Many of us have experienced the complexity of a child therapy case in which the parents are not amenable to change. If the parents are resistant, the pathological parent-child relationship is highly unlikely to improve. In my own practice, I have found this to be an issue particularly with children who have been neglected and abused, but it arises in many of my child and adolescent cases, regardless of the presenting problem.
Certainly, when dealing with a child's disruptive behavior and a parent's feelings of frustration or even clear hostility toward the child, the most successful intervention is usually some form of family intervention. Family therapy has long been our primary approach to behavioral problems with children and adolescents, with strong evidence of its efficacy. And the integration of family therapy and individual treatment has been standard practice for years, as it is not uncommon for individual members of the family to require separate but parallel help.
But I have found over the years that such parallel help is not always successful. In some cases, parental problems pose such serious difficulties for the child or adolescent that a drastically different approach is necessary. Consider the angry 11-year-old who has begun acting out, and who will soon enter the wider, more demanding world of adolescence, where his difficulties with authority could easily escalate. If his parents are also hostile and uncooperative in therapy, it often becomes a question of time; there may be some chance that the parents would benefit from an intervention effort, but not without the passage of more time than the child can afford.
The issue becomes, then: “When do we shift from trying to work within the parent-child relationship to seeing the child as a separate entity needing to find a way to protect him- or herself from the negative impact of a destructive parent?”
Three Contrasting Cases
The following three cases exemplify how major differences in parent-child relationships impact the treatment process with families, and how the child's perception of acceptance versus rejection is a key factor in this. Jane, the first case, has a mother able to work separately on her own problems in a way that aids the family therapy process. The second case, Mike, is at the other end of the continuum with a totally destructive parent. The third case, Roberta, falls in the middle, where the parents are trying to be part of the family therapy effort, but the adults' personal difficulties block the therapeutic process. The parents of Jane and Roberta contacted me at my private office seeking help for their girls, while the mother of Mike came to a community clinic where the local courts often sent youngsters and their parents for assistance.
Jane
Jane's mother and father were in a constant battle with nine-year-old Jane as she fought every rule and requirement they imposed. She had become increasingly uncooperative in school, and her peers were rejecting her. As family treatment progressed with the use of behavioral contingencies, Jane's mother reported that she was unable to follow through on negative consequences: she had a great deal of difficulty saying "no" to Jane. During an individual session she explained that she wanted Jane to grow up to be her friend. She feared that being firm with her now would make Jane "hate" her later on. Jane's mother had had a very traumatic relationship with her own mother. Jane's maternal grandmother had a serious substance abuse problem and Jane's mother went through years of feeling angry with her. The grandmother died without having reconciled with her daughter. Jane's mother's painful past relationship with her own mother was controlling her perception of her daughter ("she will learn to hate me"); in turn, this perception was interfering with her ability to be a parent to Jane.
This mother, although angry and frustrated, was bonded with her child and desired a better relationship; she was certainly not a hostile and rejecting parent. She was amenable to treatment and learned in individual work how her past experience was interfering with her relationship with Jane beyond just the issue of saying "no." She learned that changing Jane's current behavior required that she make some changes as well. As Jane's mother worked on her own issues, the family work progressed quickly.
Mike
In contrast to Jane's story, Mike's mother followed a court order to seek therapy for her 14-year-old boy who avoided school, stayed out as late as he wished, affiliated himself with a gang, and was finally arrested for stealing bikes from neighborhood children. The court placed him on probation with clear instructions that if he did not go to school, was not in his home by a specific time in the evening, and/or continued any contact with the gang members, his probation would be revoked and he would be incarcerated in a juvenile facility. Mike felt that his mother hated him and wanted him "put away." His mother refused to attend family or individual sessions herself, stating that only Mike needed help. She frequently called the probation officer to complain about Mike's behavior and avoided contact with me. Many of her complaints about Mike were issues that could have been handled by working directly with her and Mike together, with the help of his probation officer. I explained my professional opinion to his mother, but she refused to be involved. She stated that she did not have the time and believed that Mike was simply "evil."
We had started family treatment by working out an agreement regarding what was expected of Mike (e.g., getting himself to school on time, when to be home, the kids he had to avoid, the kids he could spend time with) and what his mother should do to reward his cooperation (increasing his allowance and TV game time were the "rewards" he wanted). Mike's mother, unfortunately, failed to cooperate with this agreement; this, combined with her emotional rejection of him, led to Mike seeing the agreement as a farce.
His mother's view of him had determined Mike's view of himself, which factored significantly into his destructive behaviors. He felt rejected by his mother and struggled with feelings of worthlessness as a result. On one level, he appeared to blame his mother, and made angry statements about how wrong he felt she was. At a second level, however, he blamed himself and had to deal with feelings of depression. At times he entertained self-destructive thoughts, but denied any actual plans to harm himself.
Unfortunately, Mike's justified anger at his mother's rejection left him eager to maintain a relationship with his gang friends. Eventually his mother spotted him talking to one of them and reported it to the probation officer, who revoked his probation and sent him to a juvenile facility, thus ending treatment.
Roberta
In a third case, Roberta, a 13-year-old girl, was living with her father and stepmother. She was trying to maintain contact with her mother, but her mother lived with a boyfriend who had been found guilty of sexually abusing Roberta. He had been incarcerated for a few months, and was again living with Roberta's mother, but now was not permitted to be home when Roberta visited. The mother admitted that she did not believe the abuse had occurred, and blamed Roberta for all the personal and legal difficulties she and her boyfriend had gone through as a result of the accusations.
Roberta's father, on the other hand, had married a younger woman who related to Roberta as a sibling rather than an adult. Roberta's father greatly enjoyed and depended upon the devotion of his young bride. He thought that the only way his life could proceed happily was if his daughter would cater to his wife's demands. He perceived his daughter's adolescent struggle for independence, along with her competition with his wife for his attention, as serious threats to his personal happiness.
Roberta was in an almost continuous rage as she struggled to deal with how "unfair" she said her mother and father were, how "disgusting" she said her stepmother was, and how "dangerous" she reported her mother's boyfriend to be. She continuously fought any expression of authority by all the adults in her family. She was increasingly defiant in school, and had also become sexually active with several neighborhood boys.
All of the intra- and interpersonal issues in this family were potentially amenable to treatment. However, “the parents were each involved in complex, competing relationships that resulted in therapy moving forward at glacial speed, while the child continued to struggle and act out.”
In this case, Roberta's perception of rejection was based on the negative communication from her mother and father that represented their own frustrations. The long-term conflict between Roberta and her parents served for her as evidence of rejection. The young girl was not in a position to recognize that her parents' behaviors were reactions to other complex issues in their lives, and not indicative of their love for her or lack thereof.
In addition to anger at the adults in her life, Roberta expressed strong feelings of sadness, including self-destructive thoughts, which were difficult for her to share with me. Fortunately, these stayed at the occasional "thought" level and never progressed to self-destructive plans or actions.
A Therapy Model
These types of cases are serious in terms of the potential for both antisocial acting out and self-destructive behaviors. And many of these cases do not respond at all, or much too slowly, to the usual attempts at family therapy. By "usual" I am referring to interventions that aim for the maintenance of an improved family unit. Such therapy facilitates changes in the child's behavior partly through internal changes the child makes, and partly as a result of positive intra-family changes. But what about the cases where intra-family changes may not occur at all, or only after it is too late for the child developmentally?
I have found that, in these situations, the only way to counteract the effects of a child perceiving himself as rejected, and hence unworthy, is for the youngster to perceive the rejecting behavior of his parent as evidence of his parent's deficiencies rather than his own.
The issue is not limited to dealing with the child's anger. In other cases, rejection may not be a major issue. For example, a child who has experienced the affection and acceptance inherent in a normal parent-child relationship, now an adolescent, is struggling with her parents over money, dating, homework, etc., and says things that hurt her parents. In this case, we are not dealing with the same anger issue. This child's angry interactions with parents and their inappropriate responses can often be dealt with successfully in therapy. Parents and child learn to deal with their mutual misinterpretations, develop alternate and more acceptable ways of expressing anger, and establish agreements regarding major conflict areas. By contrast, “in the cases I am discussing here, the child's anger, although a problem, is not the major issue. The real issue is the depressive effect of emotional rejection.”
Therefore, the issue is not only that of managing anger but also of dealing with the destructive effects of parental rejection. The power of that rejection is based on the child's underlying belief that the rejection means that the child is an unworthy person. The issue is now how to confront that underlying belief and assist the child in rejecting it.
One approach is to foster the psychological separation of child and parent by helping the child to recognize the ways in which his parent(s) have failed to meet the child's needs. The therapist also helps the child understand that his needs for attention, age-appropriate independence, etc., are normal. In this manner, the therapist is able to assist the child in rejecting his parents' negative perception of him. It is helpful, in this process, to find examples of ways in which the parents do things or provide things that only a parent who loves their child would do. The child can then recognize the parent's inability to meet his needs, while rejecting the validity of the parent's perception. The child finds other means of validating his worthiness.
By this time, the therapeutic process has greatly reduced the parents' emotional impact on the child. The child must now recognize the harmful effects of his own angry or frustrated responses to his parents, then learn to manage those responses in order to foster appropriate parent-child interactions.
George: Fostering Independence in Older Children
George was a 15-year-old high school student. For several years, school personnel had described him as consistently performing below his capacity, always passing his subjects but never doing more than was absolutely necessary. He recently started smoking marijuana with some frequency, and his relationship with his divorced parents (both successful professionals with busy careers) was becoming increasingly stormy.
Separately, each parent complained that there were no problems so long as George always got his own way. If either of them objected to his hours, wanted to see him put more effort into school work, questioned him about finding drug paraphernalia in his room, or made any other demands on him, George would swear at them, slam doors, break objects, and storm out the door. Sometimes, when that happened, he would go to the other parent's home and just settle in there. The "receiving parent" usually just accepted his presence and avoided asking any questions so as to avoid another emotional explosion.
George was an only child whose parents separated when he was five years old. In therapy, he recalled many fights between his parents in which he was the central figure.”He insisted that the fights between his parents went on for days and could be instigated by almost anything he did. As he explained it, "they got divorced because they hated me."”
George was unable to think positively about his future. The prospect of attending college, which both of his parents encouraged, was acceptable to him as long as he was allowed to live far away from both parents and was given enough money to be "comfortable." He was only interested in schools that had a "party – party" reputation. He refused to discuss his ideas about long-term goals or career interests.
I first met with George and both his parents together, then saw each of them for two private sessions apiece to obtain a history and for diagnostic purposes. The first treatment approach was family therapy involving all three parties. We started by dealing with such issues as George's need for his parents to respect his independence, and his parents' need for him to respect their authority. We struggled to find compromises that might reduce the conflict between them. The family failed to progress, and ultimately it became clear that each parent had significant psychological issues of their own that seriously impacted all the possible dyads—mother-father, mother-son, and father-son. The parents could not move away from blaming each other for every issue they had with their son. As they persisted in their angry recriminations and constant fault-finding with each other, George showed increasing disdain for each of them. George interpreted their behavior as simply reinforcing his perception that they blamed him for all of the family's problems.
I advised each parent that they could benefit from individual counseling, but they both refused, insisting that the problem was only with George. I terminated the family sessions and changed the therapy plan to weekly individual sessions with George and a family meeting every five or six weeks to review the current status of their family life.
In the individual sessions, George expressed his anger at his parents and his negative feelings towards himself, referring to himself as the cause of his parents' divorce and continuing conflict. I began to interpret some of George's behavioral descriptions of parent-child interaction as indicators of faults in his parents. “I suggested that some of George's memories, if they were accurate, described parents who certainly loved their child but whose behavior strongly indicated personal weakness or deficiency.” I confronted George's idea that he caused the divorce with the argument that George's early childhood behavior represented a normal range of pestering child behavior that all parents have seen. I suggested to George that his parents' responses to his behavior represented inadequacies in parenting skill.
As his descriptions moved to more recent interactions between his parents, I suggested that it was not surprising that they divorced, as they clearly had significant difficulties dealing with each other. George described a battle going on in which his father was screaming at his mother about her spending money. His mother then retaliated by blaming him for wasting money on a bike for George that she said George did not use enough. George felt that they were again fighting about him and that it was his fault. I strongly suggested that none of these battles between his parents could possibly be blamed on George, and in this case his mother was only mentioning George and his bike as ammunition in her fight with his father.
As George began to accept that his parents had real deficiencies, he started to examine his more recent conflicts with each one. At times, he would place total responsibility for an incident on the parent. For example, he expected his mother to ignore his drug use and just allow him to smoke his marijuana in the living room. She had objected, a screaming match ensued, and George walked out of the house. He complained that she "was old fashioned and didn't understand the modern world." I told George I was surprised that he did not seem to understand that no responsible parent would ever ignore their son's drug use. Even if the son is a legal adult, every person has the right to decide what is and is not allowed in their own home. He challenged me for my own views, and I shared with him many examples of my exercising parental authority with my own sons. The real issue here, I explained, was not that of smoking marijuana, but was actually his impulse to challenge his mother's authority. He was behaving as if his mother was just one of his teenage buddies. I told him that the solution was not for him to stop using marijuana, but rather for him to stop throwing it in his parents' faces.
The real issue here, I explained, was not that of smoking marijuana, but was actually his impulse to challenge his mother's authority. He was behaving as if his mother was just one of his teenage buddies.Using this type of confrontative approach, we were able to keep a reasonable focus on George's own contribution to many parent-child conflicts. This approach had two goals: developing the skills necessary to manage future interactions with his parents, and improving George's awareness that his ability to anger his parents (and others) was based on his behavior, not their innate hatred of him.
As George explored his memories of his family life, he discovered many experiences that he could easily interpret as each parent demonstrating their love for him. After a while, he was able to accept the possibility that activities and experiences like Little League and family trips to foreign places might have been motivated by their wish to make him happy, and that such a wish might indicate parental love. Slowly, he began to perceive his parents' negative behaviors as expressions of their own emotional difficulties. He understood their outbursts of anger toward him as being reasonable and expected responses to his own obnoxious behavior, instead of evidence of a basic hatred of him.
We next focused on his learning to care for himself and depend less on his parents. I helped him understand that his happiness—and he had a right to be happy—could no longer be determined and influenced by his parents. He needed to take charge of his own life. He began to perceive school success, for example, as something he was doing for himself and not for his parents. This process is, in part, congruent with the developmental process of adolescence. In George's case, it was also a response to the real issue: that his parents' difficulties prevented them from providing him with emotional support or practical guidance. Finally, George independently contacted the college and career guidance services available at his school and found the staff more able to respond to his anxieties about his future than his parents. He began to think critically about what he wanted from a post-high-school education.
Jamie: Nurturing Dependency in Younger Children
By virtue of his age, 15-year-old George was at the beginning of a developmental stage that entails building independence, greater self-reliance, and increased separation from parents. Hence, the therapy process was supported by developmental realities.
But what if George had been eight years old instead of fifteen? How could this approach possibly work? The phenomenon of pseudo-maturity is well known. “The phenomenon of pseudo-maturity is well known. Young children dealing with neglect, for example, often demonstrate role reversal and become the parent.” We describe these children as having "lost their childhood." They have difficulty trusting others, are emotionally insecure, and often exhibit symptoms of depression. The therapy approach described above, applied to a child as young as eight, would appear to promote the development of pseudo-maturity, and this is indeed a possibility.
In this type of case, we must respond to the dependency needs of the younger child while dealing with the need to separate from the parents. The case of Jamie provides an excellent example of how this can be done. Jamie, age eight, was the oldest of two children. Her parents complained that she was resistant, uncooperative, and a discipline problem. They seemed overwhelmed by her insistence on staying up later than her bedtime, arguing about what they fed her, and refusing to allow them to monitor her homework. If they argued about homework too much, she simply refused to do the work. At first, we worked on behavioral contracts with clear expectations and rewards that Jamie could earn. But her parents could not stay consistent with the program; each expressed feeling overwhelmed by having to do such things as reward their child. They simply wanted Jamie to take care of any issues related to school, eating, dressing, bathing, and so on, without their involvement. They also continued to express anger whenever a complaint from school, for example, required their time and effort.
I looked for what was positive in Jamie's life and what made her happy. She expressed a desire to have a closer relationship with a female teacher she admired, and I encouraged that. This changed her relationship to her homework: instead of seeing it as grounds for a power struggle with her parents, Jamie came to recognize the hopelessness of that interaction. Through this new relationship with her teacher, she was finally able enjoy the emotional satisfaction of academic success. As Jamie's grades improved, her emotionally destructive interactions with her parents diminished.
The emotional turmoil in the lives of Jamie's parents made even the purchase of a bike a serious issue for therapy. Questions about the type and size of the bike, which accessories to get (if any), and where they should purchase it, resulted in major distress for her parents, and certainly for Jamie as she tried to deal with them over an object that was very important to her.
In treatment, Jamie learned that she was incorrect in her perception that her parents wanted to deny her the bike because they loved her sibling more. She found many memories where her parents had given her things, had fun with her on vacations, and showed pride in her accomplishments. Independently, I learned from the parents that these memories were accurate. I directly stated to Jamie that these were the things that parents who loved their child did for them. I also explicitly interpreted to her that, regarding her parents' more negative behavior, they clearly had difficulty making decisions without exhibiting anger and confusion. This was behavior that she had often seen. Jamie did not express the need to know why this happened, but was comforted by seeing the behavior as a problem the parents had, and not her responsibility.
I have found that direct statements to a child, such as those above to Jamie, are the best way to deal with a child's misperceptions. In Jamie's case, they would quickly result in our talking about major issues. And, as with any therapist-offered interpretation, Jamie might reject what was offered, then follow up with more of her feelings about the situation. “There is always the danger that a younger child will agree with you simply because you are the powerful adult”, but I have found that my patients, even quite young ones, are very comfortable in questioning or challenging any of my input. It is a matter of the quality of our relationship during treatment.
With my help, Jamie did the necessary research and presented to her parents a firm package of bike type, size, price, and a local bike store where it was available. Her parents quickly bought her the bike and not another word was said. Her Girl Scout leader became the adult who assisted with bicycle maintenance and with whom she shared her biking adventures.
“I could meet some of Jamie's dependency needs, but, of course, no therapist should try to fulfill that role.” The therapy process required helping her find other child-adult relationships to fill this void. At the same time, Jamie needed to learn that her Girl Scout leaders, teachers, and a grandmother who lived close by could help, but also had their limitations. We addressed her jealousy of the Scout Leader's own children and of the other children in her class that her teacher showed concern for.
Parental Complications
This model calls for recognition that, in some cases, the relationship between parents and child is a damaged one, and that the primary culprit is the parents' emotional makeup. The cases described here have involved a single-parent home, or two-parent families where both parents are the problem. In other cases, one parent might be amenable to change while the other is not. The "amenable" parent's growing awareness of the other parent's pathology and consequent destructive impact on the child often results in worsening marital discord, and sometimes separation and divorce. In those cases, my work with the child is assisted by getting the parents to see someone specializing in marital therapy. I found this assistance to be essential, and in these cases successful marital therapy allowed me to be successful with the child. Unfortunately, when the disturbed parent refuses marital counseling, that parent usually wants to terminate the child's therapy as well.
Considerations to the Approach
Some parents' difficulties are long-term and extremely resistant to any intervention, but children move along a developmental timeline that waits for no one. In these cases, individual work with the child may have to become the primary intervention, and the normal process of a child's psychological separation from the parent may have to be accelerated.
There are potential problems with this approach that a therapist needs to be aware of. Therapy patients of any age can become dependent on the therapist to a degree that interferes with their progress. I believe that children are even more vulnerable in this regard. “Needy children struggling with difficult parents can easily provoke rescue fantasies in the therapist.” I have seen, for example, young therapists I was supervising jumping in and doing things for the child-patient when they should have been assisting the child to develop the skills to function independently.
A major potential stumbling block is the parents' response to the increasing independence of the child. Problems can occur if the child expresses that independence by openly rejecting the parents' authority. For example, if Jamie had announced to her parents that they need not bother to make any rules in the house because she would only follow what her scout leader said was appropriate, we would certainly have seen increasing conflict between them. The treatment process includes the child's learning how to disagree with parents in ways that avoid such difficulties.
In closing, I wish to stress that this approach is one the therapist must choose only after family therapy has already been tried energetically without success. What I have described here is a compromise in which we must give up family therapy's power to move the whole family forward, in a last-resort effort to rescue the child.
