Walking A Tightrope: Family Therapy with Adolescents and Their Families

Beyond the Comfort Zone

“Clyde is spiraling out of control,” she cried.  “He’s begun to hang out with a bunch of do-no good, do-nothing hoodlums.” She was worried that failure—or worse, tragedy—was aggressively recruiting her only child. “He is a good kid,” she attempted to reassure me, “but I worry about him being in the wrong place at the wrong time.”  Although he’d had no brushes with the law, she was terrified of any potential encounters he might have with the police—an encounter she intuitively knew could be a matter of life or death. 

“Mrs. Gilyard, like so many other parents of color, was raising her child with the police foremost in her thinking.”  While she and her husband enjoyed a solid middleclass lifestyle, both were African American and understood all too well the rules of the streets, especially regarding young black males. Mrs. Gilyard was worried because she understood that the urban streets were unforgiving for many young black males like Clyde. Unfortunately, Clyde, according to his mother, “knows everything and won’t listen to me or his father.”  In fact, Clyde had, in a very short period of time, according to his mother, transformed from a “very respectful young man” to a disrespectful, self-centered, impulsive shadow of the human being he used to be. “He’s moody, often refusing to talk for days, and all he wants to do is sleep, text message, hang out with his friends, and download music.  To be honest with you, Dr. Hardy,” Mrs. Gilyard said, “although he is my God-given son…” She paused. “I am quickly getting to the place where I can’t stand to be in his presence. I am not sure I even like him anymore. I can’t tolerate his nasty attitude. I have no patience with him. I’m worried that I might hurt him, or someone else will, if he doesn’t get some help.”

As our telephone conversation progressed, it seemed to have no end in sight. Mrs. Gilyard needed to vent and was oblivious to time or circumstance. I tried numerous times to gracefully end the phone conversation that was dangerously slipping into a full-blown noncontractual, nonconsensual therapy session, but Mrs. Gilyard was too consumed by her utter sense of desperation, now flirting with panic. 

I commented that although she seemed to have moments where she felt disdain for Clyde’s behavior, her dominant feelings towards him seemed to be worry, fear, and a deep motherly love for him. I went on to suggest that I imagined the situation with Clyde was taking a huge toll on her, as well as the entire family, and although she was seeking treatment for Clyde, I thought it would be helpful for the entire family to attend.  My comment and suggestion apparently surprised Mrs. Gilyard and immediately earned her ire. Her tone and approach to our conversation changed instantly.

“Why do we need therapy?” she demanded.  “I don’t think there is anything wrong with Claude and me, and I honestly don’t know what there is for us to gain from coming into therapy. We will do whatever to help Clyde, but he has to find himself and nobody else can do that for him. As his parents, we have to provide him with love, support, and guidance, but he has to be willing to accept it. Right now, his friends and his music seem to be all he cares about!   I don’t see how us coming to therapy is going to help him get what he needs.”

My interaction with Mrs. Gilyard suddenly shifted from the emotionally intense, unconditionally accepting reflective listening phase of engagement to one of the most delicate and thorny areas of family therapy: problem definition and who should attend the session. These issues are always critical dimensions of family therapy treatment. Mrs. Gilyard and I suddenly found ourselves on a major collision course.  She remained convinced that Clyde was the problem and that whatever was going on with him needed to be fixed inside of him.  In her world, problems were individual and the solutions were simple: you found out what was broken and you fixed it. From her perspective, Clyde was broken, like a malfunctioning carburetor in a car, and in either case the solution was a simple matter of targeting it and repairing it.  She seemed to be oblivious to the fact that even the best mechanic in world could not repair a faulty carburetor without having access to the car! This was where our worldviews collided.

I believe that all problems are essentially relational and that we all are relational beings living our lives in a relational context.  As a family therapist, I believe that problems are delicately and seamlessly interwoven in a nexus of relationships.  “It is difficult for me, if not impossible, to envision any human interaction problem without considering the relational context in which it is embedded.” So, unlike Mrs. Gilyard, I assumed that the problems were embedded in relationships and the relationships were embedded in problems.  In this regard, in cases such as the Gilyards’, it is my contention that family members contribute to the formation of a problem, the maintenance of it, or both. And if problems are embedded in relationships, so are solutions! Thus, having the entire family participate in therapy is essential. 

However, from the perspective of Mrs. Gilyard, Clyde was the problem because it was his behavior that was problematic. It was he who was broken, malfunctioning, or deviating from family and societal norms. Accordingly, Mrs. Gilyard believed that the best solution to the problem was to treat the problem: Clyde! The dilemma was that if I dismissed Mrs. Gilyard’s definition in favor of mine, therapy could not occur. Yet on the other hand, if I abandoned what I believe, how could I possibly assist the family without further problematizing Clyde? Before ever meeting Clyde, it was crystal clear to me that he was considered the problem and would continue to be until his deeds, attitudes, and behaviors complied with his mother’s wishes.  So in a sense, the only problem was the problem that was asserted by the family. And, if I insisted otherwise–i.e. that my definition of the problem should overshadow the family's viewpoint–then that would only result in creating yet another problem! This is the tightrope that all family therapists have to gently and delicately traverse.

            Despite Mrs. Gilyard’s claim that she would do anything to assist Clyde “in getting his life back,” attending therapy with him was not on her immediate list. Because I often believe that a family’s refusal or reluctance to participate in therapy is usually a result of a tendency to think individually and not relationally, and an underlying fear of being blamed and/or exposed, I knew I had to tackle both of these issues with Mrs. Gilyard if family therapy were to ever take place.

I tried to reassure her that a family session would not be about finger pointing or keeping score about who did what to whom. “It will be a place where we can develop a deeper and better understanding regarding how the family operates and how each of you is affected by what everyone does,” I explained over the phone. “You know, families cannot function well when each member attempts to do what they think is right or best without considering how it affects others.”

At this point, although unfazed and unconvinced, she at least seemed willing to listen more carefully.

“You, along with your husband, seem to be concerned, involved, and loving parents. I imagine the two of you have an infinite reservoir of information about Clyde that you have been collecting since his birth. You, quite possibly unlike any other person on the planet, have cherished early life memories of Clyde that you have probably safely tucked away in the secure closets of your mind. I know you and your husband need my help, and I am honored that you are willing to trust Clyde in my hands. But I need you and your husband’s help as well. I need the infinite knowledge and wisdom that you and quite possibly only the two of you have about him as well. My time with him will be limited no matter how much time we have, and it would be great to have the two of you as resources. You know, I am sure you have heard that old African proverb expressed a million times that it ‘takes a village to raise a child.’ Well, if Clyde is struggling as much as you say he is—and I have no reason to believe otherwise at this point—he needs a village. And we will be Clyde’s village!” 

After an impregnated pause and a chilling silence, Mrs. Gilyard, in a much softer voice, said with a slight sigh of relief and perhaps resignation, “Yes, you’re right.  Clyde is a part of me. He is like my third arm or leg. I do know him. Or at least, I used to.  I will talk to my husband. Doctor, I hope you—er, I guess I should say, I hope we can help my son.”

It Takes a Village

Exactly one week later following our phone conversation, Mrs. Gilyard made good on her promise. She, her husband of 30 years Claude, and their son Clyde arrived at my office for our first session. My initial interactions with the family were pleasant and polite as we engaged in light-hearted conversations about the weather and traffic. Throughout it all Clyde remained detached, appearing disinterested but respectful.  There was an understandable tightness to the family. They seemed tense. Mr. Gilyard was noticeably uncomfortable and asked several times in the first few minutes about how long the session would last and how many sessions would it take before they would “see results.”

I thanked the family for coming and their dedication to finding answers to issues that were plaguing them. Then I turned to Clyde. “I’ve talked to Mrs. Gilyard on the phone and know that she is worried a great deal about you.”

He smirked slightly but refused to bite the bait and respond to me verbally. I was encouraged by the smirk because it was a sign of responsiveness to being engaged—a private mental note I made certain to record.  I turned to Mr. Gilyard and asked, “Do you share your wife’s concerns?” Then, turning to Clyde again, “What do you think about all of this?” To increase the probability of participation throughout the therapeutic process, “it is imperative in family treatment to acknowledge all family members as early as possible and to invite their participation even if and when they passionately refuse.”

The room was quickly filled with a breathtaking silence and discomfort. Finally, perhaps as a function of her discomfort, Mrs. Gilyard broke the mounting minutes of silence that must have felt like hours to the family, by inexplicably saying: “You are so much smaller than I imagined you to be. I for some reason expected a bigger, older man.”

After many years of clinical practice, I am seldom surprised by the disclosures that are uttered within the private walls of therapy, but I was surprised by Mrs. Gilyard’s comment and wasn’t immediately sure what to make of it. I simply responded: ‘Oh, well… Thanks for your honesty… I always find it an interesting task to imagine what someone looks like based on their voice and telephone personality.” 

It was of note to me that Mrs. Gilyard elected to make me the focal point at the precise moment that I was attempting to engage Claude and Clyde about their perceptions about the family. Maybe this was coincidental, but I wondered if I was getting a snapshot of how hard Mrs. Gilyard worked in this family.  Since I had spent an appreciable amount of time with her on the phone, I really wanted to make a concerted effort to interact with Claude and Clyde. So I returned to father and son and asked, “What is going on with the family from where you sit?” 

Mr. Gilyard then turned to Clyde and said: ‘The doctor’s talking to you. Tell him what you think. And sit up, please. And Clyde, take off the hat. And put that thing away,” she ordered, gesturing toward his son’s iPod. Clyde sat still and stoically, dressed in a blue-and-white NY Yankee baseball cap that he had on backwards, stylishly coordinated with an elegant blue silk tee shirt, and blue-and-white Jordan sneakers.  He looked at his father and slowly removed his baseball cap, never uttering a single word. 

 Mr. Gilyard, after thinking for a few minutes, said he was worried about Clyde and believed it was getting harder and harder to reach him.  He noted that he didn’t share his wife’s short fuse with regards to Clyde’s antics but was bothered by his son’s lack of direction.  “He doesn’t take life seriously. He thinks it’s a joke, a game!  He has no sense of the sacrifices that his mother and I and many who came before us have made for his benefit.  He is reckless, impulsive, and irresponsible. He thinks only of today, this minute—this second!  He has no goals or interest in anything. He wants to sleep his life away,” observed Mr. Gilyard, his voice rising. “I am so afraid that he is going to wake up one day and suddenly discover that life is indeed short, precious, and waits for no one—a realization that will come much too late for him to do anything about it.” 

As Mr. Gilyard’s lower lip began to quiver, and his right eye began to slowly fill with a single developing tear, I asked him to turn to his son and to tell him that he loved him and that he was worried about him.  The older man seemed stunned and paralyzed by my request.  Obviously overcome and perhaps even slightly embarrassed by his emotions, he could only say to me in a tone slightly above a whisper, shaking his head slowly and affirmatively, that Clyde knew. 

“But can you turn to him and tell him?” I asked again, to which he responded by repeating his earlier refrain: “He knows.” 

A New Conversation

“Once again, Mrs. Gilyard was in her familiar role of working overtime for the family while Mr. Gilyard was working hard to emotionally retreat from the interaction.” Maybe there was something to this dynamic: maybe Mr. Gilyard’s “low pulse” for engagement heightened his wife’s anxiety, which she ameliorated by becoming more actively involved in an interaction.  Her involvement in turn  reinforced his low pulse, and his low pulse heightened her anxiety and so forth and so on. 

Meanwhile, Clyde remained a central but peripheral figure in the family’s interaction.  He was the frequent subject of his parents’ reprimands, criticism, and attempts to speak for him. While it was Mrs. Gilyard’s good intention to make sure that Clyde was reassured of the love that his dad was having difficulty expressing directly, it was nevertheless counterproductive to what I was trying to accomplish with the family at this point. So I decided to re-engage Mr. Gilyard by simply turning my body towards him and pointing to Clyde. 

He started his interaction with Clyde by telling him, critically, why he needed to change. I immediately interrupted him. “I realize this is important fatherly advice you’re offering your son,” I said, “but I want you to suspend the advice giving for a moment and simply tell your son that you love him and that you’re worried about him.” 

For the first time during the session, Clyde looked at me and said, “Boy, you’re a trip! Just give it up. Why keep asking the same frickin’ thing over and over again? I know he loves me. There. Are you satisfied? Now can we move onto something else?” It was striking to me that this one seemingly benign and simple request sent so many reverberations through the family while giving me a front-row seat to the family drama that had necessitated the Gilyards coming to therapy.

I commended Clyde. “I like the fact that you’re so honest and direct. You didn’t feel like you needed to sugarcoat your feedback for me. I think I like you, Clyde!”  I hoped that my feedback would have some resonance with him and provide a small buffer against the barrage of negative feedback he was accustomed to getting from his parents.  Clyde responded with a very faint smile, a slight shrug of his left shoulder, but for the most part he continued to sit motionlessly and without much overt expression.

 The family’s process had been marvelously effective at maintaining their status quo. The climate in the room was much less intense and they seemed more relaxed, at least on the surface. Mrs. Gilyard scanned the room with a sense of anxious anticipation. She looked as if she was wondering, “What’s going to happen next?”  Mr. Gilyard retreated and seemed far away, while Clyde nervously patted his right foot and stared at the ceiling. I sat quietly observing the family as my eyes occasionally connected with Mrs. Gilyard’s. 

After a few minutes of silence, I commented to Mr. Gilyard, “It seemed like it was a little difficult for you to talk directly to Clyde a few minutes ago. Was it difficult?”  

“You know, Doctor,” Mr. Gilyard quickly responded,  “it is not difficult for me to talk to my son and I don’t really have a problem talking to him. It’s just sometimes it seems pointless because Clyde is going to do what Clyde wants to do. I feel like the things his mother and I say to him go through one ear and out the other. So sometimes my attitude is, ‘Why bother!’” 

I noted how frustrating and seemingly futile such a dynamic could be, especially when there are legitimate worries and wishes that they would like to seriously convey to Clyde. Then I made an observation to Mr. Gilyard, trusting that Clyde and Mrs. Gilyard were eavesdropping. 

“My early sense of Clyde so far is that he is self-reflective, contemplative, and a courageous communicator,” I said. “I have noticed the way that he has sat here very quietly but has been very attuned to what is going on here, though his words have been few.  Yet as you observed a few minutes ago, when he had something to say, boy, did he say it with force, conviction, and clarity. I think a good conversation is possible between all of you if you could each attempt to have the conversation differently. Trying to have new conversations the same old way you have been attempting to have them is not working for the family. If you continue to hold onto the old ways you have been trying to engage with each other, this process will take forever and Clyde will turn to his friends for the conversations he should be having with his parents!” 

Mr. Gilyard seemed intrigued, if for no other reason than my oblique reference to the timetable for treatment, which I knew was important to him. I then asked Mr. Gilyard, “So do you think taking a different approach to talking to Clyde is something that you would be willing to try?” 

 “I am willing to do anything that you think will help me reach my son,” he replied.  

“I appreciate your willingness to give this a try,” I responded.  “I would like to return to where we were earlier. When I listen to you, I feel a kind of underlying pain—almost haunt—that you have when you think about Clyde’s life. What I hear and feel from you is worry, fear, and pain, yet what gets communicated to Clyde, and probably what he hears, is criticism, rejection, and anger. I would like for us to try this differently this time around. Can you turn to your son and tell him you love him and that you’re worried about him?” 

Mr. Gilyard looked at me with a slight sheepish grin and nodded.  He then took a minute to collect his thoughts as he stared at something beyond the room in which we are sitting. Mrs. Gilyard fidgeted a bit and nervously rubbed her hands together.  I could tell Clyde was very tuned in, although he outwardly retained his cool pose of detached disinterest. 

The silence built and so did the intensity in the room. After a few more minutes, Mr. Gilyard turned to Clyde.

 “I don’t know why this has been so hard for me,” he said to his son. “I don’t want you to think it had anything to do with not loving you…because I do love you very much, my firstborn son.  I will always love you, and I am sorry if I have somehow ever given you the message that I don’t love you or that my love for you is conditional.”

“Can you also tell him about your worries?” I encouraged him.

Mr. Gilyard sighed. “I do worry about you.”

“Can you tell him about your worries?” I prodded. “The ones that keep you up at night.”

 “I guess I worry all the time. I worry about drugs, although I don’t think you would ever    be stupid enough to do drugs. I worry about you not giving your best in school and the ways that will hurt your future. I worry about…” “Mr. Gilyard’s breathing shifted; his words suddenly seem much harder to find.” His voice was beginning to break and he now seemed more hesitant to continue.

“You’re doing great,” I told him. “This is the type of conversation that you and Clyde have needed to have for awhile now. Please don’t hold back now. Tell him about all of the fatherly worries you have about him.”

 “I worry… I worry…” Mr. Gilyard began to cry. “About something awful happening to you. About you dying, and there is nothing I or your mother can do to protect you. I worry about the damn trigger-happy police. I am worried that life is short and I don’t know what I would do if anything ever happened to you,” he sobbed. “The streets are vicious. People are vicious. And no one seems to GIVE A DAMN about young black boys like you.” He pounded the coffee table with his hand. “I can’t tell you, Clyde, the number of times that I have awakened in the middle of the night sweating from the same bad dream—the same nightmare that you are lying on 22nd Street in a pool of your own blood which is OUR blood too.” He turned to his wife. “Tell him, Geraldine, how many times you have had to comfort me from the same goddamn dream. “ Mrs. Gilyard nodded in confirmation while I gestured to her to refrain from speaking at this point. Both Mrs. Gilyard and Clyde were now beginning to cry as well.

Clyde spoke. “I don’t know what’s wrong with you and Mom. All you do is accuse me of doing bad things and being a bad person. I go to school, I get decent grades, and yet I all I ever hear is, ‘You didn’t do this. You didn’t do that. This is going to happen. That is going to happen.’” Clyde was more animated than I had yet seen him, and his voice was raised; he was crying profusely .

“Clyde,” I said, “I am so glad to hear you say how all of this affects you. I would be surprised if your parents knew that you have been affected so much by their worries and criticism of you. Thank you for again being such a courageous communicator—you know, having the courage to say what needs to be said and not just whatyou think others think you should say. Your tears—who were they for? What were they for?”

 “I don’t know,” Clyde said softly.

“Clyde, honey,” said Mrs. Gilyard, “I am sorry that I have been so caught up in my own worries that I have not taken a second to think about how all of this has been affecting you.” She began to cry even louder as she walked over and draped one arm around Clyde while reaching out with the other for Mr. Gilyard.  As she held Clyde, sobbing, she repeated, “I am so sorry. I am so sorry.” I sat quietly, observing this pivotal and sacred moment for the family, and remained appropriately peripheral for the moment.

Mr. Gilyard broke the momentary silence. “Son, we didn’t mean to hurt you and put so much pressure on you. We don’t think you’re bad. We just worry about you.”

“I honestly don’t know why you are so worried,” said Clyde. “I feel like I can’t breathe without causing somebody—you or Mom—to worry.”

Finally I stepped in. “I want to thank each of you for all of your hard work today, and thank you, Mrs. Gilyard, for your hard work in getting everyone here today. Mr. Gilyard, I am so pleased that you were able to tell Clyde about your worries. Now he knows that there are real heartfelt worries beneath all of the criticism. My hope is that you and Mrs. Gilyard can be more diligent in expressing your worries without the criticism, and that, Clyde, you could remind yourself that somewhere beneath their criticism is an unexpressed worry. By the way, Clyde, I share part of your curiosity regarding the roots of your parents’ worries.” I turned to the parents. “I completely understand your worries about the police, school, and what happens if Clyde ends up in the company of the wrong crowd. I think it’s great that you are concerned and involved parents. But as I mentioned earlier, there seems to be a ‘haunt’ when it comes to your efforts to parent Clyde. It is particularly poignant with you, Mr. Gilyard.”

As I wrapped up our first two-hour session, I reminded the family that I am a firm believer in assigning homework between sessions. “Homework is a wonderful strategy for ensuring that families continue to work together outside of treatment and not rely solely on our weekly two-hour meetings to promote change.” The actual tasks to be completed are seldom as important as the spirit of cooperation, collaboration, and communication that is generated (or not) as a result of the assignment. The Gilyards’ first homework assignment was for each member of the family to generate a minimum list of three beliefs each of them had regarding why there was so much worry in the family. They should generate their respective lists separately and then share their beliefs in a brief family meeting that should be scheduled by Mr. Gilyard and must take place before our next session. Clyde was assigned the task of keeping track of whether all of the rules had been followed by all members of the family, including himself, of course. And finally, Mrs. Gilyard was assigned the task of taking a vacation day from all coordinating tasks associated with the homework assignment.

The Gilyards showed up for our next session on time, and not only had they completed the homework assignment but had done so by rigidly adhering to all of the specified terms. While the assignment failed to produce any revelatory moments for the family, it did lay down some important groundwork for several transformative future sessions.

A Haunted Past

“It was too much responsibility and too big of burden. How can you possibly protect your children from the perils of the world?  My parents were super parents and even they could not protect Clyde and Roger,” he often reflected.  “For many years of my life, the pain of losing my brothers was so painfully gut-wrenching, I couldn’t have imagined any greater pain had they been my children. And then Clyde was born. Everything changed. Suddenly I could imagine a greater pain than what I had already experienced. For a few years, especially the early ones, he actually helped to redirect some of the pain I felt about the loss of Clyde and Roger. Maybe he gave me something else to focus on that my own father never had after losing two sons. I know that both Mom and Dad never ever recovered from Clyde’s murder, and then when Roger was killed, they simply stopped living.” 

Mr. Gilyard’s protracted mourning and shame never allowed him to be honest with his son about his uncle and namesake. He created the story about Viet Nam because it allowed him to recreate his brother in an image that was more positive and less burdened by the all of the familiar stereotypes of black men. This, unfortunately, was a huge piece of his son’s burden—a burden he undoubtedly carried from birth. He was not only his fallen uncle’s namesake, but he was a psychological object of possible redemption for his father. Suddenly all of Mr. Gilyard’s worries made sense to me. How could he not possibly once again find himself facing the dawning of the period of adolescence, without re-living the traumatic loss of his two younger brothers?  How could he not worry about Clyde, the flesh of his flesh, possibly following the pathway of brothers Clyde and Roger? “After all, life had taught him a brutally cold and unforgettable lesson that young black boys don’t live beyond age fifteen”, and Clyde was now fourteen.

As our sessions continued, it was a bit unnerving to discover just how unkind the untimely death of young boys had been in the Gilyard’s family. Mrs. Gilyard also had a younger brother, Will, who was killed at age seventeen in a terrible car accident. Although Clyde knew of his Uncle Will, and the circumstances of his death, he did not know that his uncle was illegally intoxicated at the time of his death. According to Mrs. Gilyard, Will was a passenger in a car that was driven by his best friend who was also intoxicated at the time of the accident. As Mrs. Gilyard told the story of Will’s final moments, she wept as if it had just happened yesterday.  She maintained that had Will not been in a state of an alcohol-induced stupor, he could have possibly survived the tragic accident.  Clyde’s surge into adolescence had been a significant unintended catalyst for re-igniting the unresolved grief that haunted both of his parents. In a strange way, Clyde’s life was a powerful symbolic reminder of the Gilyards’ ongoing struggle to make peace with death and loss.

I continued to see the Gilyards for a total of eleven sessions, and I believe they made tremendous strides, though there was still additional work to be done. As a result of family therapy, the parents had a better understanding of how the tragic losses of their siblings were infiltrating and sabotaging their best efforts to be the type of parents that they ultimately wanted to be.  They were far less critical of Clyde, but still resorted to blame and criticism when they felt anxious about their son’s life.  The Gilyards had made significant progress in granting Clyde considerably more breathing room, and yet this was still a major challenge for them to completely master.  Our work together had also been instrumental in helping Clyde to see and experience his parents with far more complexity. While he strongly resented their “constant nagging,” he also now understood and felt more genuinely their love for him. From our sessions together, “he had the opportunity to experience his parents as human beings with real feelings—hurt, pain, and joy”—and not just as critical, robotic and detached enforcers of the rules. He was able to develop more compassion for his parents and them for him. The family sessions afforded Clyde the opportunity to both fight with them—something that the family excelled at—as well as to cry with them—something they were not very good at. Yet, on the other hand, and in spite of it all, Clyde also continued to live up to his reputation as an adolescent.  His failure to follow through with chores, spending too much time of his cell phone, and his frequent flashes of self-righteousness continued to be challenges for him and his parents. 

Providing the Map

Both Mr. and Mrs. Gilyard terminated therapy with the understanding that the difficulties that brought us together were much bigger and more complicated than what rap music Clyde listened to or “his no-good, do-nothing hoodlum friends.” While Clyde expressed a number of troubling behaviors that at times appeared depression-like, “his” problems were much more complicated and intricately embedded in family dynamics and history than he or his parents realized Clyde’s symptomatic behavior was as much an indication of a family system that was not functioning properly as it was a sign of his individual pathology.

While the issues that constituted the core of Mrs. Gilyard’s early concerns about Clyde were significant issues, they paled by comparison to the complex, systemic, and intergenerational issues that made the Gilyards’ task of parenting so challenging. Through my work with the family, I was able early on to get a poignant snapshot of how the family was organized and how they interacted. I was able to rely more on what I observed than what they told me. There is something powerful and transformative about the process of witnessing—having the ability to experience and re-live the stories of another’s life with them.  Had I complied with Mrs. Gilyard’s request and “treated” Clyde independently of his family, he would have probably continued to live his life in the shadow of his Uncle Clyde without him or the family acknowledging it, while the family simultaneously and unfortunately maintained that the uncle who had been murdered unceremoniously and without distinction on the streets of the inner city, was instead a Viet Nam veteran and hero.  It was interesting and prophetic that Mrs. Gilyard, before our first session, noted passionately that Clyde had “become a shadow of the human being that he used to be.” I guess he had.

During this pivotal moment of therapy, Clyde was able to bear witness not only to his father’s shame, humiliation and hurt, but to his pain and humanness as well.  It changed forever how he saw his father, understood him, and more importantly, experienced and related to him.  Mr. Gilyard, in return, was able to give his beloved son and the namesake of his twin brother a gift of humility and a context for better understanding his father’s worries. And Mrs. Gilyard was finally able to “catch her breath” and exhale. She, for once, would not have to over-function to compensate for Mr. Gilyard’s reticence and emotional blockage. Finding the lovingness in him as a father also allowed her to add depth to the lovingness that she had for him as a spouse, which had the unplanned consequence of further strengthening their marital bond as well. “This is the beauty of family therapy: when it works well, it helps families to recalibrate and to experience reverberations throughout the system even across generations.”  If Clyde someday decides to become a father, I believe that the shifts he experienced in the relationships with his father specifically, and with his parents in general, will impact how he parents.  As a result of the family’s involvement in family therapy, the generational and relational arteries that connected the lives of Clyde, Uncles Clyde, Roger, and Will, as well Mr. and Mrs. Gilyard and many others, have been refreshingly and painstakingly unblocked, but will require ongoing work to remain so. This, too, is part of walking the tightrope: helping families find ways to celebrate newfound highs while simultaneously keeping them grounded enough to confront the next new challenge.

Family therapy, especially with adolescents, is often about walking on a tightrope: dangerously and delicately walking the fine line between hazard and hope. The tightrope is ultimately about encouraging and exploring that undefined, often difficult-to-measure balance between clinically taking positions and imposition, between promoting intimacy and compromising safety, and between increasing intensity and fostering comfort.  Having a willingness to tiptoe along the tightrope often means that in my work with adolescents and their families, I have to stretch myself well beyond my zone of comfort and safety. As a family therapist I have to earnestly and relentlessly push myself in treatment to ask one question more than the question I am comfortable asking, and to take risks that might expose me to failure, while at the same time offering tremendous potential for the promotion of healing and transformation.  

Augustus Napier on Experiential Family Therapy

Experiential Family Therapy

Rebecca Aponte: I want to talk to you about your contributions to psychotherapy, particularly in couples and family therapy. First off, you’ve called your approach Experiential Symbolic Therapy. Can you say what you mean by that—by “symbolic,” especially?
Augustus Y. Napier: This term really came from Carl Whitaker. The word "symbolic" has to do with the nature of therapeutic experience. Our assumption is that psychotherapy is a kind of italicized experience in that it's heightened. It provides a slice of experience that the client may not have experienced, which is more honest and more caring, with insights, etc., that they haven't had, and the assumption is that these incidents that occur in the psychotherapy interview—in the room itself—have a kind of symbolic importance. The therapist is symbolic, often of a parent or some family-like authority figure, and what we try to provide is a slice of something that's missing from the family's life. You can't reparent somebody who needed twenty years of the kind of parenting they didn't get, but you can provide them experience that is a taste of something that was missing in the family or the individual's experience. In that way, it's like a slice of a pie that goes deep but not broad.

RA: How does the therapist do that?
AN: I think by bringing a lot of focus on the here-and-now in the interview—that is, trying to make the experience as real, as immediate, and as powerful as possible. I think families bring a lot of expectations to therapy. Things have gotten pretty bad; there's a hunger for something new, and for help. Often they bring a lot of skepticism and wariness, but they also bring a need that's pretty deep. So the way that the therapist influences the symbolic nature is to, first of all, be aware that what you say, what you do, has more than ordinary importance. This is not a social conversation—this is a deeper level of conversation. So the therapist invests a kind of personal commitment to making the experience in the interview as intense, and as intensely meaningful, as possible. It's taking on a burden of making this more personal, as opposed to technical.
RA: Does that mean you allow the therapy to impact you in a personal way?
AN: Yes, it does. It means
we allow ourselves to be personally involved, and to bring our own feelings, as well as our thoughts, to the process.
we allow ourselves to be personally involved, and to bring our own feelings, as well as our thoughts, to the process.
RA: I can imagine some different schools of thought cringing at that idea.
AN: Yes, absolutely. I talked recently with a friend whom I had referred to a therapist. My friend said, "He talked about himself—I found that unprofessional." What I think should be emphasized here is that we're well aware of the danger in the therapist's personal involvement. And for that reason, we often work with co-therapists who balance the personal in some way. It's as if you're in a tag-team wrestling match: one of the therapists goes in and works for a while, and then they're sort of rescued by the other one who's been watching and monitoring and being more in his or her head. So we think about psychotherapy as freed up by the therapists being a team; that allows a more personal encounter.

We're also quite disciplined about the structure of the therapy. For example, if somebody walks out of the room to go to the bathroom, we stop the interview because we don't want a second level of interaction. Somebody might walk out to go to the bathroom and the other partner says, "I'm having an affair." So there's a discipline process around the structure. And we maintain control of the structure—for example, who comes in to the therapy—in a way that creates safety.

Heart Surgery

RA: I think that sounds ideal, and obviously people who have read The Family Crucible have glimpsed the co-therapist model in action. Is that something that’s practical, though? Is that something that’s easy to do?
AN: Well, it's expensive any time you have two therapists in a room working together. Whitaker's analogy is that
family therapy is like heart surgery: it's very complex, and you'd better not do it by yourself because you're in over your head.
family therapy is like heart surgery: it's very complex, and you'd better not do it by yourself because you're in over your head. You get sucked into the family's own drama and you lose your perspective—and that really happens to lots of therapists who try to do it alone. It's a bit like speaking to the wilderness: when you try to say this to people whose work is dictated by managed care, for example, they're not going to want to pay for two therapists. So agencies that have some freedom over their budget can do it, and in private practice it can be done, but it is a specialty. And my concern over time about the field is that the demands of this practice, of working with families and couples, are much greater than we had anticipated, and that the therapists need a lot more help, a lot more structure, a lot more support in order to do it well. So there are limitations to being able to work in teams, but I think it's necessary to do a really good job. When trying to work with families and couples alone, I've often found myself triangulated in some way, or compromised by that process, or feeling overwhelmed or discouraged, or induced into the family's own world to too great of an extent. So admittedly this is not an easy approach to do, and it's not easy to teach.
RA: Reading your book, I got the sense that a lot of problems that we as a society tend to think of as individual problems actually exist within the family or the couple. Would you say that most therapy really belongs in a family or couples context?
AN: That's my belief. There are individual, intrapsychic, historical issues that need to be worked with, but my sense is that it's best done by starting first with the group that's intimately involved—that lives together, that deals with each other in real time. And the individual work can take place within that context—that is, you can work on the husband or the wife's childhood with the other person in the room. And it takes some work to get there so that there's enough intimacy and safety. But there's a point, for example, in working with couples where conflict breaks down between the couple because it's very clear that a lot of issues come out of their histories. And that's what I would call a depressive period: when, instead of fighting with each other, you have two people who get depressed because they realize, "Oh my goodness, this really comes from childhood and from my other relationships." So there is a phase in which individual therapy in the presence of the other becomes the focus.

And sometimes, toward the end of therapy, a lot of the group issues have been resolved, and somebody wants to work on something that has to do with their own journey or their own individual issue, and then you have enough trust in the group itself for that to take place. But the first step, really, is to get all the key players in the room, and to work on building safety and trust and more intimacy with that group. Then you have tremendous freedom about where you go and what you do. But if you start with an individual, you become that person's therapist, and it can happen in two or three sessions, so that you'd be not available to the family.

The Dangers of Individual Therapy

RA: I don’t mean to suggest that it’s not helpful at all, but do you feel that most individual therapy is a waste of time? I think most people nowadays go to individual therapy; do they then go home and get in these same old dynamics?
AN: Exactly. One of the dangers in doing individual therapy, and I think they're considerable dangers, is that the therapist and the client create a fantasy about life that is a kind offolie à deux in which two people agree, "Oh, the real problem is your spouse," or, "The real problem is your mother-in-law." But when this process goes on for a long time, the client and therapist become a microsociety within which there's agreement and consensus and a kind of coziness. While that can feel good, a problem with what I would call a kind of autistic view of the world is that nobody challenges it. There's nobody there to say, "Oh, but I don't agree about that. You're forgetting about so-and-so," or, "I see you as…" So there's no encounter where an individual's perception is challenged in some way, by somebody else who knows them and is involved with them. So there are two things that can happen with individual work. I mean, there are many things, but one thing is that the family or the marriage or the context defeats the individual.
RA: What do you mean by that?
AN: She's run down. She doesn't have as much money or as much power as her husband. She is helped to feel a little better, but she doesn't have enough power to change the system, so she goes home and essentially plays the role that life casts her in there. So there's the situation where an individual fails to develop enough power to really change the system. Now, sometimes a powerful therapist can help someone change their system, and that really can happen. Usually it's because the therapist is thinking about the system and, in fact, is working with the individual on how to deal with the system. My wife Margaret treated a woman whose husband was well known, rigid, absolutely uninterested in coming to therapy. And I think her work with the wife was so targeted and so thoughtful that it really saved the marriage, even though he never came. So sometimes the issue is: Is the therapist thinking about the system? Does the therapist have a commitment to the life of the system rather than just who's in the room? Of course, it would have been a lot easier of the husband had come to therapy.
RA: Right, of course.
AN: The other danger with individual therapy—and this is something tragic I saw sometimes—I remember a woman who came in with her husband. The woman's therapist had asked me to join in because the marriage had deteriorated as the individual work progressed. And by the time I came into that system, it was very clear that this woman had decided with the therapist that the husband was impossible and that she was out of there. And they did divorce. He remarried, she never did, and I think she lived a pretty lonely life after that, without ever having had access to really concentrated work on that problematic marriage. So
sometimes individual therapy creates a coalition that really disempowers a marriage.
sometimes individual therapy creates a coalition that really disempowers a marriage. I've seen it be destructive in that way. And it's not that she shouldn't have divorced, but the marriage really never had an advocate in itself.
RA: What does it mean when you’re working with a family and the family system is your client? That’s really very different from the way that individual therapy is taught.
AN: Yes, and that's really the basis of family therapy: seeing that the problems are not just in the individuals, they're in the complexity of the relationships. And we would say that the family is always your client—that you should be thinking about your work as it impacts that group. But it's a very different way of viewing the world. It's much more difficult to say, "My client is this family. My obligation is to help them as a group." And it's something that I think more therapists should do—that is, to expand their mandate to include the family: "My responsibility is beyond the individual. I'm responsible for what's happening to the kids at home, I'm responsible for what's going on between an adult and their parents," and so forth. So it's an expanded mandate. And I think it's the ethical way to proceed with therapy, is to think in bigger terms than what your obligation is.
RA: Is the way that you engage a family significantly different than the way you would engage a non-family group, or the individuals within the family?
AN: That's a great question. I don't think it's necessarily different, from the therapist's perspective. Whitaker used to compare the family to a sports team that's been playing together for years and years: they know each other's moves, so they're powerful in their connectedness. An ad-hoc group is not powerful in that way, unless it's got a longevity commitment together. So an ad-hoc group is relatively superficial in the intensity of the connection, compared with a family. The voltage is so much higher in families; the stakes are so much higher. So with an ad-hoc group, you can develop a lot of intensity, but it tends to be focused on the individuals that make up the group.

Bringing the Past into the Present

RA: I’ve seen you conduct couples therapy in the video Experiential Therapy. Is that representational of most of your work?
AN: You know, it's interesting. Reviewing this video recently, I was surprised at how much time I spent in the interview on insight into the couple's histories. And as I looked at it, I thought I was aware of the fragile nature of the relationship, and was trying to help them gain more insight because I didn't have much time with them. But I think in ongoing work, there's a lot more emphasis on the encounter process between the members. There's a lot less therapist intervention, a lot more sitting back and watching as an episode unfolds. And then there's a point where one comes in and intervenes in a more confrontational or personal way. I started out fairly confrontational in that interview, and then for some reason I backed off and didn't push in the direction I'd been going. So I do think that typical for the experiential approach is an effort to push the family to try some interactions that they haven't been doing, and to lend one's own muscle to getting some different things to happen. For example, in the interview that you're talking about, I pushed the husband to be more assertive. So I do think that there's that component, that is, the focus on the encounter process and making it move somewhere new by adding a coalition from the therapist or by encouraging somebody to go in a direction they've been afraid to go in. But I also think of this work as having a high component of insight.

I started my career in high school reading Freud—not that I knew I was starting a career, but I picked up some paperbacks off a newsstand—and so I came into this field with a keen attachment to the idea that we understand our histories. And intellectually, I'm curious. I think people need to know a lot about themselves and their upbringings. I think this process of becoming more rational about the turbulence of the emotional world is generally a good thing. So I would probably put more emphasis on insight, for instance, than Carl Whitaker would have. But where I joined with his work was believing in getting that history to become present—that is, bringing in the family of origin, and working actively with those key players. And
it feels to me that the most powerful, impactful work that I did was bringing together extended families.
it feels to me that the most powerful, impactful work that I did was bringing together extended families. In some ways it was incredibly easy once you got people into the room, because they had a lot to talk to each other about that they really needed to deal with. And you just helped it along.
RA: And were there other families where you would have to take a more active and more confrontational role?
AN: Yes. Families where there's a big power imbalance, where there's some abusive process going on, where somebody is floundering, being suicidal. But I think, particularly when there's the danger of abuse, working carefully and confrontationally is sometimes called for.
RA: Is there a time when that goes wrong?
AN: Well, I think there are many times when psychotherapy goes in directions we didn't anticipate, sort of like a political process—you get surprised by things. Looking back over years of practice, I think that I wish I had been more confrontational more often. I think
this is one thing that differentiates experiential therapy—the willingness to be confrontational.
this is one thing that differentiates experiential therapy—the willingness to be confrontational. And to be openly caring. So that level of emotional involvement is part of what typifies this approach.

A Vague, Intuitive Therapy

RA: What sort of criticism have you heard about your method?
AN: That it's vague. That it's too subject to the therapist's own countertransference issues. That it's expensive because it often involves a team. That it's cumbersome if you try to get in people who don't want to come. That it can sometimes be authoritarian if the therapist sets rules about the process. But I think the main criticism is that it's hard to define—it's hard to say what it is. And I think part of that problem is that what it is is complex. It's atheoretical, and it's atechnical—there's generally not a set of techniques that we learn. For example, in structural therapy, there are certain theories about what you do in what situations, and techniques that you can use. And I think experiential therapists do use techniques—I don't think we're entirely pure. But there's a high focus on the therapist's intuitive process. And so when you're trying to teach experiential psychotherapy, it's generally something that's done best with a student in the room with the therapist. That is, we often trained therapists by doing co-therapy with them. And that's a very slow way to teach. It can take years of hanging out with somebody to really teach them what you're doing. I was lucky to get to work side by side with Carl for at least five years. So I think the approach is limited by the personalized way of teaching. And I'm also concerned that it's limited by the fact that it's quite complex.

So I think there are real concerns about the approach. But one of the things that I think make it exciting for the therapist is the permission to be himself or herself in the process. And
over time I've begun to think, "Gosh, I have one of the best jobs that anybody on the planet can have."
over time I've begun to think, "Gosh, I have one of the best jobs that anybody on the planet can have." I have a license to say what I feel and think. I'm trying to do something to help people, and I've given myself permission to be myself in the interview, to be real, to say what's on my mind. And that's incredible. When you look around this society, how many jobs give you permission to be honest? To care about the people who are paying you? And I began to think about it as a kind of privileged position or perspective, to be allowed to take a personal involvement with something as intricate and meaningful as a family.

So I think this approach has the promise of expanding the experience of the therapist. You're not doing a series of techniques—you are putting your own life mixed in with other lives, and it's incredibly rich emotionally. So I found the work exciting. I was always curious about what was going to happen, what this new family was going to be like. I always felt like I was learning and being forced to learn. I felt like I was being forced to confront my own devils in my own family.

And that reminds me that another part of this approach is the assumption that the therapist will have therapy—that if you do this approach, you'll find yourself having to go back to therapy because this family looks so much like the one you grew up in, or this person reminds you so much of… And the field is so charged. It's hard to distance yourself from it.
RA: Based on what you’re saying about this style of therapy–with the therapist being so emotionally involved—it would seem necessary for the therapist to be engaged in his or her own therapy.
AN: Yes—having your own therapy, having a consultation group, like a peer supervision group, and having an actual consultant with you in the therapy session. In cases where co-therapy was prohibitively expensive, we arranged within our practice group to do drop-in consultations for each other, where every four or five sessions the other therapist would come in and essentially say, "How are you doing? Has Gus gotten on somebody's side yet?" and so on. So the balancing of the personal with disciplined professional structure is what makes it really possible.
RA: Switching gears a little bit, obviously not everyone is going to work well with this style of therapy. Which clients don’t work well with this?
AN: Rigidly authoritarian families have real trouble with it, because usually they're dominated by an individual who doesn't want his or her power disrupted. Often it needs to be disrupted. So people who are personally rigid or systems that are personally rigid are threatened by this approach. They want you let them identify the problem and then have you solve it. And often it's, "Fix our adolescent son or daughter." And without the freedom to challenge that scapegoating dynamic, golly, it's really tough. One of the things we learned that helped us work with that kind of authoritarian structure is to find the vulnerability of the powerful person–being careful not to humiliate this person—but basically forming an alliance with them that says, "I know life is hard for you, too. Tell me your perspective. Where are you worried?" The aim is to co-opt that power position by going for support.
RA: Right—rather than trying to topple it in a humiliating way.

Rising to the Family’s Challenge

AN: Particularly with rigid men, you've got to tiptoe around their pride sometimes. And sometimes just getting them to come to the session is a victory. So you tread carefully with them. But at some point you know you'll have to challenge the family, and an individual in the family. You have to challenge their authority. And you guard yourself for that moment: "Okay, when's the showdown going to be?" And it's probably wise of the family to challenge the therapist, because they need to know if you can stand up to them.
They need to know that you have enough strength to take the chaos beneath the surface.
They need to know that you have enough strength to take the chaos beneath the surface. And sometimes it's an adolescent who's elected to challenge by refusing to come to the session or by being flippant, insulting. But often it's one of the parents who's threatened by the process.
RA: Do you see a big shift in the family after that confrontation takes place?
AN: Yes. It's really a critical moment in therapy, and usually the family sort of sighs with relief: "Oh, we feel in safer hands." At the beginning of therapy, the family is needy but not trusting, and they have to put you through a series of tests to find out if they can trust you. Can you challenge the dominant person in the family? It may be a bratty four-year-old. Can you be honest? Can you maintain neutrality, or can you be sucked into somebody's side? I remember a couple I worked with in Madison, one of the first ones I saw there. And I realized I was really getting on the wife's side. I didn't have a co-therapist—they couldn't afford it and I didn't have students at that time. So I got up my nerve and I said, "Listen, I am getting on your wife's side, and you've got to help me see something more sympathetic about your position."
RA: Did that work?
AN: The wife said, "Yes, I'm really good at getting people to be on my side and making him look bad." So we had a laugh, and he began to be more self-revealing. But what I'm just describing is one of the critical elements in this approach to therapy: there's this moment where the therapist says, "Do I have the nerve to say this?" And it's really the ultimate therapeutic moment, when the therapist says, "Okay, I'm going to say this. It's not going to be popular." I remember a family where the husband, a successful lawyer, was in the process of leaving his wife—affair with the secretary and so forth. I got him to bring in his mother and siblings. One of his siblings was obviously gay and frightened at being in the session, and one of the siblings was a kind of hostile-looking good ol' boy. And the husband who was leaving his wife was just one of the crowd, here. But I realized the sister was afraid of her brother's scorn and so forth, and she said something that indicated that she was gay. So, in order to make this perfectly explicit, I said to the good-ol'-boy brother, "How does it feel to have a sister who's gay?" And there was this huge silence.
RA: Oh my gosh.
AN: But it was one of those moments where my heart was in my throat. It's like, "If I can't say this, if I can't challenge the lie in this family, then I'm not earning my keep here." So there was a little talk—this was her coming out in the family. They hadn't been able to talk about it. They did talk about it, and then we moved on to other things. I ran into her years later, and she said, "You know, you asking one question changed the whole course of my experience with my family. They all warmed up to me, and they reconnected," she said. "Everybody except my brother. He never really accepted me." But the experiential approach has this demand on the therapist to be courageous in moments where there's something not being said. And I think that's the essence of the approach, really—to push yourself as the therapist to break the rules about what's permissible within the family. And it's really hard to do.

The Decline of Family Therapy

RA: You concluded The Family Crucible, which was published over 30 years ago now, with a look toward the future. Looking back now over the past three decades, I’d like to get your take on the decline of family therapy. Why is it so hard to get families into treatment?
AN: Well, part of it is cultural in that the family is more fractured. Families have trouble finding time to eat a meal together. They're fractured by time demands, stresses of work, and so forth. So
the whole idea of family unity is under attack by the society.
the whole idea of family unity is under attack by the society. We know of families who don't even have a dining table—they eat fast food sitting on the floor. So there's that cultural aspect. I think the whole idea of family loyalty has been challenged, as well, by geographic mobility. My daughter lives in Argentina, another lives in Boston; my son's in Albany, New York. So going to college, going into the military, is a lot of geographic separation, and that runs counter to families seeing each other and being involved with each other on a daily basis.

But I also think that we have failed as a profession to train family therapists adequately. I don't think we've done a good job of preparing people to do the very difficult work of family therapy. Sometimes in the latter stages of my lecturing, I depressed people because I said, "Listen, our field is failing to make family therapy work. We're letting ourselves be defeated by the insurance companies." And of course, that's another factor here: the family system as patient is in fact often prohibited. That idea was never really embraced by the insurance companies. But I don't think we did a good enough job in giving young therapists enough support to stay with it and to develop their own skills. I just think it takes so much more than we estimated. A resident I worked with in the psychiatry department at Madison said, "Family therapy is doomed because it's too difficult to do. I don't think it will ever work." And he had obviously tried it and found it too daunting. I'm debating about writing a television series based on a family therapist's life. Maybe that will rejuvenate interest. But I think a lot of forces have conspired against family therapy. And you know, it exists in pockets, and certainly there are training programs that do an excellent job, and there are people who do it. But I think the issue of enough support is what has made this so difficult. And it's discouraging to see.
RA: Yeah, it is. Are there family therapy techniques that individual therapists can start to use?
AN: Absolutely. Murray Bowen was the master at this. He would work with a family member for a while, and then he'd say, "I want to see this other one over here." So he would work serially with family members, or he would work with an individual on how to change their direction with the system, and he did that in his own family. So if you think in terms of your client as being a family, you can find a way to work with them. I was amazed that my wife could work with this really difficult, rigid husband through his wife. But he changed over time, so I think in spite of all the obstacles to getting families into the room together, if we can think about the system as something we're responsible for helping, then I think we can help them. I think the critical thing is thinking systems.
RA: And should individual therapists bring in spouses or family members to individual therapy? If they’ve already been working with someone for some time, as that person’s therapist, is that still a helpful thing to do? Is that just getting a better idea of who their individual client is when they see how they interact with others?
AN: Well, yes, indeed—both.
I think that the responsible thing if you're practicing individual therapy is to meet at least the spouse before you start the process
I think that the responsible thing if you're practicing individual therapy is to meet at least the spouse before you start the process, so that you're not dealing with some kind of myth. You see a real person here, and you don't allow a massive distortion of the other. You also learn about an individual client by seeing how they interact.

It's also possible to go in the other direction. Say somebody starts seeing a woman who can't get her husband to come to therapy, and that goes pretty well for a while, and she begins to feel more powerful and she challenges him, and the marriage begins to deteriorate. There is a way to make a transition to working with a couple or a family in this way, which is to bring in another therapist.
RA: Is that structured so that the spouse has a representative?
AN: Well, maybe in the beginning. But really it allows the therapist, who has gotten captured by the individual client, to retreat a little bit and to involve the spouse. It's quite a delicate process to go from an individual therapy process to a couples therapy or family therapy process, but it can be done. It takes another therapist's involvement, I think. I've seen too many cases where an individual therapist tried to bring in a spouse and was so biased that it just went sour very quickly.
RA: I would imagine, even if they weren’t biased, that there would already be intrinsic trust issues.
AN: Absolutely, yes. If the therapist who's been committed to the individual now spreads his or her loyalty to the other spouse, the one who's been the patient feels abandoned. So it's very tricky. Most therapists would say, "Okay, I'm going to hold myself in reserve and refer you to a couples therapist to start again with." That's also very problematic, because you're basically saying to the individual patient, "I'm going to abandon you." So my sense is that it's so much better to start with a minimal unit being the couple. I didn't see individuals in the beginning who were married. I said, "I just don't do it—I know it's going to be trouble. You've got to bring your spouse. And I'll work with you on how to do that, but we're not going to do psychotherapy—we're going to work on how to get your spouse to come to therapy for maybe five sessions."

So my sense was that marriage is the irreducible client—that we owe a certain loyalty to give that relationship an advocate. And that's really an ethical belief.
RA: I can see why. At the end of your book, you mention specifically the role of the medical model in psychiatry needing to change if family therapy is to take hold. What are your thoughts on what has happened now with respect to that? Insurance is obviously one element of the situation, but how has the medical model affected family therapy?
AN: I think in a pretty devastating way. It's not just family therapy that got medicalized—it's the entire psychotherapy process. Psychotherapy got devalued as medicine became the easy way to treat individual distress. In Wisconsin where I was trained, we had a group therapist, we had a family therapist, we had a psychoanalyst, we had a behavioral therapist. And when I went back ten years later, gosh, it all looked medical. It was all focused on medicine and biology and so forth. So I think the medicalization of psychotherapy affected the whole field, not just family therapy. But family therapy was hit particularly hard, because when you say the problem is inside the individual, and it's a biological problem and it's treatable by medicine, it doesn't leave much place for a family system. So
I think medicalization of psychotherapy in general has been a tragic thing.
I think medicalization of psychotherapy in general has been a tragic thing.

Fortunately, the research is now showing that the most effective treatment even for individual issues may be both medication and psychotherapy. So there's more balance at least, in the promoting the benefits of talking to somebody.

I think this medicalization trend fits also with the depersonalization of our world—that we've got big anonymous cities and big anonymous systems, so the whole project of human connection has been depersonalized.
RA: Can you say a little bit more about that?
AN: Well, you know, families are moved around from place to place. People work in corporations where they're pretty anonymous within those big organizations where there's a lack of a human community. People live in suburbs, miles away from any intimate relationships. And they live online. So there's this huge machinery here of interfering with the intimate relationship, the small town, the family that lived on three blocks in New York City. That whole world has changed.

I think in some ways the Internet is a countervailing trend in that it tries to connect people in ways that really facilitate more communication. I mean, I'm on the phone or on iChat with my kids from Argentina and so forth. So we have this other thing—that, in the face of anonymity and abstraction, we have the capacity to connect with each other. So I feel the Internet has many negative things, but it's also got this possibility.
RA: That’s very true.
AN: I don't know about doing family therapy over the Internet. Maybe that's possible.
RA: That’s hard for me to imagine.
AN: Yes. Once Margaret and I were working with a family, and the husband had left the family and moved to London, and he left behind three very hurt teenage sons. And his ex-wife was a therapist, so she brought her kids and we worked on the absent dad stuff and the boys' grief. So I decided to do a speakerphone interview with him. We had the speakerphone sitting in the room on a chair among the family, and his voice would come out of that thing. These boys would look at it with this combination of rage and hurt. And he looked so diminished sitting there.

A New Look to the Future

RA: If I could just ask you one last question, looking yet again into the future, what do you think we can do about the ways that family therapy has been decimated?
AN: Golly. Give me a minute… I think the main thing we can do here is to provide deeper levels of support to therapists. You're going into the equivalent of systems warfare here, and you need a lot of support and help—you need to be able to work with people who believe in your world. So we start out with building in for the therapist a community of support, and we legitimize for therapists the need for support—intellectual support, peer supervision, supervision, psychotherapy—and help the therapist seek support, and validate the need. It's important not to underestimate what it's like to go into a clinic where nobody's doing family therapy and you're trying to do it. So that's the individual work with the therapist. So how do you negotiate the conditions of your job? How do you try to set conditions that are favorable to your being successful? Most of that has to do with having some buddies who believe in the way you do, and staying in touch.

The other tack is legislative and large-system intervention in ways that would validate psychotherapy and family therapy. I think we could do a better job of educating the public about the benefits of psychotherapy and family therapy. Most people haven't heard of the family approach. So I think legislatively we can work to get, for example, insurance reimbursement, and our big associations can help with that. We could do a much better job of educating the public, and we could do a much better job of supporting the struggles of young therapists. So there's a lot of work to be done there.
RA: Yes—very important work.
AN: I think so. But we need to start with belief that this is a valid thing to do, that it's important to do: some sort of ethical commitment to the world of psychotherapy and family therapy. It's not just a trade—it's something like a calling.
RA: Yes, that resonates very deeply with me. Thank you so much.
AN: I didn't have any worry about having enough to say, thanks to your excellent questions! This has been fun.

The Path to Wholeness: Person-Centered Expressive Arts Therapy

When art and psychotherapy are joined, the scope and depth of each can be expanded, and when working together, they are tied to the continuities of humanity’s history of healing. —Shaun McNiff, The Arts and Psychotherapy

Part of the psychotherapeutic process is to awaken the creative life-force energy. Thus, creativity and therapy overlap. What is creative is frequently therapeutic. What is therapeutic is frequently a creative process. Having integrated the creative arts into my therapeutic practice, I use the term person-centered expressive arts therapy. The terms expressive therapy or expressive arts therapy generally denote dance therapy, art therapy, and music therapy. These terms also include therapy through journal writing, poetry, imagery, meditation, and improvisational drama. Using the expressive arts to foster emotional healing, resolve inner conflict, and awaken individual creativity is an expanding field. In the chapters that follow, I hope to encourage you to add expressive arts to your personal and professional lives in ways that enhance your ability to know yourself, to cultivate deeper relationships, and to enrich your methods as an artist, therapist, and group facilitator.

What is expressive arts therapy?

Expressive arts therapy uses various arts—movement, drawing, painting, sculpting, music, writing, sound, and improvisation—in a supportive setting to facilitate growth and healing. It is a process of discovering ourselves through any art form that comes from an emotional depth. It is not creating a “pretty” picture. It is not a dance ready for the stage. It is not a poem written and rewritten to perfection.

We express inner feelings by creating outer forms. Expressive art refers to using the emotional, intuitive aspects of ourselves in various media. To use the arts expressively means going into our inner realms to discover feelings and to express them through visual art, movement, sound, writing, or drama. Talking about our feelings is also an important way to express and discover ourselves meaningfully. In the therapeutic world based on humanistic principles, the term expressive therapy has been reserved for nonverbal and/or metaphoric expression. Humanistic expressive arts therapy differs from the analytic or medical model of art therapy, in which art is used to diagnose, analyze and “treat” people.

Most of us have already discovered some aspect of expressive art as being helpful in our daily lives. You may doodle as you speak on the telephone and find it soothing. You may write a personal journal and find that as you write, your feelings and ideas change. Perhaps you write down your dreams and look for patterns and symbols. You may paint or sculpt as a hobby and realize the intensity of the experience transports you out of your everyday problems. Or perhaps you sing while you drive or go for long walks. These exemplify self-expression through movement, sound, writing, and art to alter your state of being. They are ways to release your feelings, clear your mind, raise your spirits, and bring yourself into higher states of consciousness. The process is therapeutic.

When using the arts for self-healing or therapeutic purposes, we are not concerned about the beauty of the visual art, the grammar and style of the writing, or the harmonic flow of the song. We use the arts to let go, to express, and to release. Also, we can gain insight by studying the symbolic and metaphoric messages. Our art speaks back to us if we take the time to let in those messages.

Although interesting and sometimes dramatic products emerge, we leave the aesthetics and the craftsmanship to those who wish to pursue the arts professionally. Of course, some of us get so involved in the arts as self-expression that we later choose to pursue the skills of a particular art form. Many artist-therapists shift from focusing on their therapist lives to their lives as artists. Many artists understand the healing aspects of the creative process and become artist-therapists.

Using the creative process for deep inner healing entails further steps when we work with clients. Expressive arts therapists are aware that involving the mind, the body, and the emotions brings forth the client’s intuitive, imaginative abilities as well as logical, linear thought. Since emotional states are seldom logical, the use of imagery and nonverbal modes allows the client an alternate path for self-exploration and communication. This process is a powerful integrative force.

Traditionally, psychotherapy is a verbal form of therapy, and the verbal process will always be important. However, I find I can rapidly understand the world of the client when she expresses herself through images. Color, form, and symbols are languages that speak from the unconscious and have particular meanings for each individual. As I listen to a client’s explanation of her imagery, I poignantly see the world as she views it. Or she may use movement and gesture to show how she feels. As I witness her movement, I can understand her world by empathizing kinesthetically.

The client’s self-knowledge expands as her movement, art, writing, and sound provide clues for further exploration. Using expressive arts becomes a healing process as well as a new language that speaks to both client and therapist. These arts are potent media in which to discover, experience, and accept unknown aspects of self. Verbal therapy focuses on emotional disturbances and inappropriate behavior. The expressive arts move the client into the world of emotions and add a further dimension. Incorporating the arts into psychotherapy offers the client a way to use the free-spirited parts of herself. Therapy may include joyful, lively learning on many levels: the sensory, kinesthetic, conceptual, emotional and mythic. Clients report that the expressive arts have helped them go beyond their problems to envisioning themselves taking action in the world constructively.

What Is Person-Centered?

The person-centered aspect of expressive arts therapy describes the basic philosophy underlying my work. The client-centered or person-centered approach developed by my father, Carl Rogers, emphasizes the therapist’s role as being empathic, open, honest, congruent, and caring as she listens in depth and facilitates the growth of an individual or a group. This philosophy incorporates the belief that each individual has worth, dignity, and the capacity for self-direction. Carl Rogers’s philosophy is based on a trust in an inherent impulse toward growth in every individual. I base my approach to expressive arts therapy on this very deep faith in the innate capacity of each person to reach toward her full potential.

Carl’s research into the psychotherapeutic process revealed that when a client felt accepted and understood, healing occurred. It is a rare experience to feel accepted and understood when you are feeling fear, rage, grief, or jealousy. Yet it is this very acceptance and understanding that heals. As friends and therapists, we frequently think we must have an answer or give advice. However, this overlooks a very basic truth. By genuinely hearing the depth of the emotional pain and respecting the individual’s ability to find her own answer, we are giving her the greatest gift.

Empathy and acceptance give the individual an opportunity to empower herself and discover her unique potential. This atmosphere of understanding and acceptance also allows you, your friends, or your clients to feel safe enough to try expressive arts as a path to becoming whole.

The Creative Connection

I am intrigued with what I call the creative connection: the enhancing interplay among movement, art, writing, and sound. Moving with awareness, for example, opens us to profound feelings which can then be expressed in color, line, or form. When we write immediately after the movement and art, a free flow emerges in the process, sometimes resulting in poetry. The Creative Connection process that I have developed stimulates such self-exploration. It is like the unfolding petals of a lotus blossom on a summer day. In the warm, accepting environment, the petals open to reveal the flower’s inner essence. As our feelings are tapped, they become a resource for further self-understanding and creativity. We gently allow ourselves to awaken to new possibilities. With each opening we may deepen our experience. When we reach our inner core, we find our connection to all beings. We create to connect to our inner source and to reach out to the world and the universe.

Some writers, artists and musicians are already aware of the creative connection. If you are one of those, you may say, “Of course, I always put on music and dance before I paint.” Or, as a writer, you may go for a long walk before you sit at your desk. However, you are not alone if you are one of the many in our society who say, “I’m not creative.” I hope this book entices you to try new experiences. You will surprise yourself.

I believe we are all capable of being profoundly, beautifully creative, whether we use that creativity to relate to family or to paint a picture. The seeds of much of our creativity come from the unconscious, our feelings, and our intuition. The unconscious is our deep well. Many of us have put a lid over that well. Feelings can be constructively channeled into creative ventures: into dance, music, art, or writing. When our feelings are joyful, the art form uplifts. When our feelings are violent or wrathful, we can transform them into powerful art rather than venting them on the world. Such art helps us accept that aspect of ourselves. Self-acceptance is paramount to compassion for others.

The Healing Power of Person-Centered Expressive Arts

I discovered personal healing for myself as I brought together my interests in psychotherapy, art, dance, writing, and music. Person-centered expressive therapy was born out of my personal integration of the arts and the philosophy I had inherited. Through experimentation I gained insight from my art journal. I doodled, let off steam, or played with colors without concern for the outcome. Unsure at first about introducing these methods to clients, I suggested they try things and then asked them for feedback. They said it was helpful. Their self-understanding increased rapidly and the communication between us improved immensely.

The same was true as I introduced movement, sound, and freewriting for self-expression. Clients and group participants reported a sense of “new beginnings” and freedom to be. One group member wrote: “I learned to play again, how to let go of what I ‘know’—my successes, achievements, and knowledge. I discovered the importance of being able to begin again.” Another said: “It is much easier for me to deal with some heavy emotions through expressive play than through thinking and talking about it.”

It became apparent that the Creative Connection process fosters integration. This is clearly stated by one client who said, “I discovered in exploring my feelings that I could break through inner barriers/structures that I set for myself by moving and dancing the emotions. To draw that feeling after the movement continued the process of unfolding.”
It is difficult to convey in words the depth and power of the expressive arts process. I would like to share a personal episode in which using expressive arts helped me through a difficult period. I hope that, in reading it, you will vicariously experience my process of growth through movement, art, and journal writing in an accepting environment.

The months after my father’s death were an emotional roller coaster for me. The loss felt huge, yet there was also a sense that I had been released. My inner feeling was that his passing had opened a psychic door for me as well as having brought great sorrow.

Expressive arts served me well during that time of mourning. Two artist-therapist friends invited me to spend time working with them. Connie Smith Siegel invited me to spend a week at a cottage on Bolinas Bay. I painted one black picture after another. Every time I became bored with such dark images, I would start another painting. It, too, became moody and bleak. Although Connie is primarily an artist, her therapeutic training and ability to accept my emotional state gave me permission to be authentic.

Also, I went to a weekend workshop taught by Coeleen Kiebert and spent more time sculpting and painting. This time the theme was tidal waves—and again, black pictures. One clay piece portrays a head peeking out of the underside of a huge wave. My sense of being overwhelmed by the details of emptying my parents’ home, making decisions about my father’s belongings, and responding to the hundreds of people who loved him was taking its toll. Once again, my art work gave free reign to my feelings and so yielded a sense of relief. Coeleen’s encouragement to use the art experience to release and understand my inner process was another big step. I thought I should be over my grief in a month, but these two women gave me permission to continue expressing my river of sadness. That year my expressive art shows my continued sense of loss as well as an opening to new horizons.

As is often true when someone feels deep suffering, there is also an opening to spiritual realms. Three months after my father’s death, I flew to Switzerland to cofacilitate a training group with artist-therapist Paolo Knill. It was a time when I had a heightened sense of connectedness to people, nature, and my dreams. Amazing events took place in my inner being. I experienced synchronicities, special messages, and remarkable images. One night I found myself awakened by what seemed to be the beating of many large wings in my room. The next morning I drew the experience as best I could.

One afternoon I led our group in a movement activity called “Melting and Growing.” The group divided into pairs, and each partner took turns observing the other dancing, melting, and then growing. Paolo and I participated in this activity together. He was witnessing me as I slowly melted from being very tall to collapsing completely on the floor. Later I wrote in my journal:

I loved the opportunity to melt, to let go completely. When I melted into the floor I felt myself totally relax. I surrendered! Instantaneously I experienced being struck by incredible light. Although my eyes were closed, all was radiant. Astonished, I lay quietly for a moment, then slowly started to “grow,” bringing myself to full height.

I instructed the group participants to put their movement experiences into art. All-encompassing light is difficult to paint, but I tried to capture that stunning experience in color.

Reflecting on these experiences, it seems that my heart had cracked open. This left me both vulnerable and with great inner strength and light. A few days later another wave picture emerged. This time bright blue/green water was illumined with pink/gold sky.

These vignettes are part of my inner journey. I share them for two reasons. First, I wish to illustrate the transformative power of the expressive arts. Second, I want to point out that person-centered expressive therapy is based on very specific humanistic principles. For instance, it was extremely important that I was with people who allowed me to be in my grief and tears rather than patting me on the shoulder and telling me everything would be all right. I knew that if I had something to say, I would be heard and understood. When I told Paolo that I had the sensation of being struck with light, he could have said, “That was just your imagination.” However, he not only understood, he told me he had witnessed the dramatic effect on my face.

Humanistic Principles

Since not all psychologists agree with the principles embodied in this book, it seems important to state them clearly as the foundation for all that follows:

  • All people have an innate ability to be creative.
  • The creative process is healing. The expressive product supplies important messages to the individual. However, it is the process of creation that is profoundly transformative.
  • Personal growth and higher states of consciousness are achieved through self-awareness, self-understanding, and insight.
  • Self-awareness, understanding, and insight are achieved by delving into our emotions. The feelings of grief, anger, pain, fear, joy, and ecstasy are the tunnel through which we must pass to get to the other side: to self-awareness, understanding, and wholeness.
  • Our feelings and emotions are an energy source. That energy can be channeled into the expressive arts to be released and transformed.
  • The expressive arts—including movement, art, writing, sound, music, meditation, and imagery—lead us into the unconscious. This often allows us to express previously unknown facets of ourselves, thus bringing to light new information and awareness.
  • Art modes interrelate in what I call the creative connection. When we move, it affects how we write or paint. When we write or paint, it affects how we feel and think. During the creative connection process, one art form stimulates and nurtures the other, bringing us to an inner core or essence which is our life energy.
  • A connection exists between our life-force—our inner core, or soul—and the essence of all beings.
  • Therefore, as we journey inward to discover our essence or wholeness, we discover our relatedness to the outer world. The inner and outer become one.

My approach to therapy is also based on a psychodynamic theory of individual and group process:

  • Personal growth takes place in a safe, supportive environment.
  • A safe, supportive environment is created by facilitators (teachers, therapists, group leaders, parents, colleagues) who are genuine, warm, empathic, open, honest, congruent, and caring.
  • These qualities can be learned best by first being experienced.
  • A client-therapist, teacher-student, parent-child, wife-husband, or intimate-partners relationship can be the context for experiencing these qualities.
  • Personal integration of the intellectual, emotional, physical, and spiritual dimensions occurs by taking time to reflect on and evaluate these experiences.

The accompanying figure shows the Creative Connection process and principles, using expressive arts therapy. It shows how all art forms affect each other. Our visual art is changed by our movement and body rhythm. It is also influenced when we meditate and become receptive, allowing intuition to be active. Likewise, our movement can be affected by our visual art and writing, and so forth. All the creative processes help us find our inner essence or source. And when we find that inner source, we tap into the universal energy source, or the collective unconscious, or the transcendental experience.

Come with me, if you will, on a journey of inner exploration to awaken your creativity. Perhaps you are a writer who shies away from visual art, or an artist who says,”I can’t dance,” or a therapist who would like to discover methods for enhancing the counselor-client relationship. I invite you into your own secret garden.

Psychotherapy for Oppositional-Defiant Kids with Low Frustration Tolerance – and How to Help Their Parents, Too

Childhood temperament is the elephant in the living room of child psychotherapy. Just as the influence of substance use and abuse on clients' behavior problems was often minimized by psychotherapists before the 1970s, the importance of temperament in children's behavior problems is becoming an increasingly essential part of child and family therapy.

After 30 years of working with children and parents, I am convinced that, barring developmental disorders or a major family tragedy, most children who come to therapy have higher-maintenance temperaments (i.e., frequently described as difficult, spirited, or challenging) that frustrate typical parenting approaches.1 Some parents are unable to effectively deal with certain children who try their patience despite having no such difficulty with their other children. Here I will focus on one aspect of childhood temperament, frustration tolerance, its relationship with Oppositional Defiant Disorder (ODD), and how such concerns can be worked on in therapy with children and their parents. I will also examine the important role played by the therapist's inevitable personal reactions in the therapeutic process.

ODD and Children's Frustrations

When I worked with James R. Cameron, Ph.D. at the Preventive Ounce2, we observed that children with low frustration tolerance are at risk for becoming oppositional. We saw that parents often responded to these kids in ways that exacerbated their problematic behavior. ODD has also been related to the child's temperament and the family's response to that temperament. This model helps therapists work with the child's temperament, the parent's style, and the interaction between the two.

In the same vein, Barkley3 states that "children who are easily prone to emotional responses (high emotionality) are often irritable, have poor habit regulation, are highly active, and/or are more inattentive and impulsive and appear more likely . . . to demonstrate defiant and coercive behavior than are children not having such negative temperamental characteristics." He also notes that "immature, inexperienced, impulsive, inattentive, depressed, hostile, rejecting, or otherwise negatively temperamental parents are more likely to have defiant and aggressive children."

DSM-IV-TR4 (2000) and ODD

  • ODD . . . is a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months.
  • In males, the disorder has been shown to be more prevalent among those who, in the preschool years, have problematic temperaments (e.g. high reactivity, difficulty being soothed.) ODD . . . usually becomes evident before age 8 years and usually not later than in early adolescence . . .
  • The oppositional symptoms often emerge in the home setting but over time may appear in other settings as well. Onset is typically gradual, usually occurring over the course of months or years..Often loses temper, often argues with adults, often actively defies or refuses to comply with adults' requests or rules, often deliberately annoys people, often blames others for his or her mistakes or misbehaviors, is often touchy or easily annoyed by others, is often angry and resentful, and is often spiteful or vindictive.

ODD and Low Frustration Tolerance

Children with low frustration tolerance are adamant in wanting to end the cause of their frustration as quickly as possible. When they are having a hard time with a task (e.g., homework, some tasks they don't immediately understand, or a toy or game that they can't make work the way they want), they find that the best way to eliminate their frustration is to stop trying and do something else instead. If they want to do something and their parent (or another adult) won't let them do it, the best way to eliminate their frustration is to act in ways that might get the adult to change their mind and leave them to their own desires and interests.

“It is worth noting that except for being spiteful and vindictive, ODD traits and behaviors listed in the DSM represent how many children usually act when they don't want to do what they are told to do.” The children that meet DSM criteria are diagnosed with ODD, but they could also likely be children with low frustration tolerance who are acting oppositionally in an effort to eliminate their frustration. The behavior that a parent or adult calls oppositional may also, in fact, be a child's age-appropriate response to a developmentally inappropriate limit set by the parent or environment.

How Parents Make it Better or Worse

How do parents make their kids' frustration tolerance better or worse? Note that it is important to allow the child to be frustrated with life pressures and stresses rather than preventing age-appropriate frustrations. Indeed, a key task of parenting is to help children gradually take on more difficult tasks so they learn how to tolerate frustration as well as regulate emotional reactions. The work on how optimal levels of frustration relate to learning,5 how attachment develops,6 and how managing affect in disorders of the self7 point to the importance of parents helping children learn how to manage frustration. Clearly, parents make the situation better or worse by how they interact with their child. Parents make things better by setting appropriate limits, managing their own anxiety, reinforcing positive behaviors, and understanding the motivations of the child. Certainly, parents can behave in ways that make matters worse via what I call the Argument Trap and the Overly Helpful Parent.

The Argument Trap!

One way a parent can worsen the situation is by arguing with the child too much when the child doesn't do what he is asked. Here, the parent, after setting a limit for their child, keeps responding to the child's objections in an effort to have the child understand the parent's logic. This attempt to explain the limit and convince the child of its necessity often results in the child becoming more upset. The parent may then even punish the child for not complying with the limit. But since the child's goal is to remove the frustrating limit, as long as the parent and child are arguing, the child can hope that the parent changes their mind. If the parent gives in, the child is being taught to argue again next time. If the parent punishes the child, then the child has an additional reason to blame their parent for not removing their frustration.

To help a child with low frustration tolerance accept limits, the parent needs to let the child complain about the limit and have the last word, even if the last word is provocative. The parent needs to stick to the limit (unless there is good reason to give in) and not try to convince the child to agree with the limit. The child is less likely to keep arguing if the parent is not responding in kind. The parent ideally needs to set a limit, repeat the limit in as calm a voice as possible, suggest alternatives for the child, and then stop talking about the limit. Restrictions and/or time-outs can be helpful in calming the child, but when the child becomes highly agitated, these methods are often ineffective. In this case, the parent's goal is to shift the child from complaining about a limit to finding something else to do since the child can't do what they want. Thus, the argument is avoided, the child is re-engaged in an activity, and the child learns to better cope with their reactions and emotions.

The Overly Helpful Parent

Another way that parents inadvertently increase their children's low frustration tolerance is by helping their children too much when their children are faced with challenging tasks. Parents naturally help their children countless times each day. But low-frustration-tolerance children will often ask for help without trying enough on their own before seeking help. They tend to give up too soon without really testing themselves, and want the adult to jump in and solve the problem or complete the task at hand. When the parent helps too quickly, the child learns to immediately resort to fussing when frustrated, because this yields the desired results. Remember: removing the frustration is the primary goal for the low frustration tolerance child; solving the problem itself takes on secondary importance.

To help the low-frustration-tolerance child persist at a task such as homework, the parent needs to answer the child's questions when the child is able to listen to the answers. The parent also needs to help the child learn skills for dealing with frustrating situations, such as taking a break or dividing up the homework in smaller chunks and doing one part at a time. When children are upset and frustrated, they don't listen well (if at all!) until they have calmed down. “The parent's role is to help the child learn how to handle frustrating situations, not to quickly solve the frustrating situation for the child.” For example, when a parent has been helping a low-frustration-tolerance child too much with his homework, backing off from helping may lead to the child receiving worse grades for a while. But when a parent takes too much responsibility for getting homework done, the child doesn't take enough responsibility and does not learn how to cope with frustration. It is more important to teach the child to take responsibility and to learn how to do homework than it is to help the child complete any particular assignment.

Psychotherapy with ODD Children and their Parents

My hypothesis for why oppositional behavior develops in this fashion is that “parents who don't understand how to handle typical low frustration tolerance behavior have inadvertently reinforced that behavior many times over many years before that behavior becomes oppositional.” Many parents of children who meet the criteria for ODD could actually be diagnosed as having Argumentative Punitive Disorder (or APD—this is not an actual diagnosis, by the way) because they often lose their temper, argue with their children, blame their children for their ineffective parenting, are easily annoyed by their children, and are angry or resentful toward their children. One of the main goals of therapy is to help parents manage their frustration when their children become frustrated. Below, I present several therapeutic guidelines for working with these kids and their parents.

  • Who to meet with? Therapists need to work with the parents as well as the children on a constituent basis, preferably every session. I generally meet with the parent (or parents) before I see the child. We discuss what has happened since the last appointment, how to understand what has happened, and how the parent might try to work with the child before the next appointment. Then I meet with the child alone. Sometimes I meet with the parent and child together—after seeing each of them separately—if there is some issue I think we need to discuss.
  • Breaking the Cycle of Arguing: Parents need help learning how to avoid being argumentative-punitive. They need assistance finding the middle ground between too many limits/not enough limits and too much help/not enough help. This takes time and work to find an approach that is tailored to particular parents and their child.
  • Encouraging Parents: Since one of my therapeutic goals is to increase the parent's ability to help their child gain more frustration tolerance, I continually encourage parents and reinforce their attempts to find more effective ways to work with their child. I keep reminding parents and children that they are meeting with me to learn new ways to deal with their family problems because the way they are handling matters is not working. It is crucial to encourage and engage the child's parent since they are the ones who usually bring the child in, pay for the sessions, and do the majority of the work every day.
  • Validation of Parent Frustration: It is also crucial to validate the parents' feelings of exasperation, anger, and frustration. I empathize with the parents and acknowledge that I would feel similarly if I were parenting their children. I explain again how low frustration tolerance works and encourage the parents to handle their children's oppositional behavior differently even when they feel angry, exasperated, and/or frustrated.
  • Talking to the Child about being Responsible: I find it helpful to talk with the children (in language that makes sense to them) about being more responsible for what they are supposed to do instead of complaining so much about what their parents are doing or not doing. I often remind children that if they do as they are told, even if they don't want to, their parents are more likely to let them do more of what they want to. Learning how to negotiate effectively with parents is a valuable tool for any child, and particularly for these children.
  • How long is therapy? The length of therapy is highly variable depending on the age of the child, the extent of the child's low frustration tolerance, and the parent's ability and motivation to understand how they have been contributing to the problem. If the parent-child dynamic changes quickly and the child is able to respond, treatment may be briefer, but often there are entrenched problems in the family that are best worked on over a longer course of consistent therapy.

Making Use of the Therapist's Experience and Personal Reactions

Working with oppositional low-frustration-tolerance children and their parents has also frequently left me feeling exasperated, angry, incompetent, and . . . you guessed it, frustrated. For instance, when a parent and I discuss at one session how important it is not to argue and yell at the child about homework, and then the parent comes to the next session and reports another escalating homework argument that ended with the child swearing at the parent and the parent calling the child derogatory names, I sometimes feel like arguing and yelling myself. I start thinking: the parent is provoking the child's defiant behavior, the child is not being responsible about homework, I am not facilitating positive change in the family, etc. It is very easy to get sucked into this escalating family system.

I have come to see my reactions to the parent and child as similar to the reactions the parents and child are having to each other. “My feeling that I am not a competent therapist mirrors the parents' feelings that they are not competent parents. My feeling of exasperation parallels the parents' feeling of not knowing what to do when their children continue to be oppositional.” My angry feelings mimic the children's feelings at their parents' inability to manage their own behavior or their not getting their own way all the time.

Understanding and managing these personal reactions help me understand the child and their parent's frustrations more fully, making my limit-setting and direct intervention more empathic. It also helps prevents a critical or punitive therapeutic approach which mirrors the parent's approach, which is both ineffective and off-putting to the family.

I invite psychotherapists who work with children to consider the possibility that ODD is temperament-based low-frustration-tolerance behavior that well-meaning but uninformed parents have inadvertently mismanaged. I believe that psychotherapists who add this approach to their work with oppositional children will increase their effectiveness and be better prepared to manage their own personal reactions to this most difficult yet worthwhile endeavor.

Questions to ask Parents

Does Your Child Have Low Frustration Tolerance?
There is no valid and reliable test that can definitively determine whether a child has low frustration tolerance. Temperament questionnaires, observation and reflection, comparison with other children's behavior in the same situation, and parents' willingness to examine their own feelings about a child can help parents and therapists reach an informed opinion about a child's level of frustration tolerance. Here are some questions for parents to consider:

  • What is your child's temperament? Energetic-positive, energetic-difficult, passive-low energy, easy going?
  • Does your child get frustrated more easily than other children the same age?
  • Does your child get easily frustrated when you set limits? O, does your child get easily frustrated when you want your child to stop doing what they are doing and do something else instead? (Note: Some children are slow to adapt to transitions, changes and intrusions, and are likely to get frustrated when asked to stop what they are doing and do something else. Their response should not be confused with that of children with low frustration tolerance, who will complain when a limit is set but may generally not complain when a family routine is changed, the day's schedule is changed, or if you interrupt them when they are doing something. Of course, a child can be slow to adapt to changes and also have low frustration tolerance.)
  • Do you give in more often than you think you should when your child complains about a limit? Do you find yourself getting annoyed because your child keeps testing limits?
  • Is your child able to play alone or with friends in their own room or do they always have to be with you? Do you often tell your child to "go play" while you try to finish a task?
  • Has your child's frustration tolerance decreased suddenly? Has something happened recently (e.g., the birth of a sibling, a change in teachers, a death, a divorce, an illness) that could have upset your child and made your child more easily frustrated about things than previously so? If so, your child's frustration tolerance should improve as you both deal with the feelings associated with the event or change that has occurred.

References

1Chess, S., & Thomas, A. (1989) Know your child: An authoritative guide for today's parents. (New York: Basic Books)

2Cameron, J.R. & Rice, D. (2000). The Preventive Ounce Web Site. www.preventiveoz.org. (Oakland, CA: The Preventive Ounce)

3Barkley, R. A. (1997). Defiant Children, Second Edition: A Clinician's Manual for Assessment and Parent Training. New York: The Guilford Press

4American Psychiatric Association, (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. (Washington, D.C.: American Psychiatric Association)

5Stern, D. (1985) The Interpersonal World of the Infant. (New York: Basic Books)

6Hughes, D. (1998) Building the Bonds of Attachment. (Northvale, NJ: Jason Aronson)

7Schore, A. (2003). Affect Dysregulation and Disorders of the Self. (New York: W.W. Norton) 

Family Therapy with Families Facing Catastrophic Illness: Building Internal and External Resources

Ten years ago my late husband Ronald William Pulleyblank, with the help of his doctor and with a small group of witnesses, had his ventilator turned off, after living on it for seven years. Those years and the ones since then have radically affected my life and my work as a psychologist. Ten years after his death, twenty-five family and friends dedicated a redwood tree in Ron's name. In this beautiful event, after so long, we were able to place his illness and death back in what Lawrence Langer calls chronological time.

Langer, in his book, The Holocaust, distinguishes between two kinds of time: chronological time and durational time. He says that we expect a life in chronological time, made up of a past, present and future. When crises become the norm of life, durational time sets in. This is time without past or future and with a recurring experience of a disturbing present that is difficult to organize, express or forget. Langer writes that because durational time cannot overflow the blocked reservoir of its own moment it never enters what we usually experience as the stream of time. Often we and the people around us expect our grief to last for a prescribed length of time. Depending on the level of stress during an illness, this experience can last for much longer than we would expect. This assumption and others often need to be challenged, if patients and families are to find ways to live with significant illness.

 

Challenged Assumptions, Dilemmas, Necessary Conversation

1. Assumption: We each are responsible for ourselves and must make decisions for ourselves.
 
The Dilemma: A particular illness belongs to the patient. How the patient perceives this illness often determines the decisions he or she wishes to make. At the same time the perception of the illness is often quite different for family members who are responsible for the patient's care.
 
An example: Harry, who is very ill, continues to want to drive his children to school. His wife fears that his illness makes it unsafe.
 
Necessary conversations: The couple has to reassess which decisions are independent decisions and which must now be mutual. The roles and the responsibilities in their household also must be reassessed. These conversations need to include the multiple perspectives of all family members and sometimes those of extended family, caregivers and the norms of the community in which they live. The tendency to focus on the needs of the patient over the needs of caregivers and family members often must be challenged.
 
Note: Who participates in these conversations, and in fact in all conversations, often depends upon cultural values and beliefs. Before developing a treatment plan, an assessment with the family of how decisions are to be made is essential.
 

Positive Choices

2. Assumption: There are always positive choices to make, actions to take.
 
Dilemma: Often outcomes about the course of an illness are unknown. Tolerating ambiguity is a prerequisite for making decisions.
 
Example: A patient has fast-growing prostate cancer. He has the choice of following a usual course of treatment with mixed outcomes or an experimental treatment with little or no clear outcome data.
 
Necessary Conversations: Family members work to increase their tolerance of stressful emotional states due to ambiguity. They examine strategies and past experience that may help them tolerate the unknown.
 

Family Resources

3. Assumption: We often hold the belief that each family should and can provide for ill family members.
 
Dilemma: Due to the complexity of treatment and duration of treatment, there is often too much stress on family resources. This can overload the system and make it impossible for one family to provide physical, emotional, spiritual, social and financial resources adequate for all family members.
 
Examples: There is an extremely high divorce rate in families with long-term illnesses and also a high illness rate in other family members.
 
Necessary Conversations: The family explores how to build a community of support. With this support they learn ways to advocating for the needs of all family members in the family and in the wider community vs. over-relying on already overwhelmed family resources.

Maintaining Life

4. Assumption: It is the job of the medical establishment to maintain life.
 
Dilemma: Though this is a central tenet of medical practice, maintaining care is not the direct responsibility of the medical world. Separation between medical decisions in emergency rooms and the implications for life following these decisions can lead to patients being kept alive beyond their capacity to enjoy life and the capacity of their families to sustain them. As part of this dilemma, there is a medical process in place to save lives, but often no ethical process in place that offers the patient and family members a voice in deciding when enough is or is not enough. In addition to life-threatening issues, realistic care plans that take into account family resources need to be part of the medical treatment plan.
 
Necessary Conversations: Family discussions before there is an emergency about how decisions ought to be made can be very helpful. Though health-care directives are useful in this regard, they need to be re-assessed as the situation changes. Convening multiple systems that impact family life so that there is a shared understanding of what is possible and what are the wishes of the family will sometimes address issues of fragmentation that lead to unwanted decisions. Integration of services also adds to the possibilities that families have of accessing needed resources.
 

Treatment Principles

Underlying these conversations are the principles of therapy, or the backdrop of any engagement in the treatment process described below:
 
Shared human experience: No one avoids illness and death. It is an experience that bridges, by its very nature, the therapist/client relationship; therefore our capacity to be seen is crucial in entering the often lonely experience of illness and death.
 
Spiritual Practice: Thinking of the therapy room or someone's home as a sacred space. Evoking the strength of prayer, meditation, not being afraid to ask for help in facing the unknown. Starting with silence, leaving time for meditation ending with silence. Sharing one's own spiritual practice and prayer.
 
A Narrative Overlay: Arthur Frank, in his article about illness and deep listening, describes three different kinds of stories related to serious illness. They are: Restitution Stories in which there is a positive resolution (this kind is a favorite of us therapists), Chaos Stories in which things remain ambiguous (our least favorite kind), and Quest Stories in which the exploration of the unknown is a goal of the therapy.
 
Social Activism: Patients are often marginalized. They are a group fighting not to be silenced, and part of the therapy is advocating with them for their rights.
 

Examples of Treatment Issues at Different Stages of Illness

At diagnosis: Keeping things the same—a wish not to tell. A man 77 years old is diagnosed with fast-growing prostate cancer. He is experiencing a profound sense of disbelief because, though he has been having difficulty with urination, he has been told over the last three years that this is normal. He's also been told that if he does have prostate cancer it is most likely to be slow moving and he will die of something else. No tests are done until very recently, when it is discovered that the cancer is fast-moving and advanced. While he is dealing with this disbelief, he has at the same time to decide about whether or not to choose the conventional treatment or an experimental treatment, and where to get treatment. His children are scattered. His wife is highly anxious and wants a decision to be made immediately. He wants to go slowly, still focused on his disbelief that the doctors he had had faith in seemed to have made a mistake in his case. His focus is on keeping things the same. His wife's focus is on fixing things. Slowly his adult children, who up until this time have never participated in their parents' decision-making process, join their parents in making a decision—the best decision that they can make, but still a decision with uncertainty. In this family, this has a surprising enlivening effect as if everyone knows that they don't know what will happen, and so they reach out to each other and build on the strengths of their relationships.
 
Note: There are many reasons for patients and families to wish not to speak of illness. It often creates a sense of isolation as one is seen as different. It can be seen as weakening. Around particular illnesses there are many fears and judgments. Communicating about illness can have negative effects on employment and parenting responsibilities. Understanding the reasons that people avoid talking about the illness can help the therapist work with the unique timing and pace issues within each family.
 

Ongoing Crises: Living with Ambiguity

In another family that I am working with, the father, age 50, has fast-advancing ALS. He cannot communicate except with a raise of his eyebrow. Though he has decided not to go on a ventilator, there are many caregivers, involved and the ALS Center continues to try to find ways to relieve his symptoms. His mood vacillates between passive acceptance and depression. He is on antidepressants. His wife is overwhelmed. She is angry that everyone keeps expecting her to do more. She cannot sleep at night. One daughter has begun her first year at college; another daughter is away at a boarding school. We meet together as a family. Each family member has extraordinary pressing needs that seem to conflict with each other. We have a series of conversations in which the grief that is the strongest shared experience is brought into their conversation with each other. With this shared experience, sorting out who needs what, who else might help, becomes clearer, though this is a good example of an ongoing chaos story that has no good ending in sight. Sometimes even taking the time for therapy feels like a burden since there are so many people providing different services.
 

Death and Dying: Letting Go

Sometimes people can make a conscious choice to die, as Ron did in turning off his ventilator. It took many months for him to make this decision. We had conversations with family members, ethicists, psychotherapists and spiritual teachers. Once he decided to turn off the ventilator off, he went through the process of saying goodbye to the important people in his life, even though he could barely speak. More often death is not planned, but sudden, and often a crisis. Inviting families to include conversations about death and dying can be helpful, but often patients resist this fiercely as they hold onto life. Sometimes these conversations work better not all together but separately, with different family members at first and then leading to a wider discussion. When families with adult children come back together as a family often old hurts reappear. These need to be addressed and everyone needs some time to catch up with each other in order to move forward together. Families with younger children have to match conversations about death and dying with the age of each child.
 

After Death: Going Forward

As I said at the beginning, many issues of distress last much longer than people expect. Careful assessment is often needed. Different family members have different responses. When working with children in particular, it is sometimes difficult to sort out what is PTSD and what is grief. If supported in these differences, family members and the family as a whole often mobilizes new resources to transform itself.
 

Summary of Suggested Therapeutic Practices

Diagnosis 
Dilemma: Maintaining the familiar with radical change
  1. Providing a safe container for the expression of intense shock and disbelief.
  2. Facilitating conversations about the diagnosis with children and extended family members.
  3. Bearing with the family the ambiguity of not-knowing the outcome.
  4. Searching for ways to maintain the normal everyday of life, especially for children.
  5. Shifting anxiety about not knowing to finding out information from others.
  6. Discussing ways that other family members and/or friends can participate in the crisis.
  7. Helping families make and/or face medical decisions and prepare questions for meetings with doctors.
  8. Advocating for families in their dialogues with medical and insurance systems.
Ongoing Crises 
Dilemma: Sustaining hope with continuing loss
  1. Normalizing a distorted sense of time and feelings of anxiety and depression as predictable responses to ongoing crises.
  2. Including your experiences with catastrophic illness and death.
  3. Paying attention for and treating overwhelming depression or anxiety in the patient and family members.
  4. Facilitating conversations about the meanings of illness and death in the family and in the wider social context.
  5. Searching out underlying values, beliefs and family history that have led to these meanings.
  6. Looking for stories and practices in the family and in the wider culture that offer other possible meanings and responses to illness and death.
  7. Bearing and talking about the ongoing pain with the patient and the family as they witness the illness worsen.
  8. Finding creative ways for the family to spend good times together within their limited circumstances.
  9. Allowing for the different experiences and needs of the patient and family members.
  10. Facilitating dialogues and planning that take into account these differences.
  11. Convening a wider circle of friends and family to facilitate ongoing support networks.
  12. Bringing nursing, medical, spiritual and social service providers together with the family to assess ongoing needs and to provide coordinated services.
Conscious death and dying 
Dilemma: Knowing the unknowable
  1. Providing openings for conversations about death and dying.
  2. Tolerating and experiencing intense grief with family members.
  3. Exploring beliefs, meanings and family stories about death and dying.
  4. Participating with families in discussions about the economic, ethical, social and spiritual implications of life support systems.
  5. Offering opportunities for friends, family members and spiritual teachers to participate in these conversations.
  6. Discussing desired rituals and practices in preparation for dying and death.

Bibliography

Boss, P. (1999). Ambiguous Loss. Cambridge, Massachusetts: Harvard University
Frank, A. (1998). "Just Listening: Narrative and Deep Illness", Families, Systems & Health. Vol. 18, No. 3.
Hanh, T.N. (1975). The Miracle of Mindfulness. New York: Beacon.
Johnson, F. (1996). Geography of the Heart. New York: Scribner.
Kuhl, D. (2002). What Dying People Want. New York: Public Affairs/Perseus Books.
Langer, L. (1975) The Holocaust. New Haven: Yale University
Levine, S. (1987). Healing into Life and Death. New York: Anchor.
Lewis, C.S (1976). A Grief Observed. New York: Bantam.
Polin, I. (1994). Taking Charge: How to Master Common Fears of Long-Term Illness. New York: Times Books
McDaniel, S. & Campbell, T. (1997). "Training Health Professionals to Collaborate", Families, Systems and Health. Vol 15, No. 4.
Pulleyblank, E. "Hard Lessons." The Family Therapy Networker. January.
Pulleyblank, E. (2000). "Sending Out the Call: Community as a Source of Healing, Families Systems and Health. Vol.17, No.4.
Pulleyblank Coffey (2003). "The Symptom is Stillness: Living with and Dying from ALS, A Progressive Neurological Disease." Chapter in: End of Life Care, Berzoff, J. & Silverman, P (eds.) New York: Columbia University Press (in press). **
Quill, T. (2002). Caring for Patients at the End of Life. New York: Oxford Press.
Rolland, J. (1994). Families, Illness and Disability: An Integrative Treatment Model. New York: Basic Books.
Spiegel, D. (1993). Living Beyond Limits. New York: Fawcett Columbine.
Staton, J., Shuy, R., Byock, I. (2002). A Few Months to Live. Washington D.C.: Georgetown University Press.
 
**Copy of chapter available from author. Contact at: epulleybl@aol.com.