Girl with parent silhouettes
by Mercedes Samudio, LCSW
I hate doing family therapy!” a colleague of mine once said during group supervision. She was sitting across from me, and even though her comment was harsh, I could see in her eyes and expression that it wasn’t anger coming through, but frustration and despair. “I’d rather meet with the kid individually than to deal with the chaos that is going on at the kid’s home.” She finished her statement, and everyone else in the group nodded in agreement. This, my fellow social workers, is how some of us have come to view family therapy and treatment—as a burden!
I started out wanting to save the world—not unlike many other social workers who make the arduous journey through rigorous undergraduate and graduate work. And, like others, I thought that if I could just impart my clinical understanding and cultural experience with people, I could cure mental illness and save individuals one session at a time. But, as I settled into my first position out of graduate school—a community mental health agency providing services to children and families—I began to realize how ill-prepared I was to begin working with the populations we all had our hearts set on saving!
For many new social workers, working with families has become an uphill struggle fraught with missed appointments, hard-to-reach parents, children who can only be seen during school hours, and family members who sometimes undermine the clinician’s treatment with their own views about mental health. Still, families need help and new social workers are trained to help—so how do we mix the two?
The Do’s and Don’ts of Family Therapy
Family therapy is a type of group psychotherapy that involves the treatment of two or more family members during the same session. Sounds pretty easy, right? Just provide the same type of treatment you would give an individual to multiple people, right? Well, not quite.
Families have their own culture that includes not only gender, sexual orientation, race, and socioeconomic status, but also themes, roles, myths, and a developed family concept that permeates all treatment. They have a resiliency that allows them to “absorb the shock of problems and discover strategies to solve them while finding ways” to meet the whole family’s needs (Van Hook, 2008, p. 11). But it can be tough and challenging to engage families, and it requires a clinician to have “a willingness to approach your anxiety” (Taibbi, 2007, p. 4).
DO Understand the Family’s Identity
One of the main things that you must do when you begin family work is to look at how families identify themselves. A common mistake of most new social workers is to look at the family through the lens of services the family has or their current living situation. The best way to learn how a family identifies itself is to simply ask: “Would you say that your family is close or distant?” “Can you detail everyone you consider ‘family’?” You’d be surprised by the answers you receive that can help inform treatment and give you a chance to use informal supports to help the family.
DON’T Chase Chaos
When working with families, one of the many barriers that tend to arise is that they have an uncanny knack for pulling clinicians into their chaos. It can be even more difficult to avoid the chaotic atmosphere of a family when you are doing home visits. The best remedy for managing the family’s chaos and your own anxiety is this: develop a concrete, succinct treatment plan that details each family member’s role in treatment and each family member’s goals for treatment. As families begin to succumb to life stressors, it will be easier to redirect the family back to the treatment plan and even link the family’s stressors with what they are working on with you.
DO Respect the Family’s Current State
As new social workers, we have a tendency to want to tell our clients what to do—not in an offensive way, but in a naïve, overtly helpful way that allows us to share our information and training. Although that’s all well and good, it does not serve the family, nor does it help develop the therapeutic alliance you’ll need to do deeper work. Being able to respect where each member of the family is in his or her current level of functioning and being able to speak to that level of functioning will show that you are not there to run the family’s life, but rather you are there as a support for the family to heal and grow. When you are feeling tempted to give suggestions to the family on ways to improve their functioning, a good rule of thumb is to ask: “Can the family sustain this suggestion without help from me?” If the answer is no, then be patient as the family develops a new understanding of its current challenges and the solutions to them.
DON’T Judge the Family’s Current Skill Set
When working with families, it’s often easy to see the patterns and decisions that have led the family to its current state of functioning. We are trained to see the systems that affect families and are given the tools to set the family on the right course. But hold on, grasshopper! Being able to be present with the family exactly where they are and guiding them to be a functional family is a very fine line, and it all starts with honoring the family’s current set of skills. Van Hook (2008) suggests that the clinician’s role in the family is to join with the family and enable its members to experience new ways to function. Through your work with the family, they will begin to practice new behaviors. But you have to do one more thing before you can just jump in and get to practicing new skills.
DO Develop a Therapeutic Alliance
Remember in the last paragraph when we talked about joining with a family so they can begin to experience a new way to function? Well, that all occurs when you are able to build a therapeutic alliance with the core family and its extended support systems. The therapeutic alliance will help create a safe space where each family member can not only practice new skills, but also process barriers to mastering those skills. This is the part that many new therapists get hung up on—being able to actively engage with a family that may be resistant to treatment. A few key ways to develop a positive alliance, or join, with the family include:
- Being on time and present during the session;
- Actively listening and asking for clarification instead of assuming;
- Being flexible with the family’s schedule;
- Delivering value to the family by triaging needs (remember Maslow?); and
- Allowing the family’s voice to be heard in treatment.
DON’T Ignore Cultural Influences
The buzz word of our profession is cultural sensitivity, right? And, more than likely, each class in your graduate program expected you to take a cultural perspective in applying theory to practice. But as you work with families, the cultural lens has to become one of your sharpest assessment tools. Looking at everything from race, gender, and socioeconomic status to religious ideals, family rituals, and external support systems will help you get a good picture of a family’s culture. I encourage new clinicians to not get hung up on what they think are going to be cultural barriers. Take inventory of your own ideas about culture and process them in supervision so you can come to families ready to hear and observe their cultural perspectives. One suggestion is to do a cultural assessment of a family that goes deeper than the intakes you perform in your agency. In this assessment, be sure to include all the aforementioned items, as well as the following aspects of a family’s culture:
- Previous negative experiences in treatment;
- Coping efforts and beliefs about hope;
- Family organization (communication, leadership, roles); and
- The family’s basic needs.
DO Develop a Strategic Treatment Plan
Going back to making sure that you do not get caught up in the family’s maladaptive level of functioning, making sure that you have a strategic treatment plan that details the goals of treatment can be one of the keys to facilitating successful family therapy. The treatment plan should illustrate a clinical loop: assessment, diagnosis, goals, and termination. In the assessment, you’ll gather all the important information about the family (history, resources, needs, and commitment to treatment). Next, you’ll assign a mental health diagnosis to the identified patient (usually the person on your referral) that you establish from the assessment. Then, you’ll use the assessment and diagnosis to create a goal that will help the family decrease symptoms and/or increase coping strategies. Last, you should discuss termination in this plan, so you and the family understand that treatment is not indefinite and will eventually end once goals are met. This clinical loop will help you to assess the progress of the family’s treatment and allow you to pinpoint where adjustments need to be made as you traverse through treatment. Another benefit to developing a strategic treatment plan is that you can use the plan to discuss the family’s symptoms and progress efficiently during your supervision.
DON’T Underestimate Your Countertransference
We all come from families. And if truth be told, a lot of us came into this field as a result of our experiences with our own families. Honoring this truth can help you build a therapeutic awareness, so you can begin to understand your motivations and difficulties in providing effective family therapy. When we work with families, it’s not always obvious where the barriers to treatment can present themselves. As clinicians, we have a tendency to look to the families we work with to find answers to barriers in treatment. However, we can also look within ourselves to see that our own perspectives, experiences, and beliefs about families come into the way we provide services to families. It is important to discuss this countertransference with your supervisor, to rule out whether your experiences are shaping the treatment of the families you serve. And it is important to be honest with yourself about how your own family history and experiences motivate your work with families, so you do not force or undermine a family’s treatment.
The work we do with families can be transformative and life-changing. Whether you’re partial to family work or not, thinking about these Do’s and Don’ts as you serve families will give you a framework with which to do effective, meaningful work in our communities.
References
Taibbi, R. (2007). Doing family therapy: Craft and creativity in clinical practice (2nd Ed.). New York: Guliford Press.
Van Hook, M. P. (2008). Social work practice with families: A resiliency-based approach. Chicago: Lyceum Books.
Mercedes Samudio, LCSW, is a family/parent coach who has been working with families for more than six years helping them achieve results in parent-child bonding, decreasing power struggles, and developing effective discipline strategies that foster strong, nurturing relationships. She received her MSW from the University of Southern California. You can read more about her parenting philosophy at http://theparentingskill.com.