NEW SOUTH WALES 1 Lyndal Power Clinical Coordinator RAPS Adolescent Family Therapy and Mediation...
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Transcript of NEW SOUTH WALES 1 Lyndal Power Clinical Coordinator RAPS Adolescent Family Therapy and Mediation...
NEW SOUTH WALESNEW SOUTH WALES
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Lyndal PowerClinical Coordinator RAPS Adolescent
Family Therapy and Mediation Service 98901500
Email [email protected]
Working with Adolescents and their
Families
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RAPS
• Adolescent Family Therapy and Mediation Service• See teenagers, siblings and parents together• 11-20• Serious difficulties
» Conflict parents and teenagers» Truanting and school suspension» Running away» Violence» Drug use, criminal behaviour
• RAPS established 1990 to prevent youth homelessness
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RAPS
• Social Workers/ Psychologists with postgraduate training in family therapy
• Family therapy consultant- ‘live’ supervision of family therapy
• See clients across Sydney, based in Parramatta, some outreach
• Sliding scale of fees• Systemic- work with schools, juvenile
justice etc• Other work
• parenting seminars including refugee parent groups• Provide training in family therapy
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Research- Role of Family
• Family offers a secure base (caring, connectedness and belonging)- linked to positive outcomes (Luthar 2006) (Rayner & Montague 2000)
• Benefits of parental monitoring and limit setting (Luthar 2006)
• Low monitoring linked to negative outcomes: antisocial behaviour, substance use, sexual risk taking (Hayes et al 2004)
• Parents continue to advise and support young adults- parents underestimated their support- highly valued by young adults (Vassallo et al 2009)
• Family Relationships- source of pain for those cut off- desire for connection, deeply held (Dwyer & Miller 2006)
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Research- Family Therapy
• Family based therapies- among most effective for adolescent substance use (Carr 2009) (Hogue and Liddle 2009)
• Family based treatments effective for depression, eating disorders, conduct disorders, anxiety, school refusal, OCD, grief, bipolar disorder, attempted suicide and somatic problems (Carr 2009) (Cottrell & Boston 2002)
• Multisystemic therapy- effective for delinquency- improved family relations, decrease in behavioural problems and out of home placements (Utting et al 2006)
– (Multisystemic- strength based family intervention- problems are multi-determined- assess range of risk and protective factors
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Adolescents need
nurturance• Western societies- overemphasis on individuation
of adolescents as though this equates with separation from parents (Mackey 1996)
• Importance of nurturance and connection for adolescents is neglected (Mackey 1996)
• Studies show individuation fostered by connection to parents
• Strengthening relationships between parents and adolescents is essential in therapy (Mackey 1996)
• Secure attachment to parents may lessen negative influence of peers and increase adolescent responding to parental limits (Mackey 1996)
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Three dimensions of Adolescent Attachment
1. Felt security- firm
2. Use parent for emotional support- warm
3.Parent supporting child’s growing autonomy- enabling
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Balance of Connection
and Control
control
connectionchaotic
authoritativeauthoritarian
laissez-faire
Baumrind’s Four Types of Parenting
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Balance of Connection and Limits
• Parents in a position of hierarchy• Children on track when balance between
connection and limits• Parents may need to work more on one
dimension for balance• Issue of parents soft/hard split• Importance of working together• Past issues may lead to separated parents
undermining
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Relationship Discourse
• Web of relationships- To understand a dyad need to consider impact of other family relationships eg Girl (14) runs away, Fa had died, brother became closer to mother, Mo-Dau more distant.
• Parents describe identified teenager as being of bad behaviour or character eg “He’s defiant” or “She’s selfish”
• By establishing a relationship discourse, through asking relationship questions- family members begin to be seen in terms of relationships
• Shift from ‘bad’ kid to ‘sad’ kid• Asking relationship questions at every session keeps
adolescent- parent relationships central
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Misbehaving child
• Misbehaving child tends to have lowest scoring relationships with parents
Child misbehaves Parent distances/critical
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Conducting a Family Session
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Getting the whole family in
• Always easier to work from broader ie whole family to fewer members. eg harder to get a father in if not there at first session.
• If mo and children there and not partner, therapy work may be undermined at home
• At RAPS, we encourage whole household to come in. We avoid seeing a mother and her children if the father is not there eg may see her on her own to help her to get other family members in eg partner and teenager.
• We explain why we need partner/siblings there- we need their perspectives. We can work faster if we have all family member’s perspectives.
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• Explain context of agency- confidentiality• Joining- each parent, oldest to youngest child• Concerns- each person • Exploration- sequence, understanding of problem,
or impact of event eg trauma, separation, attachment disruption, relationship questions.
• Break- opinion- affirmations to each, understanding of how family got to be here eg stresses on family, interactional pattern, perhaps task
• Point to areas of work for future sessions
Summary of Stages- First Family Session
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Family Session-
Concerns• Each person’s experience- not trying to persuade them to see
another’s worry• Ask each parent the worries that have brought them to RAPS• To children/ teenager, “What are the things that worry/bother you?”• To child/ teenager, if no answer or “nothing”-
-“If you were worried about something, would it be more likely to be something at school or home?” Unpack
-If no answer, “Who in your family would most know what worries you?” Obtain from member then check with child/teenager, “How is your mum reading you?” Sometimes children will add a comment.
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Drawing out children’s concerns
• May need to re-phrase a question to ‘warm up’ child. First response is often minimal. “What worries you?” or “What bothers you?” “If you had 3 wishes and could change things…”
• Draw out children’s experiences- younger children often talk about “the fights”. This releases info to members about effects of conflict on children
• “How do the fights affect you?” “What do you do?”• “Which two people fight the most, then which two?”
and so on
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Obtaining a sequence
• A behavioural sequence is who did what, when• Introduce sequence
– “Id like to find out step by step what happened the other day when …” (eg worst incident or most recent)
• Start at beginning, before conflict. Ask one person about another’s behaviour- releases more info. “When you said that, what did your Dad do then?”“What did your daughter do next?”
• Focus is on behaviour but can also explore meanings, feelings, beliefs (try to understand what was going on emotionally for each)
• Eg “When your dad said ‘Get out!’ what did that mean to you?”
• Sequence- reveals coalitions, patterns, highlights work
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Conceptualisation
• What is your understanding of child/teenager’s difficulties?
• Use several lenses- structural, behavioural, attachment, relationship, developmental. – V.Goldner (1990)- each lens can enrich to →
fuller explanation• A structural lens can be a check on psychologising a
problem→ stuck – eg this teenager needs to be at school
• Do the parents need to work more on connection or limits or both?
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Setting Goals
• To set therapist’s goals for therapy- “If I had a magic wand, what would I wish for this family?” (Dr. L.MacKinnon)
• Like a basketball hoop- need to know where you are aiming. Have tools but must know what you are building (Miccuci 2009)
• Look at goals- where should we start? Where will we get most effect from intervening– Getting teenager into school/work eg addressing hitting
or criticism• Look for links between family goals and therapist’s goals eg
less fighting- no hitting commitment• Use openings
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Keeping engagement with both parents and
teenagers
• Neutrality (Milan)- on everyone’s side and yet no-one’s side• Lean in equally to parents’ and teenagers’ experiences- be curious
– “You said your mum takes your brother’s side, what does she do to show that?”
– “ You said your daughter is aggressive, what does she do? (Releases information about each person’s behaviour)
• If parents and teenagers start bickering/ getting reactive, get each to talk/look at you, not each other
– To parent/ teenager, “Talk to me, what are you most upset about?”
(Block interruptions, uncover person’s experience through unpacking)
• Teenagers become reactive if parents make negative comments about them or their friends
• Try to keep both parents and teenagers in the room together- may need to split session if cannot be contained
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Summary- Relationship Scan
• Allow time• Crucial members present• Introduce discussion-it’s not about love, sometimes
closer, other times, more distant• Ask easier relationships first• Ask outside the relationship before inside
- ask relationship description - unpack to build full description- ask closeness scaling question
• Ask inside the relationship • Reflect on low scoring relationships
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Asking about Parent-Child/Teenager
Relationships
• Ask outside- ask person A, about relationship between B and C – To mother, “How would you describe the relationship between
father and daughter?” Unpack to build a full description– Then scaling question, “Out of 10, if 10 is close and 0 is not
close, how close are they?”• Ask inside- ask person B about relationship with C
– To father, “How do you see the relationship with your daughter?” Unpack and then ask scaling question
• Ask inside- person C about relationship with B– To daughter, “How do you see your relationship with your
father?” Unpack and then ask scaling question
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Relationship in the Past • When was the relationship different?
eg, When 10 years old?
“ What was the relationship like? ” Ask young person last
• Unpack: “ What do you remember? ”
“ When did the relationship change? ” Nodal point
“ How was it different? ”
• Elicit losses: “ What do you miss? ”
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Comparison Questions
• “How would you compare the relationship with your mum, to your sister’s relationship with your mum?” “What is different?”
• “How would you compare the relationship with your mum to your friend’s relationship with her mum?”
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Relationships in the future
• “What sort of relationship do you want to have with your daughter?” What sort of relationship do you want to have with your mother?” (ask teenager last)
• “What sort of relationship do you want to have with your daughter when she is 25 ?”
• Hypothetical questions- “If…”- “If you were to spend more time together, what difference
would that make to your relationship?”
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Linking behaviour to relationship
• Can explore how changes in behaviour lead to changes in relationship– “You said you have been trying to ‘bite your tongue’
(be less critical) lately, how come?” – “What difference has biting your tongue (change in
behaviour) made to your relationship with your daughter?” Could also ask the other parent as well as teenager
– To parent, “When your son does his chores when asked, what difference does it make to you?” “What difference does it make to your relationship with him?”
• Behaviour is linked to relationships-furthers the relationship discourse
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Confronting parents
• Use leverage- what motivates parents to change their behaviour
Eg Father who wanted son to gain education
– Parents do not intend to damage their relationship with teenagers
• See parents without teenager to confront-– Can lean into their frustration– Point out link between parent’s behaviour→
effects on relationship and teenager’s misbehaviour
– Gain commitment to not use misbehaviour again
– Bring in teenager, parent shares commitment– Check in subsequent sessions
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Cup of Anger
• Teenager may be angry about present or past
• Find out about teenager’s anger– “What are you angry about?” Get list and ask
teenager to draw layers of cup (pie graph) on board
– “Are there reasons why you are more angry than other 15 year olds? What has happened to you? What goes into your cup of anger?”
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Imago- Couple’s dialogue
• Teenager (speaker)Says a paragraph about what is upsetting
(When teenager is fully heard, swap roles)
• Parent (listener)• Mirroring- “What I hear you saying is…”• Validating- “That makes sense to me/ I can
understand that• Empathising- “You must be feeling…(one
or two words)• “Tell me more…”(H.Hendrix and LaKelly Hunt 1997)
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Guidelines One to One Time
• 1:1 not cancelled because of misbehaviour
- use other consequences
• 1:1 time- not with others present
- ‘low person’ begins to feel no. 1
• Frequent short, better than infrequent long
• My wish- every parent 10 minutes a day with child/teenager
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Physical Connection
• Teenagers and elderly- least physical connection. eg girl who pinched her mother
• Teenagers need physical connection but may ‘pretend’ to object because of the independent part
• “3 hugs a day” to be healthy (V.Satir)
• Generally, best way to comfort someone is to hold them
• Rituals of connection (W.Doherty)
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Summary
• Adolescents need a balance between connection and limits from parents to reach adulthood
• Must consider the ‘web’ of attachment- further a relationship discourse
• Importance of seeing parents and children/teenagers together
• Help parents to set limits out of concern• Work to repair connection
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References
• Allan, D and Power, L (2011) Family Therapy with Adolescents.. In Rhodes, P, and Wallis, A, “A Practical Guide to Family Therapy: Structured Guidelines and Skills”. IP Communications:Melbourne
• Cunningham, PB and Henggeler SW (1999) Engaging Multiproblem Families in Treatment… Family Process, 38, No (3):265-286
• Goldner, V et al (1990) Love and Violence: Gender Paradoxes in Volatile Attachments. Family Process, 29, No (4): 343-364
• Gottman, J (1999) The Marriage Clinic: A Scientifically Based Marital Therapy. W.W Norton and co. N.Y
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References
• Gurman, A and Kniskern, D (1991) Handbook of Family Therapy
• Hendrix, H and LaKelly Hunt, H (1997) Giving the Love that Heals: a Guide for Parents, Atria Books, N.Y
• Mackey, S (1996) Nurturance: a neglected dimension in family therapy with adolescents, Journal of Marital and Family Therapy, 22 (4), 489-508
• MacKinnon, L (1998)Trust and Betrayal in the Treatment of Child Abuse. Guilford Press: New York
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References
• Micucci J (2009) The Adolescent in Family Therapy. The Guilford Press: New York
• Rhodes, P and Wallis, A (2011) A Practical Guide to Family Therapy: Structured Guidelines and Skills. IP communications: Melbourne.
• Robinson, E, Power, L and Allan, D (2010) What works with adolescents?... Australian Family Relationships Clearinghouse Briefing 16, 2010
• Sells, S (2004) Treating the Tough Adolescent. Guilford
Press: New York