Assessing the need for family therapy: a primer for rehabilitation counselors.

Assessing the Need for Family Therapy: A Primer for Rehabilitation Counselors

A recent literature trend recognizes that the client is part of a larger, interacting family and social system that has significant influence on the rehabilitation process (Cook & Feritor, 1985; Versluys, 1980). Studies investigating the impact of family therapy have clearly demonstrated this influence on individual client change in areas such as enhancing individual competence and independence (Webb-Woodard & woodard, 1982); changing self defeating beliefs (Watzlawick & Coyne, 1980); improving adjustment to work (Goldstein, Cohen, Thames, & Galloway, 1974); complying with medical rehabilitation treatment (Friedrich & Copeland, 1983); facilitating the grief process (Gelcer, 1983); reducing recurrent hospitalizations (Barbero, 1984); and promoting home health care (Peterson, 1985). These studies indicate that while family members offer genuine attempts to help an individual member with a disability, unproductive and potentially destructive reinforcing behaviors are sometimes developed and maintained unless family therapy is implemented. As some writers suggest (Bray, 1977; Mendelsohn & Mendelsohn, 1986), the difficulties families experience in adjusting to disability parallels that of the individual's adjustment. Family members may therefore unintentionally resist rehabilitation efforts by undermining independence, encouraging helplessness, and receiving secondary gains from illness or disability (Cottone, Handelsman, & Walters, 1986). Responding to the physical and emotional changes experienced by one family member, the family must reorganize and strive for stability or homeostasis in order to return to familiar patterns of functioning (Minuchin, 1974). The extent of reorganization will, of course, depend upon the integral function and roles assumed by the family member who becomes disabled as well as other social, economic, and emotional changes (Reagles, 1982; Sutton, 1985). Despite this empirical evidence and professional opinion that demonstrates the importance of the family in the rehabilitation process, rehabilitation counselors tend to keep things "status quo" by adhering to the myopic view of planning and delivering case services to one person (Lindenberg, 1977). The recent role and function study of certified rehabilitation counselors (Rubin et al. 1984) revealed that counselors believe talking with family members concerning rehabilitation service problems and evaluating family interest and involvement in the rehabilitation process, represents a minimal part of their job. Counselors' reasons for the apparent noninvolvement of family members include an inability to examine rehabilitation problems within a systems theory approach (Cottone, Handelsman, & Walters, 1986); a belief that family contact requires specialized knowledge and training in family therapy (Power & Dell Orto, 1980); and limited case service funds available for family treatment (Kneipp & Bender, 1981). Although recommendations to enhance counselor skills have suggested coursework in family systems (Power & Dell Orto, 1986) and supervision in family counseling (Kerosky, 1984), many practicing rehabilitation counselors may not be in a position to participate in such specialized training.

Problems in providing family therapy services can also be attributed to the family's willingness to participate in the rehabilitation process. Since the counseling process is one that many clients initially perceive as threatening, beginning discussions of family concerns may resurrect a variety of emotions such as fear, anger, sorrow, and hopelessness. The family is then left in a dilemma to decide whether it is better to examine their own adjustment concerns with a counselor or opt for perhaps the more comfortable decision to avoid any discussion in the hopes that "things will eventually work out." While families may be more receptive to examining issues during the initial crisis, once the crisis abates they may revert to earlier, more familiar interaction styles in order to regain homeostatic patterns that are more comfortable, yet not necessarily conducive to successful family functioning (Jackson, 1957).

Early intervention by the rehabilitation counselor and/or other helping professionals during hospitalization to address family concerns may set a precedent that rehabilitation is a family matter and not simply something that happens to the client alone. While therapeutic counseling within comprehensive medical rehabilitation centers are often shared between hospital social workers and psychologists (Kaplan, 1986), rehabilitation counselors are perhaps better prepared to address family concerns because their awareness of disability problems (Sutton, 1985). Subsequent family involvement in later rehabilitation phases directed to enhance functional independence and vocational self-sufficiency may become much easier if previous rehabilitation counseling efforts were directed toward the family. For example, a recent study by Bryen, Newman, Reiter, and Hakim (1987) concluded that persons with disabilities have greater employment success if family support is available. Among some of the important findings were that family involvement in the vocational rehabilitation process was rare; that persons who succeeded in competitive employment were often initially supported financially and emotionally by their families; and that persons who obtained employment had families who were strongly involved in the decision process of job selection (D.N. Bryen, personal communication, February 29, 1988). This study supports the view that counselors have not communicated a family approach to vocational rehabilitation and, as a result, clients may not expect this orientation since the traditional approach remains directed toward one person.

In summary, while some rehabilitation literature advocates involving the family, it also recognized that many counselors perceive a lack of training, time, or interest to assess family therapy needs. Obviously, the degree of counselor expertise and interest in working with families partially depends upon the type of work setting in which the counselor is employed, training received in family assessment, and the desire to examine the family's role in the rehabilitation process. However, a major fallacy that many counselors have accepted as true is that in order to use family therapy concepts and techniques one must become a family therapist (Zingaro, 1983). This paper is intended to demonstrate that family concepts and techniques can be used by rehabilitation counselors who have a desire to assess the need for family therapy but lack the knowledge in doing so.

Family Areas Requiring Assessment

Acknowledging that rehabilitation counselors are not typically acquainted in knowing how to assess family needs, interested professionals must examine family interview models (e.g., Christie-Seely, 1986; Cirillo & Sorrentino, 1986), formal testing of family functioning (e.g., Epstein, Baldwin, & Bishop, 1983; Waring, 1984) or a combination of the two approaches (e.g., Cromwell, Olson, & Fournier, 1976). However, while family therapy literature is replete with examples of procedures to assess family problems and concerns, these suggestions have not been articulated in rehabilitation literature. To date, the few rehabilitation contributions have examined basic content areas that counselors should pursue when meeting families. For example, Power and Dell Orto (1980) proposed a useful diagnostic model that examined: 1. family demographic data; 2. family communication patterns; 3. division of labor in the family; 4. extent of family members' outside socialization and access to social and cultural experiences; 5. family health or illness; 6. characteristics of disability/illness; and 7. impact of disability on the family. Accordingly, these content domains would result in appraising the residual health of family relationships and relationship damage resulting from adjustment to illness/disability. A later refinement of assessing family functioning by Power and Dell Orto (1986) suggested that rehabilitation counselors examine four particular areas--family strengths and weaknesses that influence the rehabilitation plan, family reaction to the disability, information the family has concerning the disability or illness as well as expectations held by the disabled family member, and the services needed to enhance rehabilitation. While these topics may prove valuable in ascertaining family concerns, rehabilitation counselors cannot merely apply a standard list of topics to each family member without first reconizing the importance of existing family dynamics. The manner in which these topics are introduced, who they are directed toward, and how they are discussed can result in whether the family participates in rehabilitation counseling and on what basis.

Rehabilitation counselors must be aware that any need for family therapy may not be apparent by simply asking the individual client, "How are things going at home?" In order to fully understand family distress that accompanies disability, Worthington (1987) proposes three conditions that require assessment. The first condition recognizes that a linear relationship exists between disruption of the family time schedule and family stress -- the greater the disruption, the greater family stress. With the onset of disability, family members may have to rearrange their schedules to assume new family roles. Meeting responsibilities within and outside of the family will therefore depend upon the flexibility of each member to assume new roles. In order to assess the impact of time schedule disruption, it was recommended that each family member account for how they spend their week. This discussion reveals patterns of family intimacy or closeness as well as information concerning feelings such as being overburdened, unappreciated, or isolated. A second assessment condition must examine the number of new decisions involving family disagreements. With any new transition such as the challenges that disability presents, each family member enters this new phase by adhering to a set of overt and covert family rules that were followed prior to disability but which may now need to be renegotiated. For example, when a spouse becomes disabled, new decisions may have to be made concerning sexual intimacy, parenting, leisure, education, and/or work pursuits. Worthington suggests that one method of assessing how decisions are made and by which family members is to assign the family a task discussing a current family problem in which they disagree and observe the family's interaction. Such discussion will provide valuable insight into a variety of family dynamics including questions about family roles and communication patterns -- Who is most dominant/submissive? Which family members are closest/farthest from one another? Which family member is/not listened to by others? What messages are clear or masked? What verbal/nonverbal messages are congruent? What emotions are difficult to express in this family? The final assessment area, pretransition conflict, requires ascertaining conflicts that existed prior to disability. These conflicts may be attributable to individual personality conflicts and situational factors (Sieffer, 1978). For example, persons may project their own anxiety, anger, and hurt onto the family member with the disability or rehabilitation personnel if they have relied upon this mechanism to cope with other past traumatic events. Similarly, some family members may have also learned that feelings are something best kept private to avoid family contention and, as a result, "sacrifice themselves for the good of the family."

Although analysis of these areas provides some potential clues in assessing family problems, a major difference between severely dysfunctional families and families that have made successful adjustment is that dysfunctional families have not resolved earlier adjustment conflicts (Munro, 1985). In rehabilitation counseling practice, these dysfunctional families have often been described as "non-accepting of the clients' abilities and disabilities." Munro observed that severely dysfunctional families show a variety of behavioral patterns which may aid the rehabilitation counselor in determining whether family therapy is needed. These behavioral patterns include: (1) loud, chronic complaining; (2) program sabotage; (3) extreme overprotectiveness; (4) increasing somatic complaints; (5) overt hostility; (6) symbiotic relationships that involve an unhealthy close relationship between the person with the disability and one or more family members; (7) avoidance of the person with the disability; and (8) psychosocial deprivation. While these behavioral patterns may manifest themselves either directly or indirectly, it is often the case that severely dysfunctional families will contend that "all is well" or "given time everything will work itself out."

Suggestions to Facilitate the Initial

Family Assessment Meeting

The first consideration prior to meeting family members is to recognize that while families experience the impact of an individual's disability/illness on various emotional levels, they may not wish to openly express their feelings. In a sense, families may adopt the posture that "we take care of our own" by remaining withdrawn. Acknowledging that many families do not openly discuss handicap/disability issues with one another (Rehab Brief, 1984) or initiate conversations with rehabilitation professionals (Thompson & Haran, 1984), an initial meeting with the rehabilitation counselor may be quite threatening. The notion that the counselor wants to meet with the family implies that the client is the family. In order to help the family understand the importance of their relationship to the rehabilitation process the counselor may want to use an analogy. For example, the counselor could describe a mobile which has various parts (i.E., individual family members) that are all connected by strings (i.e., the family relationships ties) and when one part of the mobile moves or changes (i.e., the family member with a disability), the other parts also move (i.e., the remaining family members). While there is movement among family members, it does not mean that all of the parts are going in the same direction, however. This analogy may demonstrate the connectedness that members have to each other and suggests that persons have thier own way of "moving through" the rehabilitation process while simultaneously impacting on one another. The counselor may then wish to explore the impact the disability has on each family member as well as any preexisting non-disability issues which may also impact on individual rehabilitation goals.

In order to explore disability impact on the family, counselors must be cognizant of the structural and relationship skills that characterize effective communication (Barton & Alexander, 1977). Structural skills are those that typify information gathering that is direct, clear, and stimulates family interaction. To illustrate, effective structuring behaviors may include aspects such as helping the family define needs, stopping chaotic interchanges, shifting one's counseling approach when one method of gathering information proves ineffective, helping clients rephrase "why" questions into statements, asking open-ended questions, directing/structuring interaction among family members and establishing "ground rules" such as confronting family members when they interrupt or speak for another person (Piercy, Laird, & Mohammed, 1983). In contrast, relationship skills are concerned with the counselor's ability to promote therapeutic relationships as characterized by self-disclosure, hope, warmth, empathy, and sense of humor (Kniskern & Gurman, 1979). Using the more familiar rehabilitation terms, structural skills are analogous to those skills used by counselors who may be characterized as information exchangers and/or information providers whereas relationship skills are used by therapuetic counselors (Bolton, 1974). As with individual rehabilitation counseling, the flexibility in adopting structural and relationship skills is an important component to assess whether family therapy is warranted.

Certainly, the structuring and relationship behaviors described in family therapy assessment would also exemplify the assessment for individual counseling as well. However, a fundamental difference in assessment of family therapy lies in the manner in which information is obtained, shared, and used therapeutically. For instance, it is critical that the counselor remain neutral toward all family members. The counselor must be sure that a therapeutic alliance with each family member exists and accept the family's interactional style with one another. It can be quite easy for the counselor to assume a role similar to that of another family member. As Gill (1985) acknowledged, rehabilitation professionals must also carefully examine their own attitudes toward disabilities to reduce any prejudices in client contacts. Implicit and explicit messages by the counselor can convey disapproval or acceptance of particular family members. If realized, the counselor only serves to compound the problem by losing objectivity and assuming a role similar to some other family member (e.g., "critical parent," "coaxing spouse," or "remorseful sibling"). Counselors are particularly susceptible to this danger especially when clients don't do what counselors want them to do. This posture only serves to mirror other family member roles when they become overwhelmed, disenchanted, or disengaged with the person having the disability. In order to emphasize the importance of remaining neutral and demonstrate the structural and relationship skills when assessing family therapy needs, all family members should leave the counselor session feeling that they were understood by the rehabilitation counselor. This suggestion becomes especially crucial in cases where one family member is already identified as a major culprit of family problems. For example, one member may be viewed as uncaring toward the family member with the disability. The counselor has to avoid displaying favoritism by reframing the seemingly negative behavior. As an example, "David, I noticed when your Dad was talking about his fear in trying to find work, you were looking around as if to suggest that you're not interested in what's going on. But I wonder if that's your way of letting the family know that you too are worried about your Dad?" This strategy may be particularly helpful especially if David is perceived as uncaring. Rehabilitation counselors certainly recognize that clients' inappropriate or destructive behaviors are often masks for their own internal stresses.

In addition to considering how to approach the family, the counselor also recognizes that each family member may not wish or be appropriate to participate in the initial family assessment meeting. While some family theorists advocate that all family members be present for assessment and later treatment (e.g., Framo, 1976), effective family therapy does not maintain this condition be absolute (Friedman, 1982). On the contrary, as the earlier mobile metaphor suggested, change in one or several family members can also result in major changes in the entire family system. For the rehabilitation counselor a basic problem involves, "Which family members should attend the initial assessment meeting?" The answer is one that the rehabilitation counselor should not decide. Instead the individual client could be asked, "Which family members do you think could benefit from an initial family meeting to discuss rehabilitation goals?" This approach places the responsibility on the client who certainly has a closer understanding of existing family concerns than the rehabilitation counselor.

Techniques of Family Assessment

While a basic tenet of family therapy is to view the individual client problem in terms of a sympton of a larger family problem (Minuchin, 1974), this emphasis could be very unproductive during the initial assessment for family therapy. As an alternative to disputing the family's definition of the problem, White (1979) suggests that counselors "join the family in solving it." By doing so, the perception that the counselor has figured out the "real" problem and has specific suggestions to remediate the situation can be avoided. Initial defenses may be minimized if family members feel supported rather than feeling threatened by a counselor who does not agree with their definition of family rehabilitation problems and concerns. Consequently, by joining the family, counselors do not place themselves in the position of being the "answer person." Instead of adopting the position of counselor vs. family, the introduction to assessing family issues and concerns could be phrased by stating that "All of us will be working together."

Watzlawick (1966) indicates that when inquiring about family problems, each family member should be interviewed separately with the counselor. At the conclusion of the interview each family member is asked not to divulge any information to other family members. After conducting individual interviews, the family reassembles at which time the counselor states that, "their individual answers have brought to light several interesting points of discrepancy, that they apparently never have discussed the problem together and that they should do so now, while the interviewer leaves the room" (p. 258). The family's next task is to reach a conclusion regarding the major family problem. Watzlawick contends that this initial step in family assessment implies the right and importance of persons to express their own unique views, that a variety of problems exists, and that these problems relate to each family member and not merely restricted to one person.

A different interviewing approach is to have all family members present throughout the initial assessment session. While this approach may be more practical for rehabilitation counselors with larger caseloads, some family therapists (e.g., Selvini, Boscolo, Cecchin, & Prata, 1980) also advocate this method because it breaks a dysfunctional family rule of keeping "secrets" from one another in order to "protect each other." Weber, McKeever and McDaniel (1985) support the notion of interviewing all family members in the presence of one another and suggest that counselors start the interview by conducting a "social phase." In this phase, each family member is requested to provide demographic information so that the interview initially will be nonthreatening. Eventually, the family is asked to define family problems and concerns and they are told that, "Often in families people have different views about what the problems is. Today I would like to hear from each of you about how you see the problem" (p. 361). While family members articulate their concerns, the counselor is careful in observing the family, especially those members who avoid participation or seem "most distant to the problem." The counselor may then wish to begin with the most distant family member and engage that person by asking questions about the perception of the problem; when did the problem begin; what advice from others has been received; and, how the advice was received? A variation in expressing family concerns is to start with the youngest child and continue through the ordinal positions of the other children, the father, the identified client, and then ending with mother. While each member has a turn to express an opinion about family issues, other members are asked to remain silent until it is their turn to speak. Barnard and Corrales (1979) who also advocate interviewing family members simultaneously contend:

... the mother is probably most familiar with the

family dynamics, followed by the identified patient 

(IP), if one is present in the family.... By moving to

the baby, an attempt is made to increase efforts to join

the family. Usually the youngest in the family is the

one who is looked upon most favorably by most, if not

all, family members. Considering this, the youngest

child is perceived as a good entrance to the inside of

the family. (p. 122) Thus, mother is perceived as the central core of family dynamics and that soliciting her views prior to other family members may "skew what the other family members would declare." The suggestion by Barnard and Corrales may be particularly useful when the rehabilitation client lives with one or both parent(s) or when mother becomes a driving force in rehabilitation efforts. Since there does not seem to be any empirical evidence for the superiority of either approach as discussed by Weber, et al., (1985) or Barnard and Corrales, as with any counseling style, the approach taken will be dictated by counselor preference and family situation.

In the second interview phase of problem identification Weber, et al., (1985) suggest that the counselor ask each family member to provide examples of family concerns and discuss what strategies have been used to resolve family conflicts. Family members are also requested to describe the interactions and reactions of other members to this problem. For example, "Lee, when your Dad refuses to look for work, what does your Mom do and what do you do?" or "Mom seems to worry the most about Dad. Tell me, who is best in helping Mom when she worries? What do they do that helps?" This technique of circular questioning (Selvini, Boscolo, Cecchin, & Prata, 1980) can also be quite effective in overcoming family resistance because it serves as an indirect method to assess family problems. Family members are then asked to reenact the problem so that a clearer behavioral description can be made and that family interaction patterns can be directly observed. Using the same example noted earlier, the counselor simply asks, "Show me what happens when Dad refuses to telephone an employer to set up job interviews." While the family re-enacts the problem, the counselor carefully observes and follows the admonition of Bornstein and Bornstein (1986) -- "Give families the opportunity to display their dysfunction and undoubtedly they will" (p. 24). Adopting this strategy allows the counselor to determine how each individual family member reacts to the identified problem and provides an opportunity to compliment the family on any concrete actions that were positive during the discussion of identified problem areas.

Based upon the initial assessment, the rehabilitation counselor and family must decide whether family therapy is warranted. One way in assisting this decision is to ask each family member to share any information that was learned about themself, another family member, and/or relationships among family members and whether this information has helped in anyway. Insights learned about the family may provide an impetus to examine additional concerns for later family therapy. If families elect to participate in therapy, counselors should assist the family in developing counseling goals during the assessment interview. One method of establishing family counseling goals is to ask each member to describe what behaviors are most upsetting and what types of changes are needed to accommodate specific positive behaviors. Weber, et al., (1985) propose the question, "What would be the smallest change that might indicate that things are moving in a better direction?" (p. 362). Each member is asked what they would like to see changed in terms of specific positive behaviors as well as what aspects family members would not like to change. This approach also provides information for future counseling directions and underscores that there are positive elements about the family. It is important to recognize that even with many dysfunctional families there exists a basic core of caring among members. In order to emphasize this point families might be told that, "Despite all of the concerns and hard feelings in this family there is obviously a great deal of caring. Certainly, your willingness to be here for this meeting says that each of you care about what happens to one another. The question is, how can we work together to resolve your concerns? In cases where the family does not wish to enter familty therapy but the rehabilitation counselor perceives a need to refer for this service, the counselor obviously must respect the family's decision. However, intervention strategies with resistant families are available and may be required if later therapy is to occur. A more detailed analysis of strategies in mastering family resistance has been discussed by Anderson and Stewart (1983) and may serve as a useful guide to rehabilitation counselors.

Conclusion

Recognizing that rehabilitation counselors often procure a variety of client services, it is hoped that referral for family therapy will be increased. While rehabilitation counselors are not trained as family therapists, counselors should be able to assess family dysfunction as it relates to rehabilitation adjustment issues and be able to make referrals to other qualified personnel (such as a clinical member of the American Association for Marriage and Family Therapy). Certainly, families deserve this counseling service as with any other rehabilitation service designed to enhance vocational, psychosocial, and independent living functioning. Although counselors who work in the acute, hospitalization phase of rehabilitation are recognizing the importance of involving the family, counselors who become involved in later vocational rehabilitation have seemingly ignored the importance of the family as a valuable asset to rehabilitation goals or assessed their relevance to the rehabilitation process. While counselors with excessive caseloads may argue whether the additional one hour to interview a family is relevant to vocational rehabilitation, research by Bryen, et al., (1987) suggest that family involvement positively relates to successful vocational rehabilitation outcome. Perhaps counselors whose primary concerns are closely associated with the number of successful job placements will recognize that if families are going to share an alliance with rehabilitation professionals (Marlatt, 1988), then a basic step toward achieving successful rehabilitation should start with an evaluation of how the family may facilitate the rehabilitation process.

Counselors must begin to examine rehabilitation problems from more than the perspective of the individual client. This individualistic focus only serves to deny that each person comes from a larger interacting family system that has great influence on the rehabilitation process. Despite overwhelming evidence which demonstrates that the family has a powerful influence on individual rehabilitation change and client progress, many rehabilitation counselors seem to ignore this process. Hopefully, this article may stimulate discussion among the professional community as well as consumers of rehabilitation services to at least expect that any need for family therapy should be assessed. The suggestions to facilitate family therapy assessment included in this paper demonstrate that rehabilitation counselors can ascertain family problems as they pertain to the rehabilitation process. Until counselors view rehabilitation as a process that influences the family, it is likely that earlier observations concerning the lack of family involvement will be repeated in the literature. Rehabilitation counselors should be beyond wondering whether, "Is it necessary to involve the family in the rehabilitation process?" One step towards answering thi question is to assess the need for family therapy and, if appropriate, refer the family for appropriate services so that rehabilitation efforts are realized.