Family Therapy & Systemic Practice

Strengthening Resilience in a Risky World: It’s all about relationships

Everyone has been talking about the amazing rescue of the 33 Chilean miners this week,
but have you stopped to think about the resilience they showed in staying calm
and rational while trapped underground for 69 days and awaiting rescue? It was
two and a half weeks before the miners even knew that the world above them was
looking for them and trying to save them, two and a half weeks in the cold and
the dark. One miner, Mario Sepulveda, talked of his internal “fight with the
devil” to stay hopeful and trusting while entombed underground – it’s hard to
imagine how they coped. Perhaps it was the presence of the other miners, and the
knowledge that there were wives, children and friends on the surface that gave
them the resilience to endure patiently while the rescuers worked to free them.

Resilient individuals seem to be able to adapt to the challenges of a difficult life, or
even to survive an extreme experience, without the psychological sequelae that
most people would expect. Resilience is often thought of as a collection of
individual qualities (easy temperament, high IQ, availability of social support,
self-esteem, internal locus of control and mastery experiences) that protect a
person from falling prey to depression, psychopathology, drug addiction or
suicide following challenging life experiences. It is true that many studies
have demonstrated that these individual-focussed traits are associated with
resilience. Does this mean that, as systemic thinkers and therapists, we can’t
work with a resilience construct?

Linda Hartling, in her 2008 article “Strengthening Resilience in a Risky World: It’s
all about relationships” challenges the view of resilience as a purely
individual trait. Rather, she sees it as a fundamental human capacity that can
be strengthened in all individuals through participation in growth-fostering
relationships. She links the individual traits previously associated with
resilience to relational mechanisms of operation, which remind us that all
childhood experience occurs within a systemic framework.

An easy temperament is certainly associated with resilience, but it does not cause
resilience – rather, a child’s easy temperament protects them because of its
positive impact on the developing parent-child relationship. Likewise,
intellectual ability does not develop in a vacuum, but is nurtured from
potential to actuality by the experiences provided to children through
relational engagement. The benefits of social support operate through the
provision of practical assistance in child rearing, but also in providing
children and adolescents with a sense of authentic connection with caring
others. Hartling provides similar re-interpretations of the impacts of locus of
control, self-esteem and mastery experiences from a relational perspective.

The article also presents a detailed case study of two sisters, Jennifer and Julie, who were placed for
adoption after a long history of abuse and neglect by their drug-addicted
parents. Julie, the older sister, was initially difficult, hyperactive, emotionally
labile and struggled intellectually, while her younger sister Jennifer was
bright, attractive, intellectually capable and showed few signs of her
traumatic past. The adoptive parents were initially troubled by Julie’s
challenging behaviours and sought support from a relational therapist. By
putting the two sisters’ behaviour in context, it became clear that Julie’s
difficult behaviours had been developed to ensure her survival in a severely
neglectful and abusive first home. Likewise Jennifer’s perfect behaviour was
that of a “parentified” child, attempting to care for her older sister.

Once the adoptive parents understood this, they were able to overcome the temptation to criticise Julie
for being inherently deficient or damaged, and find loving, creative and
effective ways to help her manage her behaviour. Julie gained greater
confidence that her family environment would provide her with safety and
support and her difficult behaviours ceased. Similarly, Jennifer saw that their
new parents could be trusted to provide loving and responsible parenting, and
thus was able to relinquish her adult-like behaviours and enjoy her childhood
authentically.

The article closes with a summary of relational techniques to strengthen resilience,
for use by therapists, school counsellors and other supporters of people
struggling with their current life situations. These include:

•  Helping clients identify, establish and expand relationships that support their ability
  to be resilient
• Encouraging clients to seek out relationships that stimulate them intellectually
  
• Focus client attention on engagement in meaningful relationships rather than focussing
  on competitive achievements or personal comparisons
• Use the development of the therapeutic relationship to demonstrate the mutually empowering nature of caring relationships, and
• strengthen the client’s ability to take positive action on behalf of others, themselves and their
  relationships.

This reconceptualisation of resilience as relationally based strengthens our ability
as systemic therapists to use the resilience construct in supporting clients to
recover from challenging life events, and provides an important development in
the use of resilience in therapy.

Linda M Hartling (2008)

Women & Therapy, Vol 31, pp51-70

Few of us would deny the obvious benefit of antibiotics, knowing that with out them we, or someone close to us, may well be dead. However our enthusistic embracing of the ‘magic bullet’ carries with it a less obvious consequence. We now, as a culture, act as if all ills; bacterial, viral and emotional can be quickly resolved by the ‘right’ pill. The logical extension of this belief leads us to to the view that SSRI’s (selective serotonin uptake inhibitors) are safe and effective solutions for depression in adolescents and by extension children.

This approach is challenged by child psychiatrist, John Jureidini in his paper “How do we Safely Treat Depression in Children, Adolescents and Young Adults?” He notes that since 2003 a number of studies have raised questions about the use of antidepressant in this population stating that although published results were often favourable ” investigators conclusions exaggerated benefits and down-played adverse effects”.This paper asseses the research evidence for the use of anti-depressants in children, adolescents and young people with particular reference to mortality, serious outcomes and quality of life. Suicide is one of the most feared consequences of depression and its prevention would have to be a key reason for the use of any treatment. In reviewing the literature Jureidini notes that for “studies suggesting an inverse correlation between anti-depressant prescribing and suicide are balanced by studies of similiar methodology that show the opposite.” He concludes ” there is no demonstrated link between suicide and anti-depressants but based on the data presented there is reason to worry.”

The paper then explores serious adverse consequences; unsuccessful suicide attempts, hospitalizations, criminality, school or vocational dropout, serious substance misuse and serious adverse medication events. He concludes that “we have no useful evidence on impact on quality of life or hospitalization; we know they cause troublesome adverse events in more than 5% of young people who take them; and we have some evidence that they do not improve outcomes in the medium term.” He concludes that prescription of medication to many young people is inappropriate and that there is an ethical imperitive to exercise caution.

Having explained the hazards of medication, the paper then presents some practical, useful and welcome advice for those who work with depressed young people. This includes excluding acute dangers by asking about self harm, alcohol or drug use and symptoms of acute anxiety or psychosis which may indicate the need for immediate psychiatric intervention, exploring reasons for the distress and then explaining the symptoms, including the fact that the natural history of such episodes is recovery within a few weeks.

It is too easy for  practitioners to be seduced by the promise of easy change. A paper like this which rationally weighs the evidence and proposes alternative approaches is to be applauded.

Jureidini,J. (2009)How do we Safely Treat Depression in Children, Adolescents and Young Adults? Drug Safety 32 (4) 275-282

It’s a common complaint among parents of adolescents…”I can’t get them up in the morninmg and I can’t get them to bed at night!” Its not just a problem for parents as Dawson (2005) notes in the paper “Sleep and Adolescents”. Sleep disruption can have a profound effect on school performance due to sleepiness, especially during periods of low stimulation like passive or monotonous classroom instruction, reading or repetitive activities. Brief mental lapses called micro-sleeps impede concentration and retention. Difficulty awakening may cause conflict in the family as parents attempt to cajole, urge and threaten their child to school and may result in greater intake of stimulants like caffeine and nicotine in an effort to wake up. Tiredness, the psychological effects of excessive sleepiness, makes it difficult for students to initiate and persist with tasks, especially those which are seen as boring or involve long term or abstract goals, for example achieving a TER sufficient to secure a university place for a future career. Emotional consequences of excessive sleepiness are highly individual and can range from emotional lability, depressive symptoms, increased irritability, impatience and low tolerance for frustration. Finally symtoms of excessive sleepiness can mimic attention problems like ADHD, especially in relation to complex tasks or those that require divided attention.

This is no minor problem given that adolescents typically need 8.5 to 9.25 hours sleep per night (the amount they sleep under controlled conditions with no clocks or lighting cues) yet fewer than 15% report getting this amount of sleep on a school night and 25% report less than 6.5 hours sleep.

So what’s to be done? Some schools have experimented with later school start times to better conform to adolescent sleep patterns and as a result report fewer depressive symptoms,reduction in absenteeism, less difficulty staying awake or falling asleep, more sleep at night and higher grades. Dawson suggests that this problem which is clearly a ‘home’ issue should be actively tackled at school by education of students,parents and teachers, accommodation by teachers to students with chronic sleep problems, approprite referral for families, intergration of the topic of sleep into curricula and investigating the feasibility of modified start timesfor school. Its a good example of two systems working co-operatively together.

Dawson,P. (2005) Sleep and Adolescents Principal Leadership,Vol 5,5 p11-15

The two children couldn’t be more different. Simon at 12 is tall, fair and vague. When addressed he either looks intently at the speaker  or appears disinterested as his eyes travel around the room. His usual response is “I don’t know” but on occassion he becomes captured by a  question and responds with an elaborate and complicated metaphorical answer. He is easily embarrassed by attention and reacts by laughing and sinking in his chair towards the floor. Linda, Simon’s younger sister, is small, intense and  alert. She quickly engages and enjoys the playful interchange. She responds instantly and succinctly to questions and appears to enjoy the conversation.

It’s difficult for both children, their parents explain. The family live on a street with many young families and the children spend a lot of time together. This is a joy for Linda who thrives on company but for Simon it’s clearly a trial. Simon would much prefer to be left home alone to play games on his computer or create the complicated drawings in which he becomes  engrossed. When he does accept the invitation to play he becomes infuriated when others fail to obey the rules and will retreat home ignoring their pleas to remain. It appears the invitation to stay is more form than substance as Linda is clearly relieved when left to play alone. He can be ‘weird’ she says and when embarrassed or upset will turn on her and kick her. She loves her brother, she explains, but some days she would much prefer he stayed at home.

Much attention has been paid to children diagnosed with an autism spectrum disorder but children live in families, often of more than one child,and these children also live with an ASD. What is it like for a sibling?

This question was addressed by Petalas, et. al, in a 2009 paper reporting on a study exploring the experiences and perceptions of eight typically developing siblings in middle childhood who had a brother diagnosed with ASD. The researchers conducted semi-structured interviews from which they extracted five key themes.  The themes included the perceived impact on the sibling and their family, other’s reactions and the implications of these, the acceptance of the brother and his situation, positive views and experiences and the siblings support network.The accounts given by the children reflected different attitudes and interpretations of their situation but all identified positive aspects of having a brother with ASD.

The authors draw a number of conclusions from their results. They suggest interaction training for siblings may enhance social behaviour and communication between them and thus reduce conflict.This would also provide a context where the sibling as well as their ASD diagnosed brother or sister receives support at critical times. Engaging parents as trainers could ensure both children receive the support they require and allow parents to reinforce and encourage siblings efforts to interact positively. Building on the positive views of siblings, recognising personal strengths and abilities, promoting positive family relationships and providing resources to enhance familial bonds can all contribute to the resiliance of all children in the family. Finally, education about ASD in schools and the wider community can ameliorate the effect on siblings of other people’s negative reactions. In a field which has traditionally focussed more on the individual than family members, this sounds like sage and practical advice.

Petalas, M., Hastings, P., Nash, S., Dowey, A. & Reilly, D .(2009) ” I Like That He Always Shows Who He Is”: The perceptions  and experinces of siblings with a brother with autism spectrum disorder International Journal of Disability  Vol 56,4  381-399

 On Friday 12^th March, Aldo Gurgone, clinical psychologist and family therapist from Perth will be presenting a one day workshop at Bower Place with the title ‘Trust, Betrayal and Rejection; Re-establishing Trust in the Couple Relationship’. In this he has promised to address different forms of betrayal in couple relationship including cybersex.

Cybersex…as if standard sexual betrayal was not enough for the average marital and family therapist!

This is a new and increasingly common presentation both with individuals and couples so in preparation for Aldo and out of curiosity I went searching and found a paper by Katherine  Hertlein and Fred  Piercy. “Therapists’ Assessment and Treatment of Internet Infidelity Cases” published in Journal of Marital and Family Therapy October 2008, (Vol. 34, No. 4, p481–497) which reports on a study of 508 practicing marriage and family therapists. The authors asked their subjects to respond to ‘several typical internet infidelity scenarios’ with the initiator’s gender being varied. The clinicians were asked about their assessment and treatment processes, evaluation of the severity of the situation, their expectations of outcome, number of anticipated sessions and whether they would focus relationally or individually. Not surprisingly, the results tell us more about therapists than the clients. Those who defined themselves as religious indicated that they would address the issue more individually than relationally. The authors also report that both age and gender of the therapist affects treatment choices with younger therapists more inclined to address environmental issues and women focussing on the couple relationship in their intervention. The therapists own experience of infidelity also influenced their assessment but not treatment.

What is clear from this study is that there is no clearly agreed upon assessment or treatment process for cases of internet infidelity. The authors suggest ‘A therapist should reflect on his or her own invisible beliefs, biases, and therapeutic guideposts. Perhaps the results of this study will support open discussion regarding our therapeutic differences where they arise, and which ones we should rethink. (p493)
 

I’m hoping Aldo’s workshop will give us the opportunity to do just that.

 Clinical psychologist and family therapist he was born in Italy and migrated to Australia as a six year old boy with his family in 1956. His father had preceded the family four years earlier. He recalls his experience of returning to his home country in 1973 saying ‘My memories of Italy were very “child” formed and I was quite shocked at Italian culture in Italy when I returned for a year in 1973.  The way of life and way of thinking of people in Italy was totally different to what I understood about Italians here in Australia and it took me the better part of 6 months to get over the culture shock I experienced.’  He is fluent in both Italian and English and has worked and trained with Maurizio Andolfi.  He is well known for his multi-cultural work and acted as presenter and consultant to the production of a Training Package, ‘COUNSELLING ACROSS CULTURES’, produced by the Fremantle Migrant Resources Centre.
Since 1972 he has practiced professionally in Italy, the United Kingdom and Australia. Currently he is Director of the William Street Family Therapy Centre where he works as clinical psychologist, family therapist, consultant and teacher. As chairperson, he has been active in the restoration of the Western Australian Family Therapy Association and the establishment of a national Family Therapy Association.
He has delivered keynote addresses to conferences in Australia, Malaysia and Singapore on the Couple Relationship & Communication and Parenting Teenagers when there is Drug Use. He presented at the 30^th Australian Family Therapy Conference Therapy on the topic “Words are Not Enough”.
He is well regarded for his work with couples and has written articles and produced psycho-educational material for newsletters, newspapers and as videos, DVDs workbooks and manuals which are used by counselling and welfare agencies around Australia and overseas.
When you speak with him he is thoughtful and considered in manner. He takes his time in conversation and speaks quietly and authoritatively. He is warm and generous in his interactions……Who is he?

News of the discovery of a young woman abducted off the streets as an eleven year old by a stranger, repeatedly abused and kept prisoner for 18 years has made daily print and television news for the past fortnight. Yet another headline about violence closer to home has passed almost unnoticed. On 1^st September 2009 the Adelaide Advertiser displayed the headline ‘Mum Murder, Domestic Killings Hit Alarming Levels’. The paper reported on the violent deaths of eight South Australian mothers over the past eight months and the call for ‘an official state review into domestic violence related killings’. The Domestic Violence Crisis Service Executive Officer, Gilian Cordel is reported as saying that ‘I don’t think the general public realizes how many women are murdered by their partners’. The response to the article has been minimal producing two letter to the editor and minimal additional coverage. Meanwhile, every day we are regaled with further detail of the investigation of the abductor of Jaycee Dugard.
Why is this so and what does it mean for those of us whose daily work involve those subjected to and perpetrating violence? Perhaps the story of Jaycee is, given its horror, paradoxically ‘easier’. It speaks to every parents’ fear of the unknown madman who randomly selects a child who is then spirited away. The story reads like an episode from a television crime show which ends with the captor’s release. There is no excuse, there is a villain and an innocent victim and the villain will be tried and punished. It can never happen to people we know, people like ‘Us’.
The domestic violence headline is different. This speaks of the murder of women in our community, women who we see in the supermarket with a black eye, whose children play with our children and whose husbands come to dinner. The violence, if it is seen is explained away as a single, random episode or the fault of the recipient. If the woman speaks out to friends she will often experience a pulling away as others feel uncomfortable knowing the secret, are unable to relate to the abuser and would rather not know. More disturbingly the damage is being done by one who should be most able to be trusted who has promised to love and to cherish through sickness and health and who shares a bed. We look into their lives and in many respects they look just like ours. No wonder the article does not precipitate an out flowing of interest. It is received just as the problem is in real life. With silence.
 
Workshop presented by Malcolm Robinson  & Marten Johns
‘Family Violence across the Lifespan: A Trans-generational Perspective’ (click to get more information and register)
 
For all other workshops and events go to http://seminars.bowerplace.com.au

In 2004 the Attorney-General’s Department, Family Law Pathways Advisory Group, published A new approach to the family law system: Implementation of reforms - discussion paper. This proposed reforms based on the 2003 House of Representatives Standing Committee on Family and Community Affairs inquiry into child custody arrangements when families separated. Reforms were proposed to address the needs of families before, during and after separation. In particular it proposed the establishment of Family Relationship Centres in the hope of providing conflict resolution for families which avoided the adversarial path.
The Family Relationship Centres were designed for a broader population than those facing family dissolution. The hope was to assist parents to prevent relationship breakdown, support separating parents and grandparents with parenting arrangements and child support issues, and provides advice and mediation services. They were designed to be “a source of information and confidential advice for families at all stages in their lives. Whether you are starting a relationship, wanting to make your relationship stronger, or having relationship difficulties, the Centres can help.”

Sixty –five centres have been established throughout Australia, the first opening in 2006 and others following in 2007 and 2008. While funded by the government the Centres are operated by family relationships services providers, including Relationships Australia and Catholic Social Services. 

With the new centres also comes specialist training in the form of The Vocational Graduate Diploma in Relationship Counseling, a practical competency based graduate course within the Vocational, Education and Training (VET) sector. The course aims to teach practical, demonstrable skills in working with children, young people and their families’ at the most stressful and distressing times in life. It is suitable for social workers, counselors, teachers, medical practitioners, psychologists, health and community workers and especially those interested in positions within the Family Relationship Centres.

As workers in the field of child and family relationships we are now well versed in the fact and dynamics of child abuse and violence. However as both the professional world and the wider community have come to embrace the need to protect children and parent in positive ways, family violence has appeared in a new guise. This is the violence which occurs in families’ of children with acute behavioral problems and parents who are helpless in its grip. Such parents view themselves as less powerful than their children and respond to their child’s demands with escalating punishment and violence, impotent acquiescence or an oscillation between the two. Such escalations feed the parents’ sense of powerlessness, hopelessness and the belief that ‘nothing works’ and allows the child to make increasingly risky and self-destructive choices.

Enter Haim Omer who has taken the ideas of non-violent resistance as practiced by Mahatma Ghandi and Martin Luther King and applied them to families with children with aggressive or other acute behavioral problems. Originally developed in Israel, this parent focused approach is now being applied in centers in Germany, England, Switzerland and Holland. Yet however intuitively appealing an intervention may be it is only as good as its objective effectiveness. The paper by Weinblatt, U. and Omer, H. “Nonviolent Resistance: A Treatment for Parents of Children with Acute Behavioral Problems” addresses this question. This is an evaluative study of a five week parent training program in the approach which randomly assigned 73 parents into a treatment and wait list control group and took measures at pre-treatment, post-treatment and one month follow up. Parents who participated in the treatment ‘showed a decrease in parental helplessness and escalatory behaviors and an increase in perceived social support’ compared to the waitlist control group. Intervention also resulted in the parents reporting a decrease in the children’s negative behaviors. One month follow-up demonstrated maintenance of change in relation to parental helplessness, parental permissiveness and child behavior. While the authors are careful to recognize the limitations of a study which was of limited duration and based on parental self report, the results are encouraging enough to warrant further exploration and application of this creative and respectful approach to extremely difficult children for whom traditional behavioral modification approaches have proved ineffective.

Weinblatt, U and Omer, H (2008) “Nonviolent Resistance: A Treatment for Parents of Children with Acute Behavioral Problems” Journal of Marital and Family Therapy, 34,1, 75-92 The answer : Each produced remarkable outcomes in seemingly intractable circumstances using methods of non-violent resistance