A child’s poor schoolwork may be a cry for help in family relationships. If the family’s request for help is ignored, the school may be left with a refractory educational problem and an angry child who may continue to fail until someone finally gets the message. In most instances, when children fail in school, some form of family therapy is warranted.
The goal of family therapy is to change structures and processes in the family or in its environment so as to relieve existing strains. Family diagnosis based on living systems theory makes it possible to determine whether pathology lies in a family as a whole, in one or more individual members, or in a suprasystein, such as an economically disadvantaged neighborhood or a school with limited resources.

The range of interventions available to families is considerable. The health, mental health, social service, pastoral care, and educational systems all deal with family problems. The field of marriage counseling has specifically focused on one aspect of the family, and family service agencies handle all aspects of the family. For faltering families the marital relationship is the most important locus: marriage counseling or marital couple therapy may be useful. For families with more serious problems, self-help groups such as Alcoholics Anonymous, Parents Without Partners, and Parents Anonymous are available in most communities. Child psychiatrists deal with the range of child, adolescent, and family problems.

The fit between clinical resource and a family is critical. Ethnic and economic factors may override psychological issues. Every clinical resource sets some limit on the range of factors it can work with in both diagnosis and therapy. These limits evolve out of the history peculiar to a given clinical setting, the training backgrounds of professionals, the socioeconomic sur¬roundings, and the nature of the social pressures.

Motivating Families for Therapy

Professionals should be sensitive to the misunderstanding, hesitation, and fear in family members as they approach help.

Each family member’s level of sophistication about psychological problems and openness to using a mental health resource varies. At the least education of the mem-bers of the family is required so that an intellectual understanding of the reasons for working with the family can be achieved. This step often is omitted with resulting misunderstandings.

Troubled families are the most likely to lack insight and even the strength to engage in family therapy. Their defensive maneuvers may he so extreme that engaging the family in therapy may depend upon equally skillful maneuvering by the therapist or the external pressure of agencies, such as the schools and the courts. If given a choice, many of these families would either drop out or limit their involvement to supporting treatment of the identified patient. Their denial and projection are particularly difficult to handle.

Ferreting out the family’s expectations of therapy is an important step toward assessing their motivation For change. For example, because dominated families involve both family and individual psychopathology, they often lodge their concerns upon a single identified patient. The other family members may not be disposed to see themselves as a part of that person’s problem and certainly not as the focus of therapy. When an attempt is made to involve the family, the parents may withdraw and look for someone who will “help”. the family member identified as a patient. As a strategy, the therapist may need to appear to join the family in its efforts to change the symptom bearer as a means of involving the entire family with the passage of time.

Conflicted families usually, require intensive family therapy in addition to consultation to other systems. such as the schools, social services, and law enforcement agencies. Chaotic families are the most difficult to engage in family therapy because their views of reality are not congruent with their social milieu. Hospitalization, medication, and consultation to other agencies may be necessary. in order to provide a foundation for family therapy.

A delicate issue in motivating families for treatment is how to separate a clinician’s responsibility to assist the family from the family’s responsibility for change. This is a problem especially when other agencies are involved with the family. For example, both school personnel and parents may look to a clinician for answers about a child. In these circumstances the clinician must carefully keep the child and the family in the position of responsibility and work through them for inter-system negotiations. Unsuccessful management of this issue can make the clinician a scapegoat by permitting both the parents and school personnel to expect that the therapist is responsible for changing the child.

From the educator’s point of view, it is important to he aware of the complicated role of the family in a child’s school problems over which educators and parents find themselves in conflict. Some parents obtain satisfaction from this fight, because they were embittered by their own past unhappy school experience and find this opportunity to retaliate. The child has an especially important role to play in this manipulative struggle. In the battle over who will control the helping process, if the school and clinical team are not coordinated, a family can find a weak link and defeat both. An effective position for school personnel in these situations is to recognize that no one can help the child until everyone works together.

The Techniques of Family Therapy

The theories and techniques employed by family therapists vary. widely. General systems theory, however, provides a rationale for integrating them.

The aims of family therapy are to promote the basic functions of the family. Forming a family unit assists adults in appropriately disengaging from their families of origin. The functions of a family relate to intimacy between family members in the form of attachment bonds and empathic communication, which can be fostered through increasing sensitivity to others and risking exposure of one’s personal vulnerability. As the heart of the socialization process, the family is the vehicle for imparting cultural customs and values through the process of identification and through learning coping skills. The family also is the forum for safely expressing transient irrational emotions and accepting them from others. In the family the irrationality of life can be accepted by acknowledging the differences between the way things should be and the way they are, between expectations and reality, and between verbalizing socially unacceptable emotions and wishes and acting upon them.

The barriers to healthy family functioning are stereotyped roles enacted by family members based upon covert scripts that are incongruent with family functions. Examples of these roles are victim, martyr, hero, tyrant, scapegoat, saint, rebel, fool, and genius. These roles are played out from ritualized scripts that maintain immature, destructive relationships and frustrate the individuation and development family members. Family therapy creates awareness of these counterproductive scripts and roles through confrontation, interpretation, playfulness, and humor in order to foster flexibility in family members within legitimate family roles.

The techniques or family therapy include behavioral, structural, and intuitive methods. The accumulation of clinical experience is demonstrating the usefulness of employing a range of techniques in an integrated style of therapy. The family therapist can assist families to more realistically function by acting as a catalyst who facilitates interaction; a critic who describes behavior; a teacher who shows new ways; a supporter who gives license and hope; an interpreter who offers explanations of behavior; a provocateur who stimulates interaction, and a model who demonstrates solving problems.

Because of its highly structured nature, the Milan method of family therapy has been employed for training purposes. It involves a therapeutic team that helps families through confronting them with more realistic views of their family interactions while encouraging family members to achieve more adaptive levels of relating to each other.

The Process of Family Therapy

Once a family becomes engaged in the therapeutic process, a varied and exciting course of growth may ensue, or the process itself may be impeded by resistance that must be worked through in order to achieve the aims of therapy.

Family members usually have linear cause-and-effect views of what goes on in the family. For example, “Jimmy’s restlessness gets us all upset.” The aim of family therapy is to shift the level of understanding from this simplistic and partially correct view to an interactional system level. An important technique for accomplishing this is through encouraging family members to comment on each other’s relationships in the family. This both opens up communication and focuses attention on interactions within the family.

Through a variety of reframing statements additional information can be given to a family to encourage more accurate interactional and psychodynamic understandings of the determinants of symptoms in family members. For example, the success that a child achieves through failing in school and sabotaging adults can be contrasted with the view of the child’s behavior as simply negative. As a family grapples with a child’s problem. their frustrations and discomforts become evident and permit redefinition of the problem in terms of family members’ personal sufferings rather than the problem child’s behavior. New communication lines ran be opened, so that an awareness of the family’s role in a child’s educational difficulties can add a crucial dimension to helping the child. The family can then realistically support the educational program for their child and assume a parent-professional alliance with school personnel.

Some parents, however, remain involved in the genesis and perpetuation of their children’s school problems. Handicapped by inflexibility, this kind of family is stable and inclined to deny the educational problem and becomes upset when the severity of the problem diminishes.

In troubled families, the double bind is a frequently encountered interactional pattern that can have devastating consequences for family members enmeshed in it. In essence, the double bind is a covert relationship in which one person has power over the other, who cannot escape. It has two important components. The first consists of paradoxical injunctions in which the less powerful member of the dyad is given conflicting messages either through impossible injunctions, for example, “be spontaneous” or through the nonverbal contradiction of verbal messages, for ex¬ample, a parent’s statement ”don’t worry about me” in an anxious tome of voice. The second component occurs over time in which the paradoxical injunctions lead to repetitive behavior patterns. The participants provoke the very behavior from each other that they deplore through incongruous behavior. For example, a mother criticized her silent daughter and encouraged here to express her feelings. When she did, however, the mother broke into tears with, “How can you feel that way after all I have done for you? Then the daughter became silent, eliciting her mother’s criticism again, because she was not speaking.

During therapy these resistant families act like well-drilled teams. When inter¬viewed together family members may feel persecuted, become confused, find it hard to think of anything to say, be preoccupied with and silent about the same secret, agree on a fabricated version of a touchy incident, or start arguing with one another and then blame the therapist for upsetting them.

These families typically employ power plays that maintain the status quo. For example, one set of parents nagged their adolescent son into being a “good boy.” To qualify he had to be passive, compliant, infantile, and sexless. When he rebelled his mother histrionically went to bed with intense heart pains, presumably induced by the son, and the father expressed the horror of one who had sired a homicidal son. Another mother coached her son in reading even though the drills ended with both in tears and obviously impeded her son’s motivation to learn. Other parents are so punitive when their children get poor grades that the children retaliate by failing even more.

A specific aim of one family script is to maintain the symptom. As an illustration, one family with a retarded reader convinced their son that he was doing as well as might expected in view or his presumed limited intelligence. They denied clinical reports that his intelligence was normal and disparaged the validity of the tests. Another aim of a family script is to maintain the acceptability of the family’s public image. For example, a family maintained the image of cheerful cooperativeness with no problems apart from their son’s retardation in reading.

Scripts also protect a family’s secrets. For example, when one son began to talk about the “skeleton in the closet” in a family session, the others started conversations on unrelated subjects. If he persisted, they continued to divert the discussion to peripheral topics or tried to talk him out or his opinion.

Some children improve in schoolwork while acquiring a new emotional or behavioral problem. In this maneuver, the children maintain their scapegoat functions in their families and do not have to deal with upsets, which would follow relinquishing their problem roles. Thus they help keep their families from becoming unstable. If the new problem is addressed therapeutically, the members of these families close ranks. They offer carefully reasoned excuses for missing appointments. They accuse therapists of using ineffectual treatment methods and may discontinue therapy. One parent simply said, “I can’t stand any more talk about me. If we have to do that, I would rather have Bryan stay in special ed.”

PARENT EDUCATI0N

Parents benefit from insight into their children’s problems, but insight alone is not enough. They need help in learning to change the emotional climate in the home.

Parent-guidance materials are important means of assisting parents to understand and to cope with a child’s characteristics. Training in parenting skills also is useful. This is particularly needed in developing communication skills through listening, talking with children, and verbal problem solving as employed in Parent Effectiveness Training. Effective communication is basic to the survival of all groups including families. More specific behavioral management techniques have been developed for hyperactive children. Literature is available to help parents play a more significant role in their children’s schoolwork.

Fostering communication between parent and child through parenting education can produce substantial gains in the competencies of children.

Babies and young children with difficult temperamental styles may cause their parents to feel threatened and inadequate with resulting unconscious rejection or scapegoating of the child. A difficult child and threatened parents, therefore, can set in motion a cyclic interaction that makes the child increasingly vulnerable. With older children parents need help in examining their childrearing techniques. Viewing themselves interacting with their children on videotapes can be particularly useful. They may unwittingly reinforce behavior problems through attention to misbehavior, double messages, failing to set limits, ignoring desired behaviors, and inappropriate punishment, all of which result in losing a child’s respect. Although striving for consistency is a laudable objective, still there are times when parental authority must be arbitrary and so acknowledged with children.

To effect a climate of communication, parents can motivate their children by helping them analyze their own behavior and select target behaviors for change. Family meetings are useful for exercising the democratic process, so that each member participates in decision making within appropriately defined limits. When the atmosphere in family meetings is conducive to discussion of problems with openness and dignity, parents can appreciate the importance of changing their own attitudes and listening to their children more carefully. Parent modeling of self-discipline, forgiveness, and a willingness to acknowledge mistakes promotes similar qualities in their children.

Parents can profit from an understanding of sibling relationships in which a mixture of pleasure, affection, hostility, aggression, jealousy, rivalry, and frustration is freely expressed. The sibling relationship can be profoundly important in shaping the development of social skills. At the same time, a younger sibling can languish in the shade of an overbearing older sibling.

Jack C. Westman, M.D., M.S., is professor emeritus of psychiatry at the University o