As a family therapist, I’m a firm believer that parents need to be actively and regularly involved in any treatment of children and teens who live at home. Although I certainly understand that there are many credible ways to do work (including individual therapy with children), after 40 years as a therapist, I am of the opinion that it is not helpful to family dynamics and the health of all family members to see kids without also treating their parents.
Outpatient therapy is generally limited to one to two hours per week. Children, by definition, are dependent on the folks who feed, shelter, and manage them the other 166 – 167 hours a week. The family needs our support.
Often enough, the child is the “symptom bearer” for the whole family. Like the canary in the coal mine, a child’s misbehavior or symptoms may be a signal that something is seriously wrong within the family. Sometimes, a child’s behaviors activate family members in ways that “solve” another family problem.
By becoming the focus of both parent’s energy and care, for example, a child may reduce his parents’ conflict with each other. Even when the etiology of the illness is genetic or medical, the impact is felt by everyone. Individual therapy for a child in such circumstances either misses the point or ignores the pain of others in the family.
Yes, the data on outcomes of family treatment when the child or adolescent in the identified patient are mixed. From my reading of studies, I think this is principally because of a lack of consistency in how parent participation and outcomes are measured for the various models of family treatment. What data is available does affirm that parent involvement does have measurable positive effects on treatment outcomes.
I suggest that there are two levels to consider when treatment planning: 1)Parent education that includes information, instruction, and resource and referral , and 2)Therapy.
When parents are more informed, they tend to be less overwhelmed and more able to participate in their child’s treatment. Although not specifically targeted to treatment goals, these activities are often therapeutic in result.
Provide information: Although the Internet has made it easier to access information, that information can be confusing or the information on some sites conflicts with the information and recommendations on another. Parents often need help sorting solid research from rumors and fad treatments. They may not know how to navigate special education meetings or how to sort out conflicting advice from multiple experts.
Develop a list of resources: Parents may be unaware of resources that are available. Therapists who work regularly with the parents of mentally ill children need to create and maintain a list of parent advocates, lawyers, hospitals, state agencies, and funding resources that can be accessed as needed.
Provide skills training in effective behavior management (discipline): Mentally ill children and adolescents often take their distress out on the people who love them the most. Research has shown that the primary coping tool of many families is “walking on eggshells” in order to not set off the ill child. Unfortunately, soothing and not disciplining these kids often helps maintain the disruptive behavior. Often such kids learn to expect the world to bend to their needs.
Help to coordinate care. Sometimes, a well-meaning relative doesn’t agree with the treatment plan and sabotages the parents’ best efforts. Sometimes, a classroom teacher doesn’t follow the Individual Education Plan. A primary care physician may prescribe medications in response to parent distress without knowing about or alerting the therapist. Parents need our help in getting other providers and helpers on board with the treatment goals and strategies.
Encourage parents to take time off: Sometimes parents manage overactive guilt or lack of confidence in other providers by being available 24/7. It’s a set up for exhaustion. Sometimes, they need help to identify and train other people to provide respite. Look into which state agencies provide funds for at least some respite hours or days.
Connect parents with a support group: Studies of self-help groups have been shown that such groups are often effective in helping group members. Support groups (such as NAMI’s Family-to-Family Education Program or FFEP ) encourage parents to become advocates and to fight the stigma of mental illness. Many clinics also offer family psycho-education programs for parents of children with mental illness.
When a child or teen is mentally ill, it affects everyone in the family. Family therapy not only addresses the immediate needs of the patient but also provides protection and support for the rest of the family. Often, it strengthens family ties.
A check for safety needs to be part of the intake: This practice includes checking for the safety of the parents and the other kids in the family as well as for the mentally ill child. Sometimes, embarrassment makes parents reluctant to share how frightened family members are because of an ill child’s aggressive or destructive behavior. Regular safety checks for everyone in the family needs to be routine as the child grows.
Involve parents in treatment planning from the start: Parents need to be respected and involved as important members of the treatment team. Unless there is specific involvement and “buy in” of treatment goals and methods, chances are that the child will not improve. Kids (and especially teens) pick up parental anxiety or hostility and are unlikely to cooperate with treatment.
Take extra care to “join” with both parents: Like any other client, if the parents “don’t believe in therapy” or don’t trust the therapist, they will not willingly participate in treatment and may sabotage it. Sometimes, parents unknowingly compete with each other to be seen as the better or more compliant parent.
In such cases, it’s critical to get the parents on the same team, dealing with the problem instead of on different teams, fighting (actively or passively) with each other. Sometimes, one parent (often the father) will leave treatment to the other parent (usually the mother) – which means that both credit – and blame – for outcomes belongs to the more involved parent.
A more subtle problem is being in competition with the therapist. Yes, the parents want their child to get better. But it is a hard pill to swallow if they think that the therapist is a better “parent” for their child than they are.
Gain agreement from both parents: When one parent agrees with goals and methods and the other parent doesn’t, it puts a child in a bind. To get better puts the child on the “side” of the therapy-friendly parent. To not get better may make the child feel she is a “bad” person. If parents are in pointed disagreement, the therapist must address it immediately.
Provide “homework:” Therapy happens for only an hour or two a week. The real work of therapy happens between sessions when the children are with their family. Parents need concrete, specific, measurable assignments that they agree are manageable in order to maximize progress. Often such assignments include new ways for the parent(s) to interact with their child. Studies show that just keeping a regular log of activity increases positive results by 20% or more.
Treat the whole family: Childhood mental illness impacts everyone in the family. Most adults who grew up with mentally ill siblings report feeling loved by their parents and love for their sib. But they also speak eloquently about how they longed for more information and protection, more room to be a normal kid, and more parental time and attention.
Some, (by no means all), sibs become symptomatic in their effort to pull more parental attention to themselves or to avoid having too much responsibility for their sibling placed on them. Many families need the safe forum of family therapy to talk about their feelings and fears and to navigate the many challenges that having a mentally ill member creates.
Consider additional treatment for the parents: Sometimes, parents are struggling with issues that have been put aside in favor of taking care of the child. Often some individual and/or couple treatment is necessary to help the parents be at their best as parents.
For More Information:
Married with Disabled Children
Taking Care of the Other Kids