Kids on the Brink of Disaster: Research on Family-Centered Interventions

The AFTA 2000 Research Plenary

by Peter Fraenkel

• How to be sensitive to the unique needs, characteristics, and capacities of each family while simultaneously providing a treatment that can be rigorously assessed for its efficacy or effectiveness.
• How to attend to the often complex and substantial needs of all family members within the twelve sessions (or less) allotted by managed care.
• How to balance the societal mandate to "get these kids under control" with a respectful, empowering stance that engages the troubled teen and family members as customers of and collaborators in therapy rather than as objects of social management.
• How to address the physical safety and emotional needs of all participants in the therapy - the violent young person, family members, and the therapist.
• How to provide expertise to a family that may sense they have exhausted their solutions while at the same time maintaining the humility that allows for truly listening to clients and learning from them.

Speaking as a true researcher-clinician, Jim's suggestion was that we must integrate rigor and sensitivity, and not allow these to become poles around which we organize our practice with any particular family, or our profession. With ample data demonstrating the superior clinical efficacy and cost effectiveness of his Functional Family Therapy approach over other approaches, he convincingly argued that manualized, researchable interventions can also respond and adapt to the particular cultural dimensions of each family's experience and style. For example, he provided data as well as verbal and videotaped clinical anecdotes showing that all families need to be engaged in a respectful manner, and to have problems positively reframed, and that each family will respond to different approaches to engagement and reframing. Jim emphasized, "We've got to understand them on their own terms."

Dan Santisteban picked up smoothly where Jim left off, describing work on extending already substantiated family interventions so that they become increasingly "culturally sensitive and appropriate to the specific needs and experiences of families." He reported on his programmatic research with senior colleague José Szapocznik and others at the University of Miami School of Medicine Center for Family Studies. The research focuses largely on Hispanic families of conduct disordered, delinquent, suicidal, and drug abusing adolescents. He described first studies on interventions designed to improve bringing families into treatment. Clinics and agencies in the Miami area were first surveyed to learn what the typical procedures were for initiating treatment. A manualized version of these approaches (centered on contacting parents by phone and politely setting the appointment) was then contrasted with a "specialized" approach that directly contacted the acting-out teen to set the appointment and discuss meaningful reasons he or she might want to come in with the family. Whereas 60% of families responded to the "as usual" approach, 81% responded to the approach of directly contacting the teen. Importantly, the additional families successfully engaged by the specialized approach, reflected by the 21% increase, included those with the most highly conduct-disordered kids - precisely those most at risk.

Dan turned next to studies demonstrating greater impact of family therapy over typical group counseling approaches for conduct disordered, delinquent youth. Once again, his focus was on identifying areas to improve these empirically-supported family therapy interventions. He raised a critical question: Although family therapy resulted in 44% of kids demonstrating substantial change at home and with peers (far more than in the group condition), what about the 5% who worsened in family therapy or the 51% who showed no significant change? What new interventions are needed for these kids and families?

Finally, Dan described what Nancy Boyd-Franklin later deemed work "at the cutting edge of the intersection between the diversity and the family fields." This work addresses the impact of immigration and acculturation on parenting and youth adjustment. Like Jim, Dan emphasized the need to be wary of simple definitions or prescriptions - in this case for such familiar terms as culture and acculturation - and reminded us of the need to "hear peoples' (unique) story." He noted familiar findings on the correlation between degree of teen acculturation to the USA and increased risk of conduct problems and drug abuse. But he posed the critical systemic question, "What gets disrupted in family process as families live longer in the US?" Dan and his colleagues have found that when Hispanic mothers hold onto their Hispanicism (their connection to Hispanic identity, parenting values and parenting styles), their parenting is better, and there is less externalizing behavior by the kids. Importantly, Hispanic parenting is often labeled by mental health professionals as "enmeshment," as it involves high degrees of child monitoring and involvement. Thus, while clinicians might unwittingly judge these parents as problematic, their parenting styles are effective with their children. These findings strongly suggest the need for clinicians to understand parenting practices within cultural context, and to be cautious about introducing practices from so-called "mainstream" US society. Dan also noted the finding that parents who were higher on "familism" (viewing the family as the main referent group - characteristic of many Hispanic families) were more effective parents.

Dan went on to describe research and clinical findings on the often powerfully traumatic impact of disruptions of the parent-child relationship when parents leave young children in the country of origin to seek opportunities in the USA. He noted that young people often harbor deep resentment about these separations, but experience loyalty-based guilt about these feelings, which they hide but which may emerge through problem behavior. Dan suggested that although these feelings are hard to get at, it is often deeply healing when families can talk openly about them. Dan's current research addresses how to introduce these complex family acculturation and immigration issues into manualized treatments. His questions include:

"What does it really mean to acculturate? How are issues of hierarchy that may have been very powerful in the country of origin being dealt with? Are kids expected to challenge their parents in the middle of a family session, or are they expected to be submissive? Are we promoting a process that's incompatible with the expectations of very hierarchical, traditional parents? How do we deal with it, how do we discuss it."

In her summary comments, Nancy praised both Jim and Dan for their long-term commitment to "reaching out to the hard-to-reach folks" - families that others have often long given up on. She emphasized their cultural sensitivity, and their mixture of clinical acumen and accountability to the need for concrete outcomes, including cost effectiveness. And she strongly urged all of us to make better use of Jim and Dan's work as "ammunition" in making the case for family therapy to managed care companies and others who control clinical practice. In her words: "We at AFTA are the teachers and the trainers. Yet many of our training programs in family therapy literally ignore research results. And I'm very struck by that because as I look at this, it seems to me very profound that, in the twenty-first century, the survival of family therapy (and family therapists), is going to depend on our ability to utilize the very results that Dan and Jim are talking about, and to teach them to our students so they can utilize them. We owe it to ourselves as an organization and to our students as the next generation to make sure they have that ammunition also."