The Peterson family on May 5th 2007 took the initiative to gain therapeutic services for their troubled son David. Throughout the therapeutic process, all family members became actively involved. Three primary family therapeutic approaches for treatment were eventually chosen by the therapist with the application of three interventions within each approach. The approaches included; Cognitive Behavioral approach, Narrative Based Therapeutic approach, and a Psychoeducational Therapeutic approach. These purposely chosen constructs were applied to the Peterson family system and with their help the Peterson family was able to assist their son David with his behavior issues.
Agency Context
The current agency, in which the Peterson family sought assistance, was the Summit Agency. Summit is an inner city agency located within the college district of Philadelphia. It is a high end agency that specializes in helping families and individuals with problematic behaviors and circumstances. Much of the clientele within the Summit Agency could be considered mid to upper class. The agency is primarily funded by direct payment from clients who are seeking highly qualified PhD. and Masters level clinicians to assist with their family issues and by private donations given by local university professors and staff.
Presenting Problem
The presenting problem according to the Peterson family has been clarified by Mr. and Mrs. Peterson as the behavior of their 16 yr. old son David. For the last two months David has been acting out in school and been disrespectful at home. Rule breaking, disrespecting teachers, and detentions have remained consistent parts of David's behaviors. This type of behavior for the Peterson family is unacceptable and has resulted in the Peterson family seeking assistance for their son's behavior. Mr. Peterson worries that if David's behavior continues, many may think that David is a real trouble maker; thus effecting his academic life and possibilities of going to college in two years. Mrs. Peterson is concerned about her son and wants his negative behaviors to cease. She feels that when he acts out in school this causes tensions within the household; especially between herself and her husband. Both Mr. & Mrs. Peterson seem to agree that they argue more and have greater difficulties on the weeks and days in which David gets in the most trouble. In sessions, David makes statements like, "I don't care about school, because you guy's don't really care about me." David, in session seems angry. He seems to be very sensitive and seems to desire more attention and time with his parents. He states that he believes no one listens to him and that the only reason he is at the Summit Point agency is because his mom & dad just want to change him. Both, Mr. and Mrs. Peterson want David to just behave at school and at home in order for him to obtain a good education and be regarded as a good young man. David states that if his parents would not work so much, he may have some time with them, and not feel so lonely. David also states that when his parents are angry, they seem to take things out on him; thus making him more frustrated and angry.
Demographics
Mr. Peterson is a 50 year old white male. Mr. Peterson is an educated man with a PhD in literature from the University of North Carolina, for which he takes great pride. Mr. Peterson could be described as having an opinionated egocentric personality, quick witted, and some how seems to respond with some type of literary quote within every response to family and friends. Mr. Peterson does not emphasize a religious preference or identity and could be considered one who maintains an upper middle class life style. Although Mr. Peterson has published a few literary works, none have been significantly successful, and this seems to be a source of pain and loss of self esteem for Mr. Peterson.
Mrs. Peterson is a 46 year old white female. Mrs. Peterson also graduated from the University of North Carolina with a PhD in literature. Mrs. Peterson seems to be a smart, pleasant person that makes references to having hobbies; such as playing tennis, biking and shopping. Mrs. Peterson does not declare a religious preference, but does say she believes in God. Mrs. Peterson has published two novels and takes great pride in their success.
David is a sixteen year old white male. He has no history of mental illness or notable behavior problems. David attends high school within the tenth grade at Highland High School. David does not consider himself to be a religious person, but does love the latest Eminem Rap CD, loves to skate board, draw, and enjoys watching horror movies. David does seem to be a sensitive young man, and at times makes efforts to express his feelings and clearly express any noticeable changes to pictures and other items within my therapeutic office; thus indicating a heightened sense of observational ability.
Treatment Plan
The current treatment plan (see figure 1.1) consist of one primary goal and intermediary objectives through a Cognitive Approach to assist in modifying David's current behavior issues. Thus far, over the past month and a half I have met with the Peterson family every week and attempted to assist David and his family with these objectives and goal with no progress. I believe that with the current information I can develop suggestions, and inform my practice by linking new strategies and intervention objectives from family therapeutic approaches to assist in solving David's difficulties.
GOAL: To decrease David's problematic behaviors
- Send home weekly progress report
- When David receives poor behavior reports he is grounded from skate boarding and other activities he enjoys
Figure 1.1
The current suggestion and decision to link family therapy approaches to this circumstance is to assist with significant issues. In retrospect, the interventions although practical, placed much of the responsibility and process upon David rather than a family oriented intervention. It was found that many times David would not even bring home his weekly progress reports for review. It was also founded that the use of negative reinforcement strategies was not effective due to David's already tattered self image. After further interactions with parents it was discovered that they rarely complimented David on what he does right, and they admitted to criticizing him at times. With this information I believe that it would be wise to now integrate a positive reinforcement plan that would assist with promoting good behavior and increasing self esteem. I feel that suggesting the use of strategies to assist with David's parents in regards to their relationship and the scape goating behaviors David describes may be beneficial. I believe that David's parents would also benefit by gaining parenting skills and education. The prior treatment plan did not allow David to experience for himself the roles of others or allow him to identify thought and feeling patterns. I believe that with the understanding of David's personality and his obvious intelligence and sensitivity, utilizing strategies that assist with thought identification may be beneficial. The newly suggested treatment plan is as follows;
Goal One: To decrease David's problematic behaviors
- To increase David's awareness of how his behavior affects others
- To assist David in identifying thoughts, feelings, behaviors, beliefs
- To assist David's parents with better parenting and relationship skills
Figure 1.2
Strategies for Change - Cognitive Approach
During session discussion I would ask David, how he thought his behavior at school made others feel and what impact his behavior had on others. After his response I feel that the "Critical Moment" Cognitive Behavioral approach intervention that I learned at the University of Michigan School of Social Work may be effective (Personal Communication, R. Tolman, October, 2006). I would suggest that a role play should be utilized with David and his parents. I would ask David to identify any time or circumstance in which he interacted with a teacher negatively and when the interaction concluded with a negative consequence for David. The circumstance I would request of David must have ended with him thinking that he should have responded differently. I would ask him to express to all of us his detailed story from beginning to end. After he expressed his story I would ask David and his parents if there were more positive responses David could have utilized that were not disrespectful. David and his parents would have good ideas regarding what David's response could have been and they would share these ideas. After sharing their ideas, I would request that David play the role of the teacher, and I then ask his father to play the role of his son David. I would ask David's father to make sure that in his response, as he acted like David that he would include the newly agreed upon positive response. As both would act out the role play, David would state the words of his teacher within the past interaction and his father would do his best to repeat what David had stated was spoken during the interaction, except for the addition of the positive statement that David should have said. After the role play, I would request a role reversal. This time David would play himself, stating what his father had stated with the positive response attached to his interaction. His father would play the teacher, and at the conclusion David would hopefully begin to understand both roles of those involved. It is hypothesized that this role reversal may change David's perceptions.
The second intervention that I believe would be helpful in allowing David to identify his thoughts and feelings and how they effect his behavior would be to utilize during the session a dry erase board in order to draw the "circle of identification" (Becvar & Becvar, 2000). This circle could indicate the process of thoughts, feelings, and behaviors. I feel that the utilization of this type of intervention may work well, considering the known information regarding David's love for drawing and visual acuity. I would suggest to David to express a time when he was disrespectful or acting out against his parents or teachers. That specific episode would be the focus in which we would identify his thoughts, feelings and behaviors to that circumstance. As a therapist I believe that as we identify his thoughts and feelings during this episode and address whether or not they were positive or negative, or whether they were realistic or distorted; at the center of David's response could lie schemas about himself and others that may not be healthy or functional for his life. It will be the goal of this intervention to address those negative schemas that may be assisting in negative responses, and purposely inserting positive collaborative thoughts created within our sessions.
Due to suspected negative reciprocity and the development of negative schemas within the family system, regarding David's consistent behaviors, it would seem to be beneficial to utilize a third cognitive approach. I feel that it may be beneficial for the Peterson family to utilize a thought, feeling, and behavior journal for all members in the family (Becvar & Becvar, 2000; Lawson & Prevatt, 1999). It would be expressed to the family that on each page of the journal there should be two headings; "What did David do today", and "How did I feel about what David did today." I believe that this could allow the family over a number of sessions to come to a realization of how they are perceiving their son, and how David perceives himself in a qualitative manner. Identifying these schemas, thoughts, and feelings may be beneficial for assisting in cognitively reconstructing the family systems perception and expectations of David's behavior.
Narrative Approach
It could be suggested that in an effort to speak about the behaviors within sessions one should seek to reduce parental "problem saturation" regarding discussions of David's behavior (Lawson & Prevatt, 1999). It could be hypothesized that due to the constant criticism and negative perceptions that David's parents have expressed regarding his behaviors, utilizing an externalization technique would be beneficial (Lawson & Prevatt, 1999). As the therapist I should ask two sets of questions; questions relating to how family members feel about David's behavior and after a series of questions regarding the families reactions to David's behavior I would ask the parents if there was ever a time in which David did not act disrespectful or behave in a negative manner (Prevatt & Lawson, 1999). All family members could then begin to identify the negative behaviors as external events in which they could seek to collaborate and work against (Prevatt & Lawson, 1999). This would seem to be an effective intervention, especially for David who has been indicated as having low self esteem and has been identified as possibly being the scape goat within the family system.
After a thorough expression of different perspectives over a number of sessions, as the therapist I would suggest to the parents to write a letter to their son. Within the letter I would ask them to express their commitment to helping David. I would express to the parents to write positive statements of affection for David and let him know that they validate his feelings. This would lend to decreased fault finding and negative reciprocity (Lawson & Prevatt, 1999). This process I believe would assist David in reducing his feelings of isolation and enhance his commitment to working against the externalized problems.
Furthermore, a third intervention that may be effective would be for myself as the therapist to write a final letter of prediction (Lawson & Prevatt, 1999). This letter would be written in a way that expressed a strengths base perspective and a positive message of hope in regards to family commitment and David's behaviors.
Psychoeducational Approach
As the therapist I would pursue concepts and processes consistent with educating the Peterson family. I would identify concepts that may be effective considering the educational level of the parents and David, as well as the families strengths and ability to utilize problem solving and communication concepts (Becvar & Becvar, 2000). Considering the suspected scape goating behaviors of Mr. and Mrs. Peterson, I feel that teaching Mr. and Mrs. Peterson better ways of communicating their own problems rather than projecting them upon David would be beneficial. I believe speaking with Mr. and Mrs. Peterson about active listening skills, practicing the communication ball technique (speaker holds the ball / listener waits their turn) would allow the Petersons to work on their listening skills. I feel that this would work well for the Petersons considering their educational level and willingness to learn.
Another intervention I would implement to enhance communication with the educational system would be to teach parents how to implement a home/school communication system (Foley, 2007). This system includes maintaining a chart that is marked by teachers and parents to indicate behaviors, moods, and activities that were completed during the day (Foley, 2007). The construction of this system creates effective communications between school staff and parents (Foley, 2007). As the therapist I would ask the Petersons to construct this system as instructed and then within one session evaluate the process and express the ideas to David. Emphasizing also to David that good reports will bring good rewards. Educating Mr. and Mrs. Peterson regarding follow through and consistency regarding the communication system would be very important.
Due to the educational levels of the Peterson family, as a therapist I would suggest interventions such as parental skills groups within the community or the use of parenting resources and educational programs within sessions. It is hypothesized that the Petersons would welcome any educational information regarding more effective parenting. Recommending web sites, books (Love and Logic) and therapeutic games to enhance a child's communication and self esteem would be possible interventions for the Peterson family. These psychoeducational interventions would assist with the third objective of the treatment plan, regarding the need to obtain greater parenting and relationship skills.
Conclusion
The difficulty I identified within the first treatment plan was that only one approach was utilized and it was not an eclectic process with at least three approaches and multiple interventions. I believe that the eclecticism should be a priority due to the nature of the problem and multiple systems involved. I felt as if in order to reduce David's negative behaviors the interventions should be creative, connected to problem solving objectives and address the entire family system.
I believe that utilizing a cognitively based approach would be an important part in identifying the negative beliefs and schemas David may have about himself as the roots of his low self esteem. By increasing David's abilities in negative thought identification, David will be able to purposely insert positive thoughts through cognitive restructuring (Becvar & Becvar, 2000). Gaining parental involvement with journaling may also be a wonderful intervention, considering that Mr. and Mrs. Peterson are writers and may give interesting and creative reflections.
What may be a concern is that David's parents could identify externalizing a problem through a Narrative approach, as a way of David not taking full responsibility for his behavior. Considering their past negative reciprocity of his behaviors and the parents' attitudes and expectations, it would be important to emphasize the significance of such a perspective.
David stated that his parents do not listen to him. Also admitted by his parents, they tend to argue more when David gets in trouble. The chosen Psycho educational approach would seem to be an effective approach. This approach I feel would assist the Petersons in gaining valuable communication skills and greater parenting strategies for David. I feel that communication building strategies would assist with what David stated as "no one listens to me." Considering the Petersons income level, community influence and positive attitude towards education, suggesting that they gain involvement in a parenting and or communications group would be an excellent intervention strategy.
I feel as the Petersons therapist that the utilization of these three approaches and choosing them according to their specific circumstance and family dynamics that they will prove to be more effective. I feel that these approaches contain all the elements that are needed to enhance the skills and reduce the problems that were chosen by the Peterson family.
Note to Reader: All participants in this article and the agency are fictional: any relation or connection to real circumstances is clearly coincidental.
L. J. Riley Jr. BSW, LLMSW
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References
Becvar, D. S., & Bacvar, R. J. (2000). Family Therapy; A Systemic Integration. (4th edition). Needham Heights; Ma: Allyn & Bacon Publishing.
Foley, S. (2007) Psychological Testing for Social Workers; The Notes.
Lawson, D. M., & Prevatt, F. F. (1999) Casebook in Family Therapy. Belmont; CA:
Wadsworth Publishing.
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