Engaging “Resistant” Families in Treatment

Many families, when presented with the option of family therapy, are less than eager to participate. This paper comprises the second and third parts of a series on engaging “resistant” families. ¹ 1 The first paper in this series, authored by J. M. Van Deusen, M. D. Stanton, S. M. Scott, and T. C. Todd, is entitled “Engaging “Resistant” Families in Treatment: I. Getting the Drug Addict to Recruit His Family Members” and appeared in the International Journal of the Addictions 15 (7): 1069–1089, 1980. A revised and expanded version of Part II is presented in M.D. Stanton, T. C. Todd, and Associates, The Family Therapy of Drug Abuse and Addictions New York, Guilford, in press.
Part II presents 21 principles and a number of techniques and strategies that have been developed for successfuly recruiting such families. These techniques should be applicable for engaging resistant families with all types of presenting problems. Part III provides an analysis of the important variables involved, along with data on cost efficiency and administrative costs. It was found that when therapists had administrative control of their cases, serving in dual roles as both therapists and drug counselors, the recruitment effort was (a) more effective (i.e., complete families, including both parents or parent surrogates, were recruited in 77 per cent of the cases), and (b) twice as cost efficient. Two-thirds of the non-engaged families were not recruited because the index patient would not allow family members to be contacted. Black families were more difficult to recruit than whites. Data on cost efficiency and on the actual administrative costs of recruiting families are also provided. We conclude that the engagement process requires a revision in therapeutic philosophy, since such families are often desperately in need of help but are unavailable unless therapists make a special effort to reach them.     

The Influence of Race and Income on Community Mothers’ Acceptance of Child Management Methods

The consideration of diverse family factors on parents’ acceptance of behavioral parent training (BPT) components aids in the development and delivery of culturally sensitive parenting programs. Perceptions of acceptability are particularly important to investigate among low-income and racial-minority families, as they are less likely to engage in nonadapted BPT programs. Therefore, the current study examines the synergistic effects of race and income on mothers’ acceptance of five common child management methods relevant to BPT. The relationship between mothers’ acceptability ratings and self-reported parenting practices was also explored. Participants were 106 White and Black mothers from different income levels who completed measures related to the acceptability of response cost, positive reinforcement, time-out, spanking, and medication. The results indicated that mothers from varying backgrounds differed in their acceptance of child management methods, particularly with regard to corporal punishment. Additionally, a relationship was found between parents’ acceptability ratings and their self-reported parenting behavior. The findings support the consideration of parents’ perceptions of child discipline methods when recommending and delivering BPT programs to diverse parents.     

Conducting Research with Latino Families: Examination of Strategies to Improve Recruitment, Retention, and Satisfaction with an At-Risk and Underserved Population

Difficulty recruiting and retaining Latino participants in clinical research may contribute to the limited number of studies addressing the mental health disparities that exist between Latino and Caucasian families in our country. The researchers developed and utilized culturally-modified research strategies to maximize recruitment, retention, and satisfaction of Latino families by targeting family systems, community, and cultural levels. Subsequently, the relationship between individual/family and cultural characteristics with participants’ motivation to participate and overall satisfaction with the research project was examined. As part of a larger research study, 70 Latino parents of children aged 5–12 years completed a measure designed to assess an individual’s motivation for participation, as well as his/her satisfaction with participating in psychological research (i.e., the Exit Survey). Parents also completed demographic questionnaire and two measures of acculturation (i.e., the Acculturation Rating Scale of Mexican–Americans-II and the Mexican–American Cultural Values Scale). Results indicate that families with more socioeconomic hardship and more acculturation to mainstream Anglo cognitions and traditional Latino behaviors were more pleased with the overall research project employing culturally-modified strategies aimed at individual/family, community, and cultural levels. Thus, researchers should strive to incorporate appropriate research strategies to recruit and retain “harder to reach” populations in clinical research studies. Better inclusion of Latinos in psychological research ultimately may lead to more culturally-appropriate mental health services and better service utilization for Latino families.     

Coping Strategies of Immigrant Parents: Directions for Family Therapy

Immigration often involves major changes in the physical, cultural, and social settings in which families function and develop. In the process of immigration, parents are often confronted with totally different child-rearing practices and ideologies held by the socializing agents of the host culture. This article proposes an ecological approach for dealing with these differences. Based on this approach, it is suggested that an “adaptive adult” image underlies child-rearing ideologies and practices in different cultures. The article presents a differential perspective based on three types of coping strategies typically adopted by immigrant families struggling with conflicting “adaptive adult” images. This perspective challenges the prevailing notion that differences result in long-term malfunctioning of the child and family. Finally, the article outlines motives for choosing a specific strategy and suggests directions for family therapy using the proposed conceptual framework.     

Family characteristics of children who self-select into a prevention program for children of alcoholics

Evaluated the efficacy of a self-selection recruitment process designed to attract fourth-, fifth-, and sixth-grade children into a school-based prevention program for children of alcoholics. Participants were 296 families comprising one child and either one or both parents. Family members' self- and collateral reports were used to assess parental problem drinking, family characteristics, and individual pathology. Analyses revealed that the recruitment process was not effective in recruiting children of alcohol-abusing parents. Furthermore, families in which children received parental consent to participate in the prevention program were indistinguishable from families whose children either showed interest without obtaining consent or showed no interest at all. Implications for recruitment strategies for future prevention programs for children of alcoholics are discussed.     

Collateral effects of behavioral parent training on families of children with developmental disabilities and behavior disorders

We evaluated collateral effects of behavioral parent training (BPT) on families with children who have developmental disabilities and behavior disorders. We compared 18 BPT graduates to 18 similar families waiting for service. The BPT graduates reported significantly less (i) child behavior problems, (ii) disruption to child and family quality of life due to child problem behavior, and (iii) stress related to limits on family opportunities and child physical limitations, up to 5 years after discharge. On a self‐efficacy scale, the graduates reported being more effective child behavior change agents in not only stopping child problem behavior, but also in preventing new occurrences and teaching the child appropriate behavior. These results suggest that BPT has persistent beneficial effects on children and parents. The findings reflect the program's focus on teaching parents how to use functional assessment derived positive teaching strategies to replace child problem behavior. Copyright © 2002 John Wiley & Sons, Ltd.     

La gestion de la souffrance par le psychologue clinicien. Étude des impacts et des stratégies de coping

We focus in this study on strategies used by clinical psychologists to cope with their own or patient psychological distress in the framework of help relationship. A self-administered form was sent to listings of professionals by e-mail. The sample is made of 187 French clinical psychologists. To cope with patients’ suffering, psychologists use mostly avoidance coping style. And the strategies they prefer are “supervision”, “personal therapy” and “speaking with colleagues” (problem focused coping strategies). To cope with their own distress, which has a lot of negative impacts on help relationship, psychologists have most frequently a problem focused coping style but their favourite strategy is to “lighten their schedules”. And almost a quarter of the sample presents a significant level of distress. In conclusion, results show that psychological distress management by psychologists is an important question with a lot of ethical questions.     

Rethinking the Notion of “Hostility” in African American Parenting Styles

African American parenting strategies are important in the development of prosocial behavior and are linked to empathy, self-efficacy, and racial identity. This study examined how adolescent-perceived parenting strategies (i.e., warmth, “hostility,” cultural socialization) combined to form parenting styles and how these related to positive outcomes. Participants were 358 low-income, urban southern African American high school students. Cluster analyses revealed four distinct parenting styles. Findings provide evidence that Eurocentric norms are inadequate for understanding socialization in African American families. Results indicate that a rethinking of what constitutes “parental hostility” is required. Implications, future research directions, and clinical application are discussed.     

Effective recruitment of parents into family-focused prevention research: A comparison of two strategies

Abstract

Recent literature highlights the need for more effective recruitment and retention strategies in prevention research. This article reports an investigation of the effectiveness of two recruitment strategies for a family-focused substance abuse prevention study. The first strategy offered prospective participants two points at which they could make a decision about their level of involvement in the research project and required only a limited initial time commitment. The second strategy required an initial commitment to participate in all phases of the project. The investigation was conducted with 208 rural families participating in the pilot phase of a five-year prevention study. There were three primary findings. First, both strategies were effective, yielding higher recruitment rates than would be predicted from relevant literature. Second, the strategy requiring a limited time commitment showed significantly higher rates of recruitment into the pretest, but was associated with significantly lower posttest retention rates. Third, data trends emerged but there were no statistically significant differences between the two recruitment strategy groups across a range of intervention participation indicators.     

Soft Meaning and Sincerity in the Family System

The concept of “sincerity” is often dismissed as being irrelevant to the understanding of families as systems, since sincerity is seen as a linear, intrapsychic construct. This paper makes the opposite argument. Much family communication involves a particular kind of “soft” meanings. Such meanings are flexible and open to varied interpretation, but their use is nevertheless framed by social rules. Sincerity rules function as social agreements to refrain from manipulating “soft” meaning in particular ways. The expectation that family members are (or are not) likely to communicate sincerely is a crucial systems property, altering both the interpersonal strategies and relationship structures that are likely to emerge within families. The analysis of soft meaning developed in this paper suggests new ways of understanding the rich, tangled, sometimes paradoxical communication typical of families. However, a number of premises frequently associated with family systems theory must be abandoned before a clear analysis of family communication can proceed.     

Optimizing Engagement in Behavioral Parent Training: Progress Toward a Technology-Enhanced Treatment Model

Low-income families are more likely to have a child with an early-onset Behavior Disorder (BD); yet, socioeconomic strain challenges engagement in Behavioral Parent Training (BPT). This study follows a promising pilot to further examine the potential to cost-effectively improve low-income families’ engagement in and the efficiency of BPT. Low-income families were randomized to (a) Helping the Noncompliant Child (HNC; McMahon & Forehand, 2003), a weekly, mastery-based BPT program that includes both the parent and child or (b) Technology-Enhanced HNC (TE-HNC), which includes all of the standard HNC components plus a parent mobile application and therapist web portal that provide between-session monitoring, modeling, and coaching of parent skill use with the goal of improved engagement in the context of financial strain. Relative to HNC, TE-HNC families had greater homework compliance and mid-week call participation. TE-HNC completers also required fewer weeks to achieve skill mastery and, in turn, to complete treatment than those in HNC without compromising parent satisfaction with treatment; yet, session attendance and completion were not different between groups. Future directions and clinical implications are discussed.     

Living in with Normal Families

Connie Hansen participated in my project, “Methodology for Studying Family Interaction,” in the mid 1960s. One of the purposes of that project was to compare several groups of families, including “normals.” Connie suggested that it might provide a rich source of data if she were to “live in” with a few of the “normal” families and observe them day to day on their own territory. (A year or so before, Dr. Jules Henry had given a talk to the MRI staff about living-in with “schizogenic” families, and I believe that Connie had discussed her idea with him.) Connie was an experienced family therapist — she was one of Virginia Satir's first students — and a most perceptive observer. She lived with three “normal” families for a week each during 1966–67; she was excited by the wealth of material and exhausted by the experience. She tried to develop a group of central themes from her data and gave me a preliminary draft of a paper in 1969. It clearly contained a number of important observations about the complexities and subtleties of family systems and some beginning attempts at conceptualization. She struggled for years to clarify and elaborate on her material. Several times she sent me portions and fragments of new drafts, each with additional insights, but she was never satisfied with her efforts. It seems a fitting tribute to Connie — she died early in 1979 — to attempt to put together her various drafts. We wanted to publish this very important material in a readable form and yet still preserve the immediateness, enthusiasm, and vividness of her observations. I hope, that if she were to read it, she would not be overly critical of this final draft. JULES RISKIN, M.D. It is a special privilege for me to participate in this posthumous publication of Connie Hansen's unique contribution to the further knowledge of family interaction. She died before the material could be published. I feel particular gratitude to the young woman who entered my first training program in 1961 at the Mental Research Institute. This was a time when such training seemed “far out” and was regarded as “probably only a fad.” She was willing to face the risks inherent to her professional standing by choosing to do this training. It was this same courage together with her imagination and curiosity and her willingness to document her experience without judging it that resulted in the article now being published. Farewell, Connie, and thank you for your presence in my life. VIRGINIA M.SATIR     

Male Athletes and the Cult(ure) of Thinness in Sport

This article troubles the “down low” (DL) discourse by focusing on an Internet forum—Craigslist.org—where people on the “down low” post. The advertisements, gathered from seven cities in two U.S. regions, reinforce some of the “down low” discussion in the previous literature, as they show a pattern of seeking “masculine” men. These ads also depart from general perceptions such as the DL being a term used predominantly by black men. The authors discuss methodological implications in research with posts, and suggest advancing analyses on the relationship between race, sexuality and power, and gender and sexuality in DL research.     

ABSTRACTS OF LITERATURE

Schizophrenia is due to a combination of genetic and environmental factors. The author asserts that there has previously been an error in conceiving the patient as being molded completely by external circumstances. In fact, it is the patient's behavior, which is a transformation of family irrationality, that constitutes schizophrenia. In 75 per cent of cases of schizophrenia seen by the author in private practice, the mother did not fit the image of the so-called “schizophrenogenic mother.” In this technique for teaching family therapy, the students take the roles of the family. Procedures, selection of players, formulating the problem, the value of the experience, and ground rules are described. This is a case report and follow-up over nine years of an alcoholic woman. The patient and husband were treated for 35 sessions by cotherapists in conjoint marital therapy. Although there was improvement in the family patterns and in drinking behavior during the treatment, the improvement did not last after termination. The case suggests that marital therapy in the absence of other treatment interventions is ineffective in changing the long-run course of women alcoholics. Based on the author's practice on an inpatient unit that specializes in the study of aggressive behavior, he describes family dynamics and treatment when the identified patient suffers from “episodic violent behavior.” The sample focuses on adolescents, most of whom had episodes of suicidal behavior and who had some evidence of “organic involvement.” Typical family patterns include overly close alliances by the adolescent with one or both parents and transmission by parents of inconsistent values regarding aggression. Family therapy is seen as the preferred treatment approach and emphasizes family ways of handling dyscontrol episodes and the responsibility of the patient for his or her actions. No results are reported. This study attempts to link family variation and core relationships in types of families with the mental health of children. Sample was from a black, poor, urban community defined in terms of the adults present in the home. Eighty-six family types were found falling into ten major classes. Measures of mental health in children were done on psychological well-being of the children and on Social Adaptational Status. Results indicate that family type is strongly related over time to child's SAS and his or her psychological well-being. Mother-alone families entail the highest risk in terms of social maladaptation and psychological well-being of the child; the presence of certain second adults has important ameliorative functions—mother/grandmother families being nearly as effective as mother/father families, with mother/stepfather families similar to mother-alone in regard to risk. Inferences from this data and implications and interventions are discussed. This is a clinical essay on the role of family therapy for black families. In addition to the usual family stresses, black families are subject to the additional strain of discrimination. Support is achieved mostly from the family and from the kinship network, rather than the community. Treatment strategies for this situation are proposed. This essay reviews recent regulations concerning consent procedures and protection of privacy as they apply to children and their families. Rigorous sample selection, nearly complete follow-up, and objective assessment of outcome are virtually impossible at this point. It is concluded that compliance with current “subjects' rights” regulations sometimes seems potentially more harmful to the subjects than the research itself. One case example is presented in support of the hypothesis that brief family therapy has the potential to lead to individual personality changes that are long-lasting. The identified patient was a 15½ year old boy with the symptom of having a falsetto voice. Father, mother, and child were seen in twelve family therapy sessions with changes in the boy's self-image documented in “man-figure” drawings. Nine-month follow-up revealed no recurrence of the presenting symptom and an improvement in social and familial relationships of the identified patient. This is another in a series of papers from a divorce-counseling project. The focus in this paper is on preventive clinical interventions developed for children of various ages in divorcing families. Developmental assessment was achieved with a “brief” history from the parents, detailed information from school, and “direct observation” of the child. This paper covers treatment strategies, interventions, failures, therapist's role, and professional dilemmas in divorce counseling of 60 families with 131 children between the ages of 3 and 18 at the time of divorce. The technique of counseling was to see one parent and child separately by the same therapist three to six times over a three-month period. This is a research study to provide data on the question of whether the disturbed behavior of parents with a schizophrenic child preexists or is a response to an identified patient's pathology. Method was to administer a conceptual task called the Twenty Questions Task individually to each family member and to the family as a unit with a sample of 36 schizophrenic families, 13 non-schizophrenic controls, and 38 normal controls. Results “indicated that far more schizophrenic sons than control sons were much more efficient individually than with their families.” A number of schizophrenic sons performed competently as individuals, but the subsequent performance of parents and sons together on the same task was generally inferior to that of the son alone. Results suggest that the parental behavior plays a part in the etiology of schizophrenia.     

Is Political Conservatism Adaptive? Reinterpreting Right‐Wing Authoritarianism and Social Dominance Orientation as Evolved,Sociofunctional Strategies

The Dual Process Model (DPM) explains prejudice and political conservatism as functions of Right‐Wing Authoritarianism (RWA) and a Social Dominance Orientation (SDO; Duckitt, 2001). From an evolutionary perspective, such orientations may represent specific adaptations to coalitional competition in the ancestral environment (Sinn & Hayes, 2016). Supporting this view, recent research suggests the two orientations represent divergent strategies, with RWA pursuing an honest‐cooperator strategy and SDO a deceptive, cooperation‐mimicking strategy (Heylen & Pauwels, 2015). In two studies, we examine additional evidence for an adaptationist interpretation of DPM. Utilizing life history theory, Study 1 finds that RWA reflects the predicted “slow” strategy by endorsing planning and control, investment in family relationships, altruism, and religiosity. In contrast, SDO reflects a “fast” strategy by devaluing planning and control, secure relationships, and altruism. Utilizing rank management theory, Study 2 finds that RWA reflects a prosocial orientation, endorsing coalition building and social networking while rejecting deception and manipulation. In contrast, SDO reflects an exploitive orientation, rejecting coalition building and networking but endorsing ruthless self‐advancement and deceptive tactics. These findings support an adaptationist revision of RWA to recognize its prosocial, honest‐cooperator dimension and of SDO to recognize proself, “dark” tactics seeking power within groups.     

Emotion as Substitute Response

This study confirmed an earlier finding that two strategies, termed formula and graphic, markedly affected the speed of learning a binary task, with the former being much the superior. Both “fast” and “slow” learners were able to utilize these strategies; however, “fast” learners were superior throughout, both in terms of number of trials to criterion and total amount of time taken to learn the tasks. Evidence also was obtained suggesting that the use of the more efficient (but also more demanding) strategy by “slow” learners had a certain cost associated with it. Overall, “slow” learners exhibited much more anxious and avoidant behavior than did “fast” learners. Post hoc data obtained on the Ss suggested slow binary task learners to be more field dependent than fast learners.     

ADOLESCENTS' PERCEPTION OF POLYGAMOUS FAMILY AND ITS RELATIONSHIP TO SELF-CONCEPT

This study investigated children's perception of the degree of affection present in their monogamous/polygamous families and assessed the influence of the perception on the subjects' self-concepts. It also examined the relationship of polygamy/monogamy to children's self-concepts. A total of 308 adolescents (134 from polygamous families and 174 from monogamous families) in eight secondary schools in Oyo State, Nigeria filled out a questionnaire and Akinboye's (1975) self-concept inventory. The subjects' assessment of their families was categorized into “secure ”and “insecure”. The results indicated that self-concept significantly correlated with the subjects' assessment of their families as “secure ”or “insecure”. Self-concept was also significantly related to the family being polygamous or monogamous. Family structure (polygamy/monogamy), however, showed no significant correlation with children's perception of their family as “secure ”or “insecure”.     

The Qualified Pronoun Count as a Measure of Change in Family Psychotherapy

The purpose of this study was to evaluate the original Multiple Family Psychotherapy group at Georgetown University, Department of Psychiatry. The author, a clinician, used the technique of content analysis of recorded interviews and developed a “change ratio” which is called the “qualified pronoun count.” Although “therapeutic improvement” is not the main goal of the treatment strategy under research here, ordinarily anyone that exhibits the kind of change in differentiation from “family ego mass” ( 1 ) reflected in this study, also experiences diminution or remission of symptoms. Preliminary findings indicate this new system of observing change is useful in determining variations in differentiation, and that these families did change.     

Sequential analysis as a method of feedback for family therapy process

Abstract

The purpose of this study was to examine the relationship between therapist verbal behavior and family cooperation and resistance during the second session of family therapy with juvenile delinquents. Sequential analysis was used to investigate the impact of one therapist's behavior on family resistance and cooperation in a sample of 12 families. The results of the sequential analysis revealed that therapist “support” and “teach” behaviors were associated with significant increases in the likelihood of family cooperation. The study provides an example of how sequential analysis can be used to inform family therapists about the impact of their behavior on families.     

Recruiting Young Adult Cancer Survivors for Behavioral Research

Young adults have been dramatically underrepresented in cancer survivorship research. One contributing factor is the difficulty recruiting this population. To identify effective recruitment strategies, the current study assessed the yield of strategies used to recruit young survivors for an exercise intervention including: clinic-based recruitment, recruitment at cancer-related events, mailings, telephone-based recruitment, advertising on the internet, radio, television and social networking media, distributing brochures and word-of-mouth referrals. When taking into account the strategies for which we could track the number of survivors approached, recruitment at an oncology clinic was the most productive: 38 % of those approached were screened and 8 % enrolled. When evaluating which strategy yielded the greatest percentage of the sample, however, mailings were the most productive. Given widespread use of the internet and social networking by young adults, investigators should also consider these low-cost recruitment strategies.