whole person by elucidating the interactions between the biological, psychological, and social aspects of an individual. Using this model in relation to a child, the family unit environment would be the nigh important social cistron. It is easy to understand how this family environment substantially impacts a child.⁶ Normal child development is associated with the positive family processes of secure attachment relationships, effective parenting practices, and emotionally nurturing environments. On the other manus, risk factors for childhood psychiatric disorders include the negative family processes of parental pathology, family unit and marital disharmonize, coercive parenting practices, and persistent negative impact.²

Research using twin and adoption studies has been conducted to investigate the impact of both genetic and family factors. I study found that adopted children with a high genetic chance for schizophrenia were more sensitive to agin rearing practices in their adoptive family than were adopted children with low genetic adventure.⁶ There was a clear clan between the diagnosis of schizophrenia and disordered rearing in the children with high genetic hazard, which was not seen in the children with low genetic risk. The characteristics of family operation associated with disordered rearing included a tendency to be critical, to be constricted, and to have purlieus issues. The conclusion was that both genetic risk and rearing surround were interactive in promoting either the protection against or the emergence of schizophrenia in the adoptive kid.⁶ Another study looked at how family dysfunction afflicted recovery from a major depressive episode. Inpatients who viewed their family operation every bit beingness "healthy" were more than likely to recover within 12 months then those who rated their family functioning equally "poor." Family dysfunction in this study was characterized by poor communication, poor problem solving, and criticalness.^six

Although it may at start seem intuitive that family processes that precipitate childhood psychiatric disorders place all children in a family at equal take a chance, findings from the behavioral genetic literature make a convincing argument that this is not the case.⁷ Shared ecology influences, although the same for all children in a home, are experienced and interpreted differently by each child, so that these events become different for each individual child based on the child's own temperament. In add-on, children's private characteristics affect parenting behavior. Even siblings, who are like due to their genetic makeup, are different based on their individual temperaments.⁷ Individual temperaments have an impact on how children'due south parents relate to them, such that each kid in a family unit may experience a different parenting style.

J'due south family dynamics. J's family unit consisted of his mother, stepfather, 18-year-old older sister, and 11-yr-old sister. J's biological parents divorced when he was ii years sometime and his mother remarried when he was six. His mother reported that his biological begetter was calumniating toward her, but not the children. She left him later on an incident where he struck her while she was holding J when he was an infant, and she felt J'due south safety was being seriously threatened. J had little contact with his biological father since the divorce, but contacted him recently because he wanted to go out his current family and live with him in another country. To J's disappointment, his biological father's response was noncommittal.

J's mother reported symptoms of posttraumatic stress disorder (PTSD) from the abuse she suffered from J's biological father as well as from a sexual attack in her boyish years. She likewise experienced chronic headaches and fatigue, which sometimes limited her interest with her children. She revealed that her family of origin was unstructured and that she had "too much freedom," which she felt contributed to the sexual assault she suffered. She believed that she was immune to "run wild" and became involved with booze at a immature historic period. Of her children, she felt most similar in temperament to J. She feared that without more parental supervision he could terminate up like her and put himself in unsafe situations.

J always had a distanced relationship with his stepfather. J's stepfather was a retired police officer who highly valued social club and subject field. He did not agree with J's long hairstyle or passion for acting. He forced J to cut his hair and change his manner of dress after he was caught smoking. J admitted that sometimes he feared him when his temper ignited. The stepfather was by and large suspicious of mental health providers and viewed psychiatric symptoms equally an excuse or a weakness. This caused marital problems in relation to the female parent'southward PTSD symptoms also as J's depressive symptoms.

J's older sister had bipolar disorder and although she had been stable for the last two years, she had a hard fourth dimension for several years and was unable to nourish a regular school. J felt his older sister was not held to the same standard as he was because of her psychiatric illness, and he felt this was unfair. J felt that the expectations for success were all the more potent for him due to his sister'due south illness. His sister also smoked cigarettes and, as far equally J could retrieve, had never been reprimanded for this beliefs. J's younger sister had no mental health diagnosis, simply did have exaggerated separation anxiety when she was a immature child, some of which was still axiomatic. She got along well with her siblings, only spent most of her time with her mother at the exclusion of peers. Several times a year she would complain of a stomachache until she was allowed to stay abode from school. This was more than frequent following the atmospherics betwixt J and his stepfather, which raised the stress level for everyone in the dwelling house.

Psychodynamic Family unit Therapy

Family therapy can exist divided into several dissimilar schools of thought: psychodynamic, structural, strategic, and cognitive behavioral. Although the goals of each school are similar, the techniques and strategies each employs are unique. A combination of these approaches is used in contemporary family therapy.

The psychodynamic approach to family therapy is based on psychoanalytic theory. From this viewpoint family unit psychopathology is based on the intrapsychic processes of individual members.⁵ These intrapsychic processes shape i'south interactions with others, most prominently in intense emotional relationships similar those among family unit members. The commonage processes of all members merge into the "family unit neurosis."

According to psychoanalytic theory, prominent intrapsychic processes take place in the unconscious. These include repression, projective identification, some aspects of unresolved grief, and transference. An important concept that involves these processes is "psychic determinism." Psychic determinism refers to the idea that mental events practice non occur at random and that every behavior has a cause or source embedded in the private's history. Transference occurs when one'southward feelings, thoughts, and wishes are projected on another person who has come up to stand for a person from an individual'southward past. One feels about and treats the other person (the "object") as though he or she were that of import person from the past. In private psychoanalytic psychotherapy, transference occurs inside the therapeutic relationship and refers to projections of the patient onto his or her psychiatrist. Past contrast, when speaking of family transference, the emphasis is on intrafamily projections and non those projections focused on the psychiatrist or family unit therapist.^v

The process of dynamic family therapy involves bringing unconscious conflicts between family members into consciousness using techniques similar interpretation. Change is facilitated by 'working through' the unconscious transference distortions of each family member. Through this process, parents get enlightened of how conflicts in the present family arrangement are related to their unconscious attempts to primary quondam conflicts arising from their family of origin.⁸

Treating J and his family using psychodynamic family therapy. When the psychodynamic family therapist viewed J's family through a psychodynamic lens, the conflict between J and his stepfather was rooted in past relationships: The stepfather was predictably resistant to engaging in treatment based on his suspiciousness of the mental healthcare arrangement, but with time and the nonjudgmental credence offered by the therapist, all members, including the stepfather, began to run across treatment as a safe surroundings.

Information technology is revealed that the stepfather also was harshly disciplined by his ain father and at times physically reprimanded for not beingness masculine enough. J'southward long hair and interest in acting threatened his stepfather because his stepfather was unconsciously projecting his own fears and memories of punishment onto his stepson.

The mother's conflict with J was also embedded in her past. Her over-identification with J could exist understood as projective identification of herself as a struggling boyish. She was unable to enforce limits on him due to her ain unresolved conflict with her female parent for not providing this for her every bit an adolescent. The female parent's unconscious anger toward her parents for not stepping in and protecting her was likely being internalized into her somatic symptoms of headaches and fatigue. These physical symptoms also served the hidden purpose of giving her a way out of difficult parenting decisions and leaving them up to the stepfather.

J'southward symptoms of depression also served an unconscious purpose. J spent the majority of his formative years with his mother and his siblings. E'er since she had married his stepfather, J perceived that the stepfather took the attending and dearest of his mother abroad from him. This created an "oedipal" conflict where J felt unconscious aggression toward his stepfather. This unresolved disharmonize manifested itself through J's current psychiatric symptoms.

The psychodynamic family therapist used interpretation of selected textile to increase the family's insight into how the past was standing to impact the nowadays. With this insight, too equally an expanded repertoire of emotional expression, the family could solve its nowadays conflicts effectively without being weighed downward by the past.

Structural Family Therapy

The structural family therapist views symptoms that occur in a particular family fellow member, oft the identified patient, to be directly linked to the organizational context of the family.⁹ Family unit structure can exist defined as the system of the family unit that dictates how family members relate and how diverse family functions are carried out.^x The family structure involves a set of functional demands that organize the way in which family unit members interact. This construction is invisible to the members themselves. It is the therapist's goal to sympathize this construction and ultimately to facilitate transformation of the structure as a ways of solving problems.^five

Of import elements of family structure include boundaries, hierarchies, alliances, and coalitions. The clarity of boundaries within a family unit is vitally important to the overall functioning of the family and can range from disengaged to enmeshed. Members of a disengaged family take no contact with each other. An enmeshed family unit has besides much contact with each other. Boundaries are most important between generation levels or 'subsystems' within a family unit. For family unit functions to be carried out finer, parents and children must take contact with each other, but not interfere with each other.⁵

The showtime job of a family unit therapist who is utilizing a structural orientation is to determine the family construction. This is accomplished past careful observation of how family members talk and interact within the consulting room in relation to the presenting trouble.^iv Therapy involves shifting the family construction, and this is achieved through the re-creation of family unit dialogues and manipulating geographical arrangement during sessions and via behavioral assignments exterior of session. The re-creation of family dialogues occurs when the therapist directs a family member to talk directly to another member rather than to another person almost the detail family fellow member's behavior. This technique is valuable in that is forces families to enact transactional patterns rather than describe them. Another in session technique just changes where item family unit members are sitting in the consulting room to physically correspond the thought of challenging existing family structures like hierarchies and alliances. The out-of-session behavioral assignments likewise aim to shift family construction by strengthening or weakening existing family boundaries.⁴ These assignments may include excluding or including family members from certain moments of family life and therefore irresolute the existing boundaries between particular family members into more advisable ones.

Handling of J's family using structural family therapy. Through careful observation of J'southward family in the consulting room, a structural family therapist would uncover a dysfunctional structure of his family and work to transform it into a functional one. The boundaries of this family unit were a circuitous combination of enmeshment and disengagement. The mother and younger sister characterized an enmeshed human relationship and, to a bottom extent, the same held true for the boundary between J and his mother. On the other hand, J and his stepfather characterized a disengaged relationship.

The hieratical structure of the family was likewise skewed because the stepfather was at the top, but then a large gap existed between him and the mother. This placed the mother closer to the children than to the over-ascendant stepfather. Another dysfunctional chemical element was the palpable alliance between J and his mother against his stepfather.

To brainstorm to shift this construction, the therapist recreated the family dialogue that transpired when J's stepfather defenseless him smoking. The therapist was conscientious to ensure that each family fellow member talked to the other person and not near the other person or the upshot.

• Psychiatrist: J, can you tell me what y'all remember about the time y'all were caught smoking?

• J:I was in my room and I thought my parents were however at piece of work when my dad bursts open my door and starting yelling. I was afraid he was going to hit me he looked so mad.

• Psychiatrist: Tin can you lot look at your dad and tell that story once more to him?

• J: I guess….. Dad, I was really scared by yous when yous were yelling. I know I did something incorrect but….

• Stepfather: (Looking at psychiatrist) I didn't mean to scare him.

• Psychiatrist: Dad, can you say that to J.

• Stepfather: I didn't mean to scare you, but I know you lot are really a proficient kid at heart and information technology hurts me to come across you making stupid decisions.

The seating organization in the room was shifted to stand for the desired changes in the bureaucracy and in the alliances of the family. The female parent and the stepfather were placed together and on equal basis and the children were placed together too, separated from the mother. To tackle the boundary problems of the family, behavioral assignments were employed to bring J and his stepfather closer together and too to create space betwixt Mother and both J and his younger sister. J and his stepfather were assigned to accept upwardly a hobby together one time a week and the mother was assigned to join an action exterior of the home to allow both J and his younger sister some time and space of their own.

Strategic Family Therapy

The strategic orientation is "solution focused." The family therapist is responsible for planning a strategy to solve the presenting problem. Strategic therapy tin be viewed as almost the opposite of psychodynamic therapy in terms of where emphasis is placed.^eleven A strategic family therapist focuses on how families tin carry differently, non why families conduct the way they practice. The past is largely ignored, while the importance is placed on the present and the current, repetitive family unit processes.¹²

Change is brought about past formulating clear goals that target changing relational and advice processes within the family.^eleven The strategic family therapist views the problem as the family'south unsuccessful attempt at a solution. The therapist recognizes that this unsuccessful endeavour exacerbates the problem and plans a successful solution using innovative problem solving strategies. These strategies include such tactics as reframing, restraining the system, positioning, and prescribing the symptom.^iv

Reframing challenges the mode in which family members perceive the family reality based on their private perspectives. This challenge reframes the symptom or situation in a less conflicted mode and often with a more positive spin. This helps family members see the trouble differently and ultimately conduct differently.^three Restraining the system is when the therapist discourages change or emphasizes the risks of change in an endeavor to propel the family toward change as a reaction against the therapist'south advice. Positioning is a tactic where the therapist chooses 1 family fellow member's position and agrees with it, but exaggerates the position in a manner that makes information technology distasteful. Positioning is often used when two family unit members hold opposing positions. The goal of this exaggerated and somewhat unpleasant position supported by the therapist is to motivate the family unit fellow member into change. Prescribing the symptom follows the same logic, but must be used with circumspection. For this strategy to exist successful, the strategic family therapist must encourage the very symptom he or she is trying to extinguish. This is done by using a plausible rationale to effort to convince the family members that they need to continue the symptom or problematic beliefs to report its effects or even that they demand to increment the symptom's frequency. One must be conscientious not to seem insincere or manipulative when using this intervention. If done appropriately, the family'south perception of the symptom is changed from something that is out of its control to something within its control. Once family members perceive they have the ability to change or dispense the symptom, the elusive quality of the symptom is gone and replaced by a feeling of control.ⁱⁱⁱ The therapist hopes to unite the family against the therapist's advice and cause them to insubordinate and, therefore, finish the problematic behavior on their ain.

Treatment using strategic family therapy. Using the strategic arroyo, the family therapist viewed that the family's unsuccessful attempts to solve the presenting problem actually became the problem. The therapist devised a solution that replaced the unsuccessful attempts with a successful i. A possible arroyo to creating a "success" for the family unit's problem-solving attempts was to explain that the stepfather'southward reaction to J's smoking was due to the stepfather's obvious concern about the wellbeing and future of J. The stepfather'due south extreme reaction was evidence of just how much he cares. This tactic admitted that the stepfather's reaction may have gone too far, merely emphasized the love he had for his stepson and non the bad behavior on either family member's part.

• Psychiatrist: There are often multiple ways to view a situation. For instance, Dad's reaction to catching J smoking was to become aroused. Although there may have been a ameliorate and less hurtful style of treatment the situation, the level of his acrimony shows only how much he really cares for J. Afterward all, if he didn't care much at all for J or his time to come, he would non care or get angry if J were smoking. J is really very lucky to have a dad who cares and then much about him, even if Dad does accept a hard time showing it sometimes.

• J: Well, it doesn't feel like he cares most of the time.

• Stepfather: I hope you know that I practise love you and I just desire what is best for you. I am quick to anger, I'll admit that.

• Mother: I agree. Nosotros both love y'all so much. Maybe we need to say that more.

• J: Ok, ok, I get information technology. Y'all care nearly me and that is why you care and so much when I practice bad stuff.

A positioning tactic could be to play off the disagreement between the mother and the stepfather on how to deal with J'due south beliefs. The therapist could exaggerate The mother's position and in the procedure make it a flake distasteful by explaining that the female parent should stick by her son at the expense of her relationship with her husband because it is obvious that trying to be both a wife and a mother is too overwhelming for her in her fragile, physical condition.

Finally, a way to prescribe the symptom would be to rationalize with J that it is of import to continue to remain depressed to make sure everyone in the family can feel with him what is it like to feel true depression. This will help the family understand and empathize with him and then that they will no longer exist angry nearly his behaviors.

This technique worked to unite the family against the therapist, with the goals of empowering the mother to balance her relationship with her husband and her children and helping the stepfather to "back off" and brand articulation decisions with the mother. This strategy ultimately motivated J to move beyond his depression.

Cognitive-Behavioral Family Therapy

Cognitive-behavioral family therapy applies many of the bones principles of individual cerebral-behavioral therapy. In addition, it as well relies heavily on family unit psychoeducation. Just as strategic family unit therapy can be understood by how it differs from the psychodynamic approach, then tin can cognitive-behavioral therapy. While the psychodynamic therapist emphasizes the importance of intrapsychic forces, the cognitive-behavioral therapist emphasizes the importance of external social forces.⁵ In this orientation, all behavior is learning-based and can exist unlearned using basic principles of beliefs modification. In fact, this type of family therapy grew out of behavioral modification programs for immature children with deviant behavioral problems.¹³ The cerebral-behavioral family unit therapist plays the office of a teacher or coach and brings most change by agreement the influence family members have upon each other and utilizing this influence by offering positive and negative reinforcements.¹⁴

Techniques employed include operant conditioning, contingency contracting, idea diaries, communication training, and psychoeducation.^xv Operant-conditioning strategies attempt to shape behavior through positive and negative reinforcements and may utilize time-out procedures with younger family unit members. Contingency contracts are behavioral plans family members concord to perform that replace subversive patterns related to the presenting problem. Thought diaries are homework assignments given to family members that rail thought patterns with the goal of uncovering and and then correcting mutual cognitive distortions similar catastrophic thinking or overgeneralization. The cognitive-behavioral family therapist likewise coaches families in fundamental communication skills, such as how to heed empathically, limited positive feelings, and convey negative communications respectfully.^xvi Psychoeducation as well is a fundamental role of the cognitive-behavioral approach to family therapy and can be tailored to each individual family'south needs. Psychoeducation can include a broad range of topics from general principles of learning theory to specific information well-nigh a family member's psychiatric diagnosis.

Treatment using cerebral behavioral family therapy. One of the central components of cerebral-behavioral family unit therapy is operant conditioning, and this can be used in several means. Positive reinforcements similar time to play his favorite video game or an allowance toward his first car were used to reward J for making good grades in school. On the other hand, negative reinforcements were used similar not increasing J's allowance if he is caught smoking or skipping class. The younger sister's behavior was as well modified using operant conditioning. If she stayed dwelling house due to a stomachache, the stepfather would stay home with her instead of the mother in order to remove the perceived advantage of staying close to her mother. She also received a prize, her favorite dessert, or a movie night out if she did not miss whatever school for 1 month.

Communication skills preparation also was incorporated. With the therapist as the coach, the skills of listening and sharing feelings and ideas respectfully was practiced in session and and then at home. This would improve many intrafamily relationships. Psychoeducation is a wise use of the cerebral behaviorist's resources in this case, especially in light of the stepfather's belief that psychiatric symptoms were a sign of weakness. The therapist discussed important topics, such equally normal adolescent development, signs and symptoms of depression, and acrimony management.

Conclusion

Family unit therapy shifts the focus of the psychiatrist's attention away from the child and onto the family every bit both the source of pathology and the target for treatment. Information technology is clear that a child's mental health stems both from genetic factors and from family dynamics. Although a child's genetics cannot, at this fourth dimension, exist modified, the family unit dynamics are at our disposal.

The historical backdrop and subsequent outgrowth of the unlike schools of thought about family therapy are like to the schools of thought about individual therapy. They arose from the theoretical orientations in the broader mental health community and sometimes from reactions against earlier orientations. Although several different schools of family therapy exist and strategies of recommended treatment differ, contemporary family therapy that utilizes a multimodal approach incorporates insights and techniques from each schoolhouse of thought based on an individual family unit's needs and the therapist'south style.³

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719446/

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