Chapter 5 - Engaging the Family Into Treatment

Previous chapters have described the basic concepts of BSFT, how to assess and diagnose maladaptive interactions and their relationship to symptoms, and the intervention strategies characteristic of this approach. These concepts also are the building blocks for the techniques that are used to engage resistant families into counseling.

This chapter defines, in systems terms, the nature of the problem of resistance to treatment and redefines the nature of BSFT joining, diagnosing, and restructuring interventions in ways that take into account those patterns of interaction that prevent families from entering treatment.

Regardless of their professional orientation and where or how they practice, all counselors have had the disappointing and frustrating experience of encountering "resistance to counseling" in the form of missed or cancelled first appointments. For BSFT counselors, this becomes an even more common and complex issue because more than one individual needs to be engaged to come to treatment.

Unfortunately, some counselors handle engagement problems by accepting the resistance of some family members. In effect, the counselor agrees with the family's assessment that only one member is sick and needs treatment. Consequently, the initially well-intentioned counselor agrees to see only one or two family members for treatment. This usually results in the adolescent and an overburdened mother following through with counseling visits. Therefore, the counselor has been co-opted into the family's dysfunctional process.

Not only has the counselor "bought" the family's definition of the problem, but he or she also has accepted the family's ideas about who is the identified patient. When the counselor agrees to see only one or two family members, instead of challenging the maladaptive family interaction patterns that kept the other members away, he or she is reinforcing those family patterns. In the example in which a mother and son are allied against the father, if the counselor accepts the mother and son into counseling, he or she is reinforcing the father figure's disengagement.

At a more complex level, there are serious clinical implications for the counselor who accepts the family's version of the problem. In doing this, the counselor surrenders his or her position as the expert and leader. If the counselor agrees with the family's assessment of "who's got the problem," the family will perceive his or her expertise and ability to understand the issues as no greater than its own. The counselor's credibility as a helper and the family's perception of his or her competence will be at stake. Some family members may perceive the counselor as unable to challenge the status quo in the family because, in fact, he or she has failed to achieve the first and defining reframe of the problem.

When the counselor agrees to see only part of the family, he or she may have surrendered his or her authority too early and may be unable to direct change and to move freely from one family member to another. Thus, by beginning counseling with only part of the family, excluded family members may see the counselor as being in a coalition with the family members who originally participated in therapy. Therefore, the family members who didn't attend the initial sessions may never come to trust the counselor. This means that the counselor will not be able to observe the system as a whole as it usually operates at home because the family members who were not involved in therapy from the beginning will not trust the counselor sufficiently to behave as they would at home. The counselor, then, will be working with the family knowing only one aspect of how the family typically interacts.

Some counselors respond to the resistance of some family members to attend counseling by agreeing to see only those who wish to come. Other family counselors have resolved the dilemma of what to do when only some family members want to go to counseling by taking a more alienated stance saying: "There are too many motivated families waiting for help; the resistant families will call back when they finally feel the need; there is no need to get involved in a power struggle." The reality is that these resistant families will most likely never come to counseling by themselves. Ironically, the families who most need counseling are those families whose patterns and habits interfere with their ability to get help for themselves.

Dealing With Resistance to Engagement

When some family members do not want to participate in treatment, has called the counselor asking for help, that parent is not powerful enough to bring the adolescent into counseling. If the counselor wants the family to be in counseling, he or she will have to recognize that the youth (or a noncooperative parent figure) is the most powerful person in the family. Once the reason the family is not in treatment is understood, the counselor can draw upon the concept of tracking (as defined in Chapter 4) to find a way to reach this powerful person directly and negotiate a treatment contract to which the person will agree.

Counselors should not become discouraged at this stage. Their mission now is to identify the obstacles the family faces and help it surmount them. It is essential to keep in mind that a family seeks counseling because it is unable to overcome an obstacle without help. Failed tasks, such as not getting the family to come in for treatment, tend to be a great source of new and important information regarding the reasons why a family cannot do what is best for them. The most important question in counseling is, "What has happened that will not allow some families to do what may be best for them?"

In trying to engage the family in treatment, the counselor should apply the concept of repetitive patterns of maladaptive interaction, which give rise to and maintain symptoms, to the problem of resistance to entering treatment. The very same principles that apply to understanding family functioning and treatment also apply to understanding and treating the family's resistance to entering counseling. When the family wishes to get rid of the youth's drug abuse symptom by seeking professional help, the same interactive patterns that prevented it from getting rid of the adolescent's symptom also prevent the family from getting help. The term "resistance" is used to refer to the maladaptive interactive patterns that keep families from entering treatment. From a family-systems perspective, resistance is nothing more than the family's display of its inability to adapt effectively to the situation at hand and to collaborate with one another to seek help. Thus, the key to eliminating the resistance to counseling lies within the family's patterns of interaction; overcome the resistance in the interactional patterns and the family will come to counseling.

In working to overcome resistant patterns of family interaction, tasks play a particularly vital role because they are the only BSFT intervention used outside the therapy session. For this reason, tasks are particularly well-suited for use during the engagement period, when crucial aspects of the family's work in overcoming resistance to counseling need to take place outside the office--obviously--because the family has not yet come in.

The central task around which engagement is organized is getting the family to come to therapy together. Thus, in engagement, the counselor assigns tasks that involve doing whatever is needed to get the family into treatment. For example, a father calls a BSFT counselor and asks for help with his drug-abusing son. The counselor responds by suggesting that the father bring his entire family to a session so that he or she can involve the whole family in fixing the problem. The father responds that his son would never come to treatment and that he doesn't know what to do. The first task that the counselor might assign the father is to talk with his wife and involve her in the effort to bring their son into treatment.

The simple case. The counselor gives the task of bringing the whole family into counseling to the family member who calls for help. The counselor explains why this task is a good idea and promises to support the family as it works at this task. Occasionally, this is all that is needed. Often people do not request family counseling simply because family counseling is not well known, and thus it does not occur to them to take such action.

Fear, an obstacle that might easily be overcome. Sometimes, family members are afraid of what will happen in family therapy. Some of these fears may be real; others may be simply imagined. In some instances, families just need some reassuring advice to overcome their fears. Such fears might include, "They are going to gang up on me," or "Everyone will know what a failure I am." Once these family members have been helped to overcome their fears, they will be ready to enter counseling.

Tasks to change how family members act with each other. Very often, however, simple clarification and reassurance is not sufficient to mobilize a family. It is at this point that tasks that apply joining, diagnostic, and restructuring strategies are useful in engaging the family. The counselor needs to prescribe tasks for the family members who are willing to come to therapy. These need to be tasks that attempt to change the ways in which family members interact when discussing coming to therapy. In the process of carrying out these tasks, the family's resistance will come to light. When that happens, the counselor will have the diagnostic information needed to get around the family's patterns of interaction that are maintaining the symptom of resistance. Once these patterns are changed, the family will come to therapy.

It should not be a surprise that families fail to accomplish the task of getting all of their members to counseling. In fact, the therapist's job is to help the families accomplish tasks that they are not able to accomplish on their own. As discussed earlier, when assigning any task, the counselor must expect that the task may not be performed as requested. This is certainly the case when the family is asked to perform the task of coming together to counseling.

The application of joining, diagnosing, and restructuring techniques to the engagement of resistant families is discussed separately below. However, these techniques are used simultaneously during engagement, as they are during counseling.

Joining

Joining the resistant family begins with the first contact with the family member who calls for help and continues throughout the entire relationship with the family.

With resistant families, the joining techniques described earlier have to be adapted to match the goal of this phase of therapy. For example, in tracking the resistant family members to engage them, it is necessary to track through the caller or initial help seeker and any other family members who may be involved in the process of bringing the family to counseling. The counselor tracks by "following" from the first family member to the next available family member to the next one and so on. This following, or tracking, is done without challenging the family patterns of interaction. Rather, tracking is accomplished by gaining the permission of one family member to reach the others.

Establishing a Therapeutic Alliance

An effective way for the counselor to establish a therapeutic alliance they want to solve their problems and that the counselor wants the same thing. It must be recognized, however, that each family member may view the problem differently. For example, the mother may want to get her son to quit using drugs, while the son may want peace at home.

A therapeutic alliance is built around individual goals that family members can reach in therapy. Ideally, the counselor and the family members agree on a goal, and therapy is offered in the framework of achieving that goal. However, in families in which members are in conflict over their goals, it is necessary to find something for each of them to achieve in therapy. For example, the counselor can say to the mother that therapy can help her son stop using drugs, to the son that therapy can help him get his mother off his back and stop her nagging, and to the father that therapy can help stop his being called in constantly to play the "bad guy." In each case, the counselor can offer counseling as a means for each family member to achieve his or her own personal goal.

In engaging resistant families, the counselor initially works with and through only one or a few family members. Because the entire family is not initially available, the counselor will need to form a bond with the person who called for help and any other family members that make themselves available. However, the focus of this early engagement phase is strictly to work with these people to bring about the changes necessary to engage the entire family in counseling. The focus is not to talk about the problem but rather to talk about getting everyone to help solve the problem by coming to therapy. By using the contact person as a vehicle (via tracking) for joining with other members of the family, the counselor can eventually establish a therapeutic alliance with each family member and thereby elicit the cooperation of the entire family in the engagement effort.

In engagement, the purpose of diagnosis is to identify those particular patterns of interaction that permit the resistant behavior to continue. However, because it isn't possible to observe the entire family, the BSFT counselor works with limited information to diagnose those patterns of interaction that are supporting the resistance.

To identify the maladaptive patterns responsible for the resistance, diagnosis begins prior to therapy, when a family member first calls the counselor. Because it is not possible to encourage and observe enactments of family members interacting before they enter counseling, engagement diagnosis has been modified so that it can be used during engagement to collect the diagnostic information in other ways.

First, the counselor asks the contact person interpersonal systems questions that allow him or her to infer what the family's interactional patterns may be. For example, the counselor may ask, "How do you ask your husband to come to treatment?" "What happens when you ask your husband to come to treatment?" "When he gets angry at you for asking him to come to treatment, what do you do next?" Through these questions, the counselor tries to identify the interplay between these spouses that contributes to the resistance. For example, is it possible that the wife is asking the husband to come to treatment in an accusatory way, which causes him to get angry? An example might be, "It is your fault that your son is in trouble because you are sick. You have to go to treatment."

As was indicated earlier, counselors do not like to rely on what family members tell them because each family member is very invested in his or her own viewpoints and probably cannot provide a systemic or objective account of family functioning. However, when counselors have access to only one person, they work with the person they have, strictly for the purpose of engaging that person in treatment.

Second, counselors explore the family system for resistances to the task of coming to therapy. This is done by assigning exploratory tasks to uncover resistances that cause the family to fail at the task of coming to therapy. For example, in the case above, the counselor might suggest to the wife that she ask her husband to come for her sake and not because there is anything wrong with him. At that point, the wife may say to the counselor, "I can't really ask him for my sake because I know he's too busy to come to the family meetings." This statement suggests that the wife is not completely committed to getting the husband to come to treatment. On the one hand, she claims to want him to come to treatment, but on the other, she gives excuses for why he cannot. The purpose of exploring the resistance, beginning with the first phone call, is to identify as early as possible the obstacles that may prevent the family from coming to therapy, with the aim of intervening in a way that gets around these obstacles.

What makes this type of early diagnostic work possible is an understanding of the Principle of Complementarity, which was described in Chapter 2. As noted earlier, for a family to work as a unit (even maladaptively), the behaviors of each family member must "fit with" the behaviors of every other family member. Thus, for each action within the family, there is a complementary action or reaction. For example, in the case of resistance, the husband doesn't want to come to treatment (the action), and the wife excuses him for not coming to treatment (the complementary action). Similarly, a caller tells the counselor that whenever she says anything to her husband about counseling (the action), he becomes angry (the complementary reaction). The counselor needs to know exactly what the wife's contribution is to this circular transaction, that is, what her part is in maintaining this pattern of resistance.

In the process of engaging resistant families, the counselor initially sees only one or a few of the family members. It is still possible, through these individuals, to bring about short-term changes in interactional patterns that will allow the family to come for therapy. A variety of change-producing interventions have already been described in Chapter 4: reframing, reversals, detriangulation, opening up closed systems, shifting alliances, and task setting. The counselor can use all of these techniques to overcome the family's resistance to counseling. In the process of engaging resistant families, task setting is particularly useful in restructuring.

The next section discusses the types of resistant families that have been identified, the process of getting the family into counseling, and the central role that tasks may play in achieving this goal. Much of counseling work with resistant families has been done with families in which the parents knew or believed the adolescent was using drugs and engaging in associated problem behaviors such as truancy, delinquency, fighting, and breaking curfew. These types of families are typically difficult to engage in therapy. However, the examples are not intended to represent all possible types of configurations of family patterns of interaction that work to resist counseling. Counselors working with other types of problems and families are encouraged to review their caseload of difficult-to-engage families and to carefully diagnose the systemic resistances to therapy. Some counselors may find that the resistant families they work with are similar to those described here, and some may find different patterns of resistance. In any case, counselors will be better equipped to work with these families if they have some understanding of the more common types of resistances in families of adolescent drug abusers.

Types of Resistant Families

There are four general types of family patterns of interaction that emerge repeatedly in work with families of drug-abusing adolescents who resist engagement to therapy. These four patterns are discussed below in terms of how the resistant patterns of interaction are manifested, how they come to the attention of the counselor, and how the resistance can be restructured to get the family into therapy.

Powerful Identified Patient

The most frequently observed type of family resistance to entering treatment is characterized by an identified patient who has a powerful position in the family and whose parents are unable to influence him or her. This is a problem, particularly in cases that are not courtreferred and in which the adolescent identified patient is not required to engage in counseling. Very often, the parent of a powerful identified patient will admit that he or she is weak or ineffective and will say that his or her son or daughter flatly refuses to come to counseling. Counselors can assume that the identified patient resists counseling for two reasons: It threatens his or her position of power, and counseling is on the parent's agenda and compliance would strengthen the parent's power.

As a first step in joining and tracking the rules of the family, the counselor shows respect for and allies with the adolescent. The counselor contacts the drug-abusing adolescent by phone or in person (perhaps on his or her own turf, such as after school at the park). The counselor listens to the powerful adolescent's complaints about his or her parents and then offers to help the youth change the situation at home so that the parents will stop harassing him or her. This does not threaten the adolescent's power within the family and, thus, is likely to be accepted. The counselor offers respect and concern for the youth and brings an agenda of change that the adolescent will share by virtue of the alliance.

To bring these families who resist entering treatment into treatment, the counselor does not directly challenge the youth's power in the family. Instead, the counselor accepts and tracks the adolescent's power. The counselor allies himself or herself with the adolescent so that he or she may later be in a position to influence the adolescent to change his or her behavior. Initially, in forming an alliance with the powerful adolescent, the counselor reframes the need for counseling in a manner that strengthens the powerful adolescent in a positive way. This is an example of tracking--using the power of the adolescent to bring him or her into therapy. The kind of reframing that is most useful with powerful adolescents is one that transfers the symptom from the powerful adolescent/identified patient to the family. For example, the counselor may say, "I want you to come into counseling to help me change some of the things that are going on in your family." Later, once the adolescent is in counseling, the counselor will challenge the adolescent's position of power.

It should be noted that in cases in which powerful adolescents have less powerful parents, forming the initial alliance with the parents is likely to be ineffective because the parents are not strong enough to bring their adolescent into counseling. Their failed attempts to bring the adolescent into counseling would render the parents even weaker, and the family would fail to enter counseling. Furthermore, the youth is likely to perceive the counselor as being the parents' ally, which would immediately make the adolescent distrust the weak counselor.

Contact Person Protecting Structure

The second most common type of resistance to entering treatment is characterized by a parent who protects the family's maladaptive patterns of interaction. In these families, the person (usually the mother) who contacts the counselor to request help is also the person who is-- without realizing it--maintaining the resistance in the family. The way in which the identified patient is maintained in the family is also the way in which counseling is resisted. The mother, for example, might give conflicting messages to the counselor, such as, "I want to take my family to counseling, but my son couldn't come to the session because he forgot and fell asleep, and my husband has so much work he doesn't have the time."

The mother is expressing a desire for the counselor's help while protecting and allying herself with the family's resistance to being involved in solving the problem. The mother protects this resistance by agreeing that the excuses for noninvolvement are valid. In other words, she is supporting the arguments the other family members are using to maintain the status quo. It is worthwhile to note that ordinarily this same conflicting message that occurs in the family maintains the symptomatic structure. In other words, someone complains about the problem behavior, yet supports the maintenance of the behaviors that nurture the problem. This pattern is typical of families in which the caller (e.g., the mother) and the identified patient are enmeshed.

To bring these families into treatment, the counselor must first form an alliance with the mother by acknowledging her frustration in wanting to get help and not getting any cooperation from the other family members to get it. Through this alliance, the counselor asks the mother's permission to contact the other family members "even though they are busy and the counselor recognizes how difficult it is for them to become involved." With the mother's permission, the counselor calls the other family members and separates them from the mother in regard to the issue of coming to counseling. The counselor develops his or her own relationship with other family members in discussing the importance of coming to counseling. In doing so, he or she circumvents the mother's protective behaviors. Once the family is in counseling, the mother's overprotection of the adolescent's misbehavior and of the father's uninvolvement (and the adolescent's and father's eagerness that she continue to protect them) will be addressed because it also may be related to the adolescent's problem behaviors.

Disengaged Parent

These family structures in which one parent protects the family's maladaptive patterns of behavior are characterized by little or no cohesiveness and lack of an alliance between the parents or parent figures as a subsystem. One of the parents, usually the father, refuses to come into therapy. This is typically a father who has remained disengaged from the problems at home. The father's disengagement not only protects him from having to address his adolescent's problems but also protects him from having to deal with the marital relationship, which is most likely the more troublesome of the two relationships he is avoiding. Typically, the mother is over-involved (enmeshed) with the identified patient and either lacks the skills to manage the youth or is supporting the identified patient in a covert fashion.

For example, if the father tries to control the adolescent's behavior, the mother complains that he is too tough or makes her afraid that he may become violent.2 The father does not challenge this portrayal of himself. He is then rendered useless and again distances himself, re-establishing the disengagement between husband and son and between husband and wife. In this family, the dimension of resonance is of foremost importance in planning how to change the family and bring it into therapy. The counselor must use tasks to bring the mother closer to the father and distance her from the son. That is, the boundary between the parents needs to be loosened to bring them closer together, and the boundary between mother and son needs to be strengthened to create distance between them.

To engage these families into treatment, the counselor must form an alliance with the person who called for help (usually the mother). The counselor then must begin to direct the mother to change her patterns of interaction with the father to improve their cooperation, at least temporarily, in bringing the family into treatment. The counselor should give the mother tasks to do with her husband that pertain only to getting the family into treatment and taking care of their son's problems. The counselor should assign tasks in a way that is least likely to spark the broader marital conflict. To set up the task, the counselor may ask the mother what she believes is the real reason her husband does not want to come to counseling. Once this reason is ascertained, the counselor coaches the mother to present the issue of coming to treatment in a way that the husband can accept. For example, if he doesn't want to come because he has given up on his son, she may be coached to suggest to him that coming to treatment will help her cope with the situation.

Although the pattern of resistance is similar to that of the contact person protecting the structure, in this instance, the resistance emerges differently. In this case, the mother does not excuse the father's distance. To the contrary, she complains about her spouse's disinterest; this mother is usually eager to do something to involve her husband; she just needs some direction to be able to do it.

Families With Secrets

ometimes counseling is threatening to one or more individuals in the family. Sometimes the person who resists coming to counseling is either afraid of being made a scapegoat or afraid that dangerous secrets (e.g., infidelity) will be revealed. These individuals' beliefs or frames about counseling are usually an extension of the frame within which the family is functioning. That is, it is a family of secrets. The counselor must reframe the idea or goal of counseling in a way that eliminates its potential negative consequences and replaces them with positive aims. One example of how to do this is to meet with the person who rejects counseling the most and assure him or her that counseling does not have to go where he or she does not want it to go. The counselor needs to make it clear that he or she will make every effort to focus on the adolescent's problems instead of the issues that might concern the unwilling family member. The counselor also should assure this individual that in the counseling session, "We will deal only with those issues that you want to deal with. You'll be the boss. I am here only to help you to the extent that you say."

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