The residential treatment setting presents unique challenges to family engagement. The Building Bridges Initiative proposes a framework for successfully working with families. Using structural family therapy, residential treatment teams can facilitate lasting change.
Structural family therapy
As Salvador Minuchin theorized, for a family structure to maintain health, there needs to be a clear but permeable boundary between the roles of the parent(s) and child(ren) (Families and Family therapy). The first task of family treatment is to map the roles and dynamics through interaction with the family. While discussion of the conflict pattern is somewhat helpful, the family will enact their roles if provided the opportunity and allow the pattern to be seen and reflected by the participants. Once this is clear, the family can focus on areas for adjustment towards a healthier system. This requires in-person participation of the family, including the subsystems of parent(s) but ideally including siblings and other significant members.
In these interactions, the family members can identify their expectations of family roles. This can include the parents naming norms in their families of origin and their strengths and needs in making changes. Family therapy is hard! Changing structure requires focus on mindfulness in interactions as it is natural to feel drawn towards old, comfortable patterns. The family will need to practice as much as possible in their natural environment and home community to generalize changes.
Challenges of the residential setting
When a family enters residential treatment, and yes, I mean the family, they have undergone a series of interventions that likely include crisis hospitalization, police involvement, etc. Of course, it could be expected that family members experience “burn out” or emotional exhaustion, and a combination of guilt and relief at the prospect of residential treatment. In the Building Bridges Initiative, families reflect on the overwhelming admission process and their confusion or concern about the residential system. The road to residential is an exhausting process, often emotionally painful. Continuing into the treatment experience, parents identified their experiences in residential treatment that included losses: the time lost with their child that include the normative experiences, milestone, and feeling of connection. Families can feel like visitors rather than significant members of their child’s treatment. They may worry that their child will be institutionalized and that the strategies that were effective in residential will not translate home.
Best practices to move forward
So what can we do to promote parental engagement and empowerment? At the point of admission, families need to know that their involvement is critical to the success of treatment. Their perspective about what the family needs is required early and often, and sensitivity to the overwhelming nature and significance of entering into residential treatment. Maybe most importantly, families need to be a part of a transparent process that includes any decision-making and emphasizes “demonstrating in word and deed the utmost respect for children, youth, and families, and one another”. The parents and child need to understand the reasons for any changes or interventions proposed and to be active voices in planning. Families are not “visitors” and need to be offered the change to preserve normalcy, including through daily contact. When partnering with families, we need to create programs that we would be comfortable if our own sons or daughters attended. When asked what families needed from professionals, families cited some fairly basic courtesies:
- Ask us what we think.
- Learn what our goals are.
- Ask us what has already been tried and what worked or didn’t work – and why.
- Keep us informed and plan for us to be involved.
- Be honest with us, but be hopeful.
- Treat us with dignity and respect.
A core component of the Building Bridges Initiative (BBI, 2009) is the reframing of family “resistance”. Again, parents have likely taken much time off work and may have been involved in a variety of meetings seeking services for their child. The other children may have been feeling stressed and in need of their parents’ attention. Siblings and parents both may have suffered as victims or witnesses and need to be involved in healing. It is understandable that parents will experience considerable anxiety in going on “passes” home. Furthermore, financial, transportation and scheduling barriers are not small challenges.
But, phone calls will not suffice in generalizing changes in the family structure. Once barriers to this in-person involvement are identified, community supports need to be mobilized to “work to maintain, restore, repair, or establish relationships with family and community” (BBI, 2009). To engage the family, barriers to regular (weekly) face-to-face family therapy, visits, and passes to the home and community need to be identified early and recognized as significant. The clinician will problem-solve and work with the family to engage the natural family and community supports.
In terms of ongoing practices related to improving family engagement, increasing transparency and proactive parental involvement continues to be an area of focus. It also requires us to have a cultural shift in how we view not only calls and visits but ongoing collaboration and feedback from the family. Reframing and perhaps not using the word “resistance”, involving families as partners and regularly asking what we can do better is a powerful start. At Grafton we are committed to improving family engagement and are doing so by asking better questions, paying attention to improving communication practices and increasing active involvement from families in the treatment process.