LGBTQ Couples Therapy: The Additional Problems Therapists Encounter

LGBTQ Couples Therapy: The Additional Problems Therapists Encounter

John R. Stafford

Brandman University

Abstract

Couples therapy provides unique situations for any therapist. Each couple has a different dynamic, interpersonal relationship, and individual personality traits that either exacerbate or alleviate the daily stressors that a couple experiences. However, other couples encounter more than the every-day nuances of negotiating a healthy relationship. LGBTQ couples face the same issues like any other couple, but their societal status produces additional stressors that many other couples may never encounter.

Keywords:  LGBTQ, LGBTQ Couples Therapy, Couples Therapy

LGBTQ Couples Therapy: The Additional Problems Therapists Encounter

One of the most significant societal expectations is that we, as humans, mature and find someone to couple with and start a family. From a young age, children are molded by experience and natural instinct to seek a mate. Once a suitable mate is found, the couple begins to blend their individual lives into what they hope will be a cohesive family unit. It sounds easy, but combining two different entities is not as easy as it may seem. Moreso than not couples, both new and seasoned find internal and external forces introduce speedbumps into the relationship. Whether it be the simple act of moving in together and merging belongings, the birth of a child, or the death of a family member, each new experience is bound to result in some level of relational change.

Issues for LGBTQ Couples

Outside of the nuclear family model, which most couples and family therapy techniques developed, there are alternative family models that do not adhere to the baseline assumptions at the root of family and couples therapy (Sue, & Sue, 2016). For decades, LGBTQ couples hid, and continue to conceal their relationships from society. Many same-sex couples derived elaborate stories that resulted in the creation of a false relationship portrayed to friends, family, co-workers and the general public. Additionally, the experiences LGBTQ people experience in day-to-day life may introduce personal psychological issues that result in relationship problems. Mental stress related to abuse, alienation from family and friends, job discrimination, denial of essential services, and even exposure to medical conditions like HIV/AIDS create unique issues that get introduced to the relationship dynamic.

Relationship Facades

It was not uncommon for two men or women engaged in an intimate relationship to form a façade of being roommates when moving in with one another. They would set up two separate bedrooms to serve as an indicator to family and friends that they were in fact, just friends sharing a living space (Niolon, 2011). The fake family status created by gay and lesbian couples is only one detrimental aspect placing additional pressures on LGBT households. Societal acceptance of gay and lesbian people, in general, adds stress to the individuals in a relationship because he or she may experience issues of violence, prejudice, and discrimination in the workplace, or in obtaining essential services (Kessler, & Yalom, 1996).

Gay and lesbian individuals may also have problems stemming from their family of origin that carry over into their relationship (Sue, & Sue, 2016). He or she may have experienced abuse, both physical and psychological, or abandonment from parents and other family members (Kessler, & Yalom, 1996). Some LGBTQ men and women may not have experienced any of these issues at all. Individuals who came out to friends and family and received full acceptance will not have an understanding of a partner’s fears of being outed. Additionally, an individual employed in an environment that promotes equality may equally find it hard to understand why a partner in a more conservative work environment does not invite him or her to company parties or events in fear of being discovered (Kessler, & Yalom, 1996; Sue, & Sue, 2016).

Marriage Equality

Over the decades, LGBTQ people have received more recognition in society. Countries around the world have enacted laws protecting LGBTQ people from discrimination in the workplace, housing, and access to essential programs. Many nations have adopted laws recognizing same-sex unions, while others have made advancements in legalizing marriage equality. Although these improvements indicate a changing landscape for LGBTQ people, they do not suggest that societal acceptance is advancing in the same strides. While it may be legal for a gay or lesbian couple to marry, many may not because of issues related to acceptance of family or societal concerns. An excellent example of these matters in America is the growing movement to legally discriminate against LGBTQ couples based on a religious objection, also known as the First Amendment Defense Act (H.R. 2802, 114^th Cong., 2015).

Raising Children

Raising children is considered by society to be a marker of adulthood and a successful relationship. However, for the LGBTQ couple, this widely accepted marker of success poses unique problems. Studies evaluating the academic performance, cognitive and social development,  psychological health, and early substance abuse and sexual activity of children raised in same-sex households indicate no variation when compared to children raised in different-sex households (Crowl, Ahn, & Baker, 2008; Manning, Fettro, & Lamidi, 2014). In one study at the University of California-San Francisco, Gartrell, & Boss (2010) concluded that adolescent sons and daughters of lesbian parents rated higher in academic, social, and total competence, and lower in social problems, aggressive and externalizing problems, and rule-breaking than their age-matched peers.

Although these studies provide supporting evidence for the stability of children raised in same-sex households, they also offer indicators that children can be negatively affected by socioeconomic circumstances, lack of opportunity and support for same-sex parents (Crowl, Ahn, & Baker, 2008; Gartrell, & Boss, 2010). In addition to the stressors related to parenting, the lack of opportunity and support, and other socioeconomic issues, same-sex parents and their children also face problems related to discrimination in school administrations, teasing from peers, and alienation from specific social activities (Manning, Fettro, & Lamidi, 2014).

Extended Family Issues

The extended family of LGBTQ couples may pose additional stressors in the relationship. These problems could be related to alienation of one or both of the partners from their family of origin or from hiding the relationship from family and friends. Another factor for extended family issues is the circle of friends one or both of the partners may have. Because many LGBTQ couples are alienated or estranged from the family of origin, friends of one or both partners become surrogate family members in which they can share experiences like holidays and other relationship milestones. While friends do sometimes make acceptable surrogates for the family of origin, they are not without pitfalls.

Every couple is destined to contend with death in the extended family. As the couple matures, family members age and eventually die. With the introduction of HIV/AIDS in 1981. The LGBTQ community landscape changed. People were dying at wholesale rates (U.S. Department of Health & Human Services, n.d.). A friend someone saw at a party a couple of weeks previously was now dead. Although treatment had advanced and improved the lifecycles of those infected, the rate of death in the LGBTQ community remains high. For couples who are extended family consists of friends, the grief of loss may be more of a typical occurrence than those in close contact with their families of origin (Kessler, & Yalom, 1996).

HIV, Intimacy, and Relationships

One of the leading issues in relationships is intimacy. Couples experience a myriad of problems including loss of sexual desires, sexual dysfunction due to injury or other causes, and daily issues that restrict quality alone time for the couple. LGBTQ couples experience these same problems, however, many couples today face another challenge with intimacy. With the widespread epidemic of HIV in the LGBTQ community, it is not uncommon for one or both partners in a relationship to be HIV positive. Advancements in HIV treatments have enhanced and expanded the life expectancy of those infected with HIV, and studies indicate that more people with HIV are 50 years old and growing (Psaros, Barinas, Robbins, Bedoya, Safren, & Park, 2012).

Although medical advancements have improved the quality of life for HIV patients, difficulties arise in couples where one partner is HIV positive, and the other is not. The HIV negative partner may express concerns about accidentally forgetting to use protection in the heat-of-the-moment, or in some cases may express a desire to become HIV positive as to avoid having to be concerned about using protection. Both of these situations present emotional concerns for both partners because the HIV positive partner may be overly worried about his partner’s health, or may feel regret and distress that his partner may wish to contract HIV to remove a barrier between them (Rhodes, & Cusick, 2000). Additionally, the HIV negative partner may push harder on issues like creating wills and making funeral preparations earlier than other couples or attempting to increase the number of experiences the couple shares out of fear the HIV positive partner may die prematurely (AIDSmap, n.d.).

Roles and Role-Models

Roles and role-models for same-sex relationships present unique problems. Society places role expectations on people based on an archaic belief that women are nurturers and child bearers and men are hunters and protectors. This view instills into society a biased view of masculinity and femininity as it relates to gender orientation. Gay and lesbian children raised with these biased opinions may experience difficulties in their relationship. However, using these assumptions, therapists can understand, and help clients understand psychological feminity and masculinity roles within each other ( American Association for Marriage and Family Therapy, n.d.).

Consequently, society emphasizes the nuclear family concept. This outdated notion maintains that a proper family unit is most likely a white, opposite-sex couple with two children, a husband that works and provides for the family, and a stay-at-home mother responsible for maintaining the household and family. This ideal, to this day, dominates mainstream entertainment outlets and marketing channels, leaving same-sex couples little to model their family structure. Additionally, because same-sex relationships remained mostly hidden in society, many young same-sex partners lack not only societal but also personal role models (Kessler, 1996).

Therepeutic Implications

 Couples present to therapy for a wide variety of concerns that range from learning how to negotiate arguments to dealing with infidelity. The crucial function of the therapist, while varied by the dominant theory applied, is to be a facilitator to help the couple resolve dysfunction within the relationship. Although most people seek couples therapy to address dysfunction and improve the quality of their relationship, others may enter treatment to help end the relationship in an amicable manner (Gurman, 2008). No matter the presenting problem, the therapist is placed in a position that demands specific attributes. First, the couple may present a problem that reminds the therapist of his or her own experiences. In this situation, the therapist must be aware of counter-transference. While many therapists find it inappropriate to share personal experiences, others may find it beneficial to divulge just enough to help the couple understand that he or she is capable of relating to their problem (Gurman, 2008). Therapists may also become exposed to situations that conflict with personal values, which place implications of ethical interactions with the client if the therapist is not able to see past his or her own biases (Sue, & Sue, 2016).

Working with LGBTQ Couples

Most therapists will find that working with same-sex couples is similar, if not identical, to working with couples of the opposite sex. Many of the presenting issues will be the same, and the treatment paths will be the same. However, there are also issues that same-sex couples will encounter that differ from opposite-sex couples and others that are unique to same-sex couples. One of the problems related to working with same-sex couples is the bias related to studies of gay and lesbians in couples therapy. In a compelling article in the Journal of Family Therapy, Ussher (1991) argued that couples therapy, at the time, was widely unavailable due to a lack of referrals and that therapists were ill-equipped both psychologically and by lack of understanding the dynamics of same-sex couples to provide adequate treatment. Acknowledging this pitfall also provided compelling arguments “that established forms of intervention are effective with gay clients, provided that the specific needs and problems of the gay and lesbian community are addressed by the therapist” (Ussher, 1991 p.1).

Therapeutic Techniques

As referenced earlier, most standard therapeutic techniques used with opposite-sex couples will work equally as well with same-sex couples. The issues that a same-sex couple will present for treatment are most likely to be the same as those of any other couple, and the process of treating the presenting problem the same as well (Ussher, 1991). Accounting for issues considered unique to same-sex couples, the therapist may use Structural Couples Therapy or Cognitive Behavioral Couples Therapy, or a combination of these or other therapeutic models he or she is most comfortable with.

Structural Couples Therapy

Structural Couples Therapy (SCT) is a product of Structural Family Therapy developed by Salvador Minuchin. SCT focuses on systemic issues in a relationship based on the assumption that each member of the family plays a role in the family system and subsystem (Gurman, 2008). Using SCT, clinicians can assess the family system, subsystem[s], and external contexts that impact same-sex couples (DeDiego, 2016). For example, a gay couple preparing to start a family may experience difficulties based on the lack of traditional “mother and father roles.” Under SCT, the clinician addresses issues of hierarchy and power boundaries by refocusing family roles beyond the traditional gender roles (DeDiego, 2016).

Cognitive Behavioral Couples Therapy

Cognitive Behavioral Couples Therapy (CBCT) focuses on educating clients on the biological and psychological processes in the relationship, and how couple interactions become ineffective (Hubbard, 2016). Using this baseline, clinicians can work with couples to assess how their interactional patterns interfere with the relationship and provide opportunities to practice troubled areas like communication and challenge disruptive thoughts and behaviors that are causing relationship dysfunction (Gurman, 2008; Hubbard, 2016). CBCT can be helpful when working with LGBTQ couples where one partner’s low self-esteem or self-worth are causing dysfunction in the relationship by enhancing the couple’s ability to communicate more efficiently while challenging the feelings of the individual. For example, a couple presenting about constant arguments in the household. During the assessment, the clinician discovers that one partner has low self-esteem because his family of origin degraded him and eventually alienated him for coming out. Using CBCT, the clinician can address the communication problems while at the same time, challenging the feelings of low self-esteem of the partner.  This process not only helps the individual begin to change how he sees himself but also helps the other partner understand how these feelings can cause problems.

Conclusion

Clinicians working with couples are sure to experience a myriad of issues that are as unique as each couple, as well as presenting problems that share a commonality. No matter how many clients a clinician has worked with, knowing exactly how to contend with the next client has an air of uncertainty. Although traditional opposite-sex couples share some commonalities, this is never something that can be assumed. Besides the conventional nuclear family couple, some couples do not fit this mold, and who present issues that may be outside the usual box. Same-sex couples for example not only share the standard problems like any other couple, but also experiences that add a new layer of complications to a relationship. For clinicians to work efficiently with same-sex couples, he or she needs to be aware of not only personal biases that could interfere with the clinician-cleint relationship but also aware of the unique issues that LGBTQ peope experience in life and bring into the relationship.

References

AIDSmap. (n.d.). HIV & sex - Relationships with an HIV-negative partner. Retrieved October 10, 2017, from http://www.aidsmap.com/Relationships-with-an-HIV-negative-partner/page/1637216/

American Association for Marriage and Family Therapy. (n.d.). Therapeutic Issues for Same-sex Couples. Retrieved October 10, 2017, from https://www.aamft.org/iMIS15/AAMFT/Content/Consumer_Updates/Therapeutic_Issues_for_Same-sex_Couples.aspx

Crowl, A., Ahn, S., & Baker, J. (2008). A Meta-Analysis of Developmental Outcomes for Children of Same-Sex and Heterosexual Parents. Journal of GLBT Family Studies,4(3), 385-407. doi:10.1080/15504280802177615

DeDiego, A. C. (2016, September 28). A systemic perspective for working with same-sex parents. Retrieved October 10, 2017, from https://ct.counseling.org/2016/09/systemic-perspective-working-sex-parents/

Garanzini, S., Yee, A., Gottman, J., Gottman, J., Cole, C., Preciado, M., & Jascula, C. (2017). Results of Gottman Method Couples Therapy with Gay and Lesbian Couples. Journal of Marital and Family Therapy,43(4), 674-684. doi:10.1111/jmft.12276

Gartrell, N., & Boss, H. (2010). US National Longitudinal Lesbian Family Study: Psychological Adjustment of 17-Year-Old Adolescents. Pediatrics,126(1), 28-36. Retrieved October 10, 2017, from http://pediatrics.aappublications.org/content/126/1/28

Gurman, A. S. (2008). Clinical handbook of couple therapy(4th ed.). New York: Guilford Press.

Hubbard, B. (2016). CBT for Couples Marital Therapy. Retrieved October 12, 2017, from http://cognitive-behavior-therapy.com/relationship-couples-marital-therapy/

KESSLER, H., & YALOM, I. D. (1996). Treating couples. San Francisco: Jossey-Bass.

Manning, W. D., Fettro, M. N., & Lamidi, E. (2014). Child Well-Being in Same-Sex Parent Families: Review of Research Prepared for American Sociological Association Amicus Brief. Population Research and Policy Review,33(4), 485-502. doi:10.1007/s11113-014-9329-6

Niolon, R. (2011, August 02). Issues for Same-Sex Couples | PsychPage. Retrieved October 10, 2017, from http://www.psychpage.com/family/library/gay-lesbian.html

Psaros, C., Barinas, J., Robbins, G. K., Bedoya, C. A., Safren, S. A., & Park, E. R. (2012). Intimacy and Sexual Decision Making: Exploring the Perspective of HIV Positive Women Over 50. AIDS Patient Care STDS,26(12), 755-760. doi:10.1089/apc.2012.0256

H.R. 2802, 114th Cong., Www.congress.gov (2015) (enacted).

Rhodes, T., & Cusick, L. (2000). Love and intimacy in relationship risk management: HIV positive people and their sexual partners. Sociology of Health & Illness,22(1), 1-26. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/1467-9566.00189/pdf

Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: theory and practice(7th ed.). Hoboken, NJ: John Wiley & Sons, Inc.

U.S. Department of Health & Human Services. (n.d.). A Timeline of HIV and AIDS. Retrieved October 10, 2017, from https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline

Ussher, J. M. (1991). Family and couples therapy with gay and lesbian clients: acknowledging the forgotten minority. Journal of Family Therapy,13(2), 131-148. Retrieved from http://onlinelibrary.wiley.com/doi/10.1046/j..1991.00418.x/pdf

Life Cycle Development

Life Cycle Stages: The Human Path

John R. Stafford

Brandman University

Abstract

Life cycle stages are a concept used by researchers and clinicians to delineate the different phases of the human lifespan. By breaking up the lifespan into separate steps, we can explore and identify specific markers of each level that influences an individual’s growth and development. In turn, this exploration and understanding aids researchers in understanding human interactions and coping mechanisms on a larger scale of family and societal interactions.

Keywords:  Human Development, Life Cycle, Infancy, Childhood, Adolescence, Adulthood

Life Cycle Stages: The Human Path

The human lifespan matures over several phases, simplified as early childhood, adolescence, adulthood, and old age. Each of these steps has key milestones and markers that influence how an individual perceives events and interactions with others, how he or she will react when faced with difficult choices and life events, and how he or she will carry on societal, cultural and familial rituals. Understanding how an individual develops unlocks the greater understanding of how personal experiences shape the overall functioning of the individual, the family, and wider societal functions (Mintz, Moores, & Moores, n.d.).

Childhood Stages

Early and middle childhood is a bonding and learning stage. It is a time where a child is wholly reliant on parental interaction for survival and nurturing. It is a stage in life where the individual is not entirely self-aware, or capable of performing basic tasks taken for granted in later stages of life. Eating, using a restroom, walking, and talking are all simple tasks that are new to babies in the formative years, and becomes easier as he or she learns through various methods of trial, error, and learning. It is also a time in a child’s life where nutrition and proper care are critical aspects of development (Johnson, 1990). Children in the preschool ages one to five years of age experience significant postnatal neurologic and cognitive development (Rosales, Reznick, & Zeisel, 2009). Poor nutrition before and during birth can contribute to the various health and developmental issues like childhood obesity (Zwiauer, 2003), and cognitive development (Rosales, Reznick, & Zeisel, 2009). As children age, nutrition remains a major factor in higher development functions related to verbal ability, cognitive capacity, and physical strength (Rosales, Reznick, & Zeisel, 2009).

Nutrition, while directly linked to developmental aspects of children’s lives is also attributed to the cultural and economic history of the family. For example, poorer children in school may have to rely on lunch programs for nourishment, whereas children from upper-middle-class families may bring lunch provided by a parent, or afford to buy lunch from the school cafeteria (McGodlrick, Carters, & Garcia-Preto, 2013). Additionally, cultural influences may place restrictions on dietary intake a child can have. Some cultures restrict consumption of certain foods like pork or beef or promote a higher intake of vegetables and fruits that make eating from the school cafeteria more difficult (Rosales, Reznick, & Zeisel, 2009).

Childhood is also a time where children begin to develop an identity both of self and within their surroundings. The process varies depending on cultural and societal differences and can start as early as infancy. Gillespie, & Petersen (2012) assert that rituals are events that signify particular actions associated with emotionally significant events or transitions that deepen connections and relationships. Some cultures like that of Jewish, Christian, and many others start at infancy by performing rituals like baptism, circumcision, and christenings (McGoldrick, Carter, & Garcia-Preto, 2013), and in later years by starting preschool and transitioning to elementary school (Gillespie, & Petersen, 2012). Parents, family, and friends also take a more passive role in identity development by the choices in colors, toys, and clothing provided to the child in the earliest stages.

Developing habits in early childhood is beneficial because they provide a constant and predictable set of events that provide stability to both the parent and the child (Gillespie, & Petersen, 2012; McGoldrick, Carter, & Garcia-Preto, 2013). As the child ages, eating patterns, playtime, and bedtime aid the child to develop skills associated with self-regulation by providing a routine associated with these events (Gillespi, & Petersen, 2012). Although this process may vary based on individual needs, the familiar pattern of consistent events provides children with a stable framework or normality, which will benefit the child as he or she starts school and engaging in other social interactions (Gillespi, & Peteresen, 2012).

Another aspect of identity is one of gender. Although gender identity meets with heated emotion from religious and cultural beliefs, research on sex differentiation is both long-standing and ongoing. Martin, Ruble, & Szkrybalo (2002) state that “observations of gender typing in children as young as 5-years old led researchers to examine how socialization process in the home might contribute to this early acquisition of gender-linked behavior” (p.1). Process inside the home are not the only factors in gender differentiation. Social justice issues and other external influences inside the preschool environment also affects children’s choices of exploration, who they play with, and how they may identify themselves (Solomon, n.d.) It is fair to note that gender differentiation and sexual attraction or preference are not the same.

A stable family life is integral to childhood development. While some argue that the “nuclear family” model is the most healthy environment for infants and young children, research is emerging that indicates that children raised in alternative family situations experience similar psychological and physical growth (McGodlrick, Carter, & Garcia-Preto, 2013). Family structure, stability, and a nurturing environment are the most important aspects of childhood development. A child raised in a low-income household with an alcoholic parent who abuses his wife or children is less likely to be as outgoing, accepting, and psychologically balanced as a child raised in a middle-class household with a loving and supportive single parent (McGoldrick, Carter, & Garcia-Preto, 2013). Children raised in volatile environments tend to be more withdrawn and have more problematic behaviors than those raised in stable environments.

Adolescence Stages

Another significant period of development is adolescence. It is a transitional time between childhood and adulthood where a young boy or girl begins to experience cognitive, psychosocial, and physical changes associated with rituals and different levels of social responsibility and interactions (Morelli, & Zupanick, n.d.). A child who is entering adolescence begins a period of emotional turmoil resulting from chemical changes in the neurological system. It is also a time where familial conflicts arise between the child and parents, grandparents, and siblings as he or she seeks more independence and autonomy in their lives (Morelli, & Zupanick, n.d; McGoldrick, Carter, & Garcia-Preto, 2013). However, in other cultures adolescence may be an overlooked lifecycle stage because children become adults earlier in life, and enter the workforce to help support the family of origin, and even start families of their own (McGoldrick, Carter, & Garcia-Preto, 2013).

Adolescence is also a time where experiences and confusion associated with gender identity and sexual attraction surface. Gender identity relates to the gender a person identifies as (Science Daily, 2015), whereas sexual attraction or preference refers to the impulses and emotions associated with being attracted to someone else sexually (Fugère, 2016). These issues can often be associated with extreme behavioral problems like depression and anxiety because the person does not know how family and friends will react to his or her feelings or self-image. For example, a child raised in a nuclear family structure based heavily on religion may have higher levels of anxiety about being Gay, Lesbian or Transgender than his or her counterparts raised in an agnostic household more accepting in nature (McGoldrick, Carter, & Garcia-Preto, 2013).

While evident in elementary school, social status becomes more prevalent in adolescence. It is a time where adolescents seek approval from peers and struggle to find acceptance with older teens in their environment (Morelli, & Zupanick, n.d.). In some cases, acceptance of peers is a substitute for parental guidance and acceptance in the home that can lead teens to destructive patterns of drinking, drug use, and delinquent affiliations that may require intervention or treatment (Brodie, 2009). While acceptance is one factor in delinquency in teens, other factors include economic stability, parental guidance, and abuse. “In 2014, 1.1% of all persons age 12 or older (3 million persons) experienced at least one violent victimization” (Bureau of Justice Statistics, n.d., p1). Further estimates indicate that between 2009 – 2013 Child Protective Services agencies reported 63,000 sexual abuse claims that held substantial evidence. Of those, one in nine girls and one in 53 boys under the age of 18 experienced sexual (National Family Safety Program, NGHA, n.d.) abuse or assault by an adult (RAINN, 2016).

Teens raised in lower socioeconomic and culturally different families also have certain disadvantages than their upper-class and middle-class peers (McGoldrick, Carter, & Garcia-Preto, 2013). These problems include education and access to contraceptives (Brown, & Eisenberg, 1995), lowered self-esteem (Veselska, Geckova, Gajosova, Orosova, Dijik, & Reijneveld, 2009), health issues, education, and family well-being (American Psychological Association, n.d.). Although socioeconomic and cultural differences vary, it is important to take note of the variations. Self-esteem problems appear more in poor Black families than in upper or middle-class White households (Valeska, et al., 2009), and teenage pregnancy and education is higher in Hispanic and Black families than their Asian or Jewish counterparts (McGoldrick, Carter, & Garcia-Preto, 2013).

Sex education and teen pregnancy are one of the most critical issues facing teens.  A 2015 survey performed by the Centers For Disease Control and Prevention indicates that 41% of students in America have not had sexual intercourse, while 30% had sexual intercourse within a 3-month period. Of that 43 % did not use a condom, 14% did not use any form of birth control, and 21% were under the influence of alcohol or drugs at the time of intercourse (Centers for Disease Control and Prevention, 2017). Furthermore, the same survey indicated that only 10% of those students received testing for HIV. A report released by the U.S. Department of Health & Human Services shows that in 2014 teen birth rates dropped from 26.5 in 2013 to 24.2 in 2014 and that nearly 89% of those occurred outside of marriage (U.S. Department of Health & Human Services, 2016). While this is a sharp decline, the implications of these numbers correlate with unwed mothers (and fathers) dropping out of school to raise children, and additional stressors on already taxed family infrastructures to assist in rearing babies of teen mothers (McGodlrick, Carter, & Garcia-Preto, 2013).

Adulthood Stages

Reaching adulthood is a milestone in the human lifecycle often accompanied with rituals associated with rituals associated with graduation, starting a family, and elevation in social status. It is a time where young adults begin implementing plans for the future. Whether this is moving away from the family of origin to begin college, start a family of their own, or starting a job and moving into a place of their own (McGoldrick, Carter, & Garcia-Preto, 2013). However, these immediate plans do not always come to fruition. In some cases, leaving home is not a viable option for young adults. He or she might stay home to assist with taking care of siblings, and older family member (McGoldrick, Carter, & Garcia-Preto, 2013), financial difficulties (Goldsheider, Hofferth, & Curtain, 2014), or single parenthood requiring childcare assistance from older family members.

In lower-income and minority families, it may be more common for young adults to stay home out of family-first loyalty. This type of behavior is more common in Hispanic, Black, and Italian families than their White or Jewish counterparts (McGoldrick, Carter, & Garcia-Preto, 2013). Carter (2012) asserts that 40% of young adults are less likely to move to a new state and the percentage of young adults in their 20’s living at home doubled between 1980 and 2008. Although staying at home may produce benefits, there are also deficits in the adjustment of the family of origin. Issues like living as adjusting household rules to accommodate both the family and young adult can cause turmoil resulting in arguments (McGoldrick, Carter, & Garcia-Preto, 2013), defining household responsibilities, and reducing the financial burden on the parents (Carter, 2012).

Under the nuclear family model, there is an expectation that young adults have established a family and life away from the family of origin before reaching middle adulthood. However, changes in modern culture have demonstrated that the nuclear model is antiquated (McGoldrick, Carter, & Garcia-Preto, 2013). Women are placing more emphasis independence by attending college or establishing a career before starting a family, or becoming single mothers before getting married (McGoldrick, Carter, & Garcia-Preto, 2013). Additionally, the rise of alternative-lifestyle families is changing the landscape and meaning of the nuclear family. LGBTQ families and single-parent families are becoming more common. While these new family structures rise, there are complications of establishing equality and recognition in society (Elizur, & Ziv, 2001). Additionally, increase in divorce rates factor heavily in newer family models. Commonly, divorce results in single mothers raising children, which may place unusually high financial difficulties on the household. These challenges may require the single mother to seek outside assistance programs, or ask for help from family members for childcare or living arrangements (McGoldrick, Carter, & Garcia-Preto, 2013).

The transition from young adulthood to mid-adulthood, traditionally marked by milestones of having established family, career, and home. It also marks a point in life where the family of origin has adjusted to the extended family and transitioned relationships with children to that of friendship and peers (McGoldrick, Carter, & Garcia-Preto, 2013). Mid-adulthood is also a period where individuals and families begin to consolidate careers and concerns about establishing and guiding younger generations take a higher priority. It is common for people in mid-adulthood to refocus efforts on family unity and interaction with ongoing commitment, and preserve and pass down cultural values to younger generations (Malone, Liu, Vaillant, Rentz, & Waldinger, 2016). This period also involves preparation for family concerns for older-generational needs. In many cases, older generations are entering retirement, experiencing health issues, and dying, which places additional stressors on the family (McGoldrick, Carter, & Garcia-Preto, 2013).

Old Age Stages

Transitioning to old age is a period referred to as the wisdom stage (McGoldrick, Carter, & Garcia-preto, 2013). This shift adds additional stressors related to health problems, retirement, and eventual death. For many people reaching old age, retirement is not as feasible as for others. Adults from poorer classes often find that they are required to work longer; sometimes up to a point where they can no longer work due to illness (McGoldrick, Carter, & Garcia-Preto, 2013). This realization often results in some form of destructive behaviors like increased drinking, smoking, and drug use (Hagger-Johnson, Carr, Murray, Stansfeld, Shelton, & Head, 2017). The combination of stressors and behavioral dysfunction also leads to mental disorders like depression and anxiety, which are prominent in people of older ages (Seeley, Manitsas, & Gau, 2016). However, retirement is not the only factor in addressing mental dysfunction in elderly adults. Loss of mental capacity, physical problems resulting in the need for increased care (Seeley, Manitsas, & Gau, 2016), and loss of loved ones are determining factors researchers need to address (McGodlrick, Carter, & Garcia-Preto, 2013).

            

Adults not experiencing problems of old age are likely to find satisfaction in their golden years. Many make plans to retire and move to a new location, buy a motorhome and begin a more transient lifestyle, travel globally, or foster deeper relations with younger family members (Grish, 2011). Older adults may find that by shedding the responsibilities of middle age provides them the ability to spend more time for increased intimate relationships with their partners (Stein, 2017). Others may focus on activities they were not able to do in their younger years like skydiving or scuba diving, buying a motorcycle, or other adrenalin raising activities (Woodhead, Blackett, & Hollaender, 2013). Additionally, many older adults enjoy the rewards associated with being the elders of the family and societal structures (McGoldrick, Carter, & Garcia-Preto, 2013). They invest time in sharing the history of cultural and societal value to younger generations, spending time with, and even assisting in limited parental interactions like summer camping trips with grandchildren. Many decisions made by and for older adults relies on cultural history. Asian and Hispanic cultures are more likely to include elderly family members in the same residence as younger family members while many European cultures favor independence (McGoldrick, Carter, & Garcia-Preto, 2013).

Conclusion

The lifecycle development process is one filled with many experiences. As individuals, people experience similar aspects of growth and development from birth to death. Although life experiences share similarities, they are unique in many ways. Children are taught to explore, grown, and develop physically and mentally, but cultural, societal, and economic differences result in variations that make their progression through the lifecycle a single path leading to differences that shape individual outcomes. The only assurance people have is that death is the inevitable end to the journey. Hence it is the responsibility for all to pass down their experiences and knowledge so that younger generations will learn cultural and societal history, and build upon that knowledge to create a new and exciting future for the generations that follow.

References

American Psychological Association. (n.d.). Children, Youth, Families and Socioeconomic Status. Retrieved June 15, 2017, from http://www.apa.org/pi/ses/resources/publications/children-families.aspx

Brodie, B. R. (2009). Adolescence and Delinquency: An Object Relations Theory Approach (Book Review). Retrieved June 15, 2017, from http://www.apadivisions.org/division-39/publications/reviews/delinquency.aspx

Brown, S. S., & Eisenberg, L. (1995). The best intentions: unintended pregnancy and the well-being of children and families. Washington, D.C.: National Academy Press.

Bureau of Justice Statistics. (n.d.). Criminal Victimization, 2014. Retrieved June 15, 2017, from https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5366

Carter, C. (2012, April 10). The Stuck-at-Home Generation. Retrieved June 16, 2017, from https://www.psychologytoday.com/blog/raising-happiness/201204/the-stuck-home-generation

Centers for Disease Control and Prevention. (2017). Adolescent and School Health. Retrieved June 15, 2017, from https://www.cdc.gov/healthyyouth/sexualbehaviors/

Children and Teems: Statistics. (n.d.). Retrieved June 15, 2017, from https://www.rainn.org/statistics/children-and-teens

Elizur, Y., & Ziv, M. (2001). Family support and acceptance, gay male identity formation, and psychological adjustment: A path model. Family Process, 40(2), 125-144. Retrieved June 16, 2017, from http://eds.b.ebscohost.com.libproxy.chapman.edu/eds/detail/detail?vid=1&sid=946a3903-046e-408b-8b5e-33b16ed3f707%40sessionmgr101&hid=119&bdata=JkF1dGhUeXBlPWlwLHVpZCZzaXRlPWVkcy1saXZl#AN=000169566100001&db=edswss

Fugère, M. A. (2016). 3 Shocking Truths About Sexual Attraction. Retrieved June 15, 2017, from https://www.psychologytoday.com/blog/dating-and-mating/201603/3-shocking-truths-about-sexual-attraction

Gillespie, L., & Petersen, S. (2012). Rituals and Routines: Supporting Infants and Toddlers and Their Families. Young Children, 76-77. Retrieved from https://www.naeyc.org/yc/files/yc/file/201209/Rock-n-Roll_YC0912.pdf.

Goldscheider, F. K., Hofferth, S. L., & Curtin, S. C. (2014). Parenthood and Leaving Home in Young Adulthood. Population Research and Policy Review, 33(6), 771-796. doi:10.1007/s11113-014-9334-9

Grish, K. (2011). Coming of age: getting older isn't about fighting time, but enjoying it. In honor of Natural Health's 40th Anniversary, we've collected 40 of the most surprising and inspiring tips on how to live a longer, healthier life. Who says aging has to get old? Natural Health, 5(56). Retrieved from http://eds.a.ebscohost.com.libproxy.chapman.edu/eds/detail/detail?sid=061019f6-baf0-4dcb-bd3c-b7693c90b3bb%40sessionmgr4009&vid=2&hid=4108&bdata=JkF1dGhUeXBlPWlwLHVpZCZzaXRlPWVkcy1saXZl#AN=edsgcl.256364817&db=edsggr

Hagger-Johnson, G., Carr, E., Murray, E., Stansfeld, S., Shelton, N., Stafford, M., & Head, J. (2017). Association between midlife health behaviours and transitions out of employment from midlife to early old age: Whitehall II cohort study. BMC Public Health, 17(1). doi:10.1186/s12889-016-3970-4

Johnson, G. D. (1990). A Multidimensional Theory of Early Modern Western Childhood. Journal of Comparative Family Studies, 21(1), 1-11. Retrieved from http://eds.a.ebscohost.com.libproxy.chapman.edu/eds/detail/detail?sid=a30789bf-80ca-4fb6-882d-74346acf90dd%40sessionmgr4006&vid=0&hid=4202&bdata=JkF1dGhUeXBlPWlwLHVpZCZzaXRlPWVkcy1saXZl#AN=edsjsr.41602046&db=edsjsr

Malone, J. C., Liu, S. R., Vaillant, G. E., Rentz, D. M., & Waldinger, R. J. (2016). Midlife Eriksonian psychosocial development: Setting the stage for late-life cognitive and emotional health. Developmental Psychology, 52(3), 496-508. doi:10.1037/a0039875

Martin, C. L., Ruble, D. N., & Szkrybalo, J. (2002). Cognitive theories of early gender development. Psychological Bulletin, 128(6), 903-933. doi:10.1037//0033-2909.128.6.903

McGoldrick, M., Carter, E. A., & Garcia-Preto, N. (2013). The expanded family life cycle: individual, family, and social perspectives (Fourth ed.). Upper Saddle River, NJ: Pearson Education.

Mintz, S., Moores, J., & Moores, R. (n.d.). Life Stages. Retrieved June 15, 2017, from www.usu.edu/anthro/childhoodconference/Reading%20Material/life_stages.doc

Morelli, A. O., & Zupanick, C. E. (n.d.). An Introduction to Adolescent Development. Retrieved June 15, 2017, from http://www.mhmrcv.org/poc/view_doc.php?type=doc&id=41149&cn=1310

National Family Safety Program, NGHA. (2014). Retrieved June 15, 2017, from http://www.slideserve.com/valmai/national-family-safety-program-ngha-january-28-th-and-29-th-2013-presentation-3-step-1-of-the-public-health-approach-to-child-maltreatment-prevention

Networks of the brain reflect the individual gender identity. (2015). Retrieved June 15, 2017, from http://www.sciencedaily.com/releases/2015/01/150107082133.htm

Rosales, F. J., Reznick, J. S., & Zeisel, S. H. (2009). Understanding the role of nutrition in the brain and behavioral development of toddlers and preschool children: identifying and addressing methodological barriers. Nutritional Neuroscience, 12(5), 190-202. doi:10.1179/147683009x423454

Seeley, J. R., Manitsas, T., & Gau, J. M. (2016). Feasibility study of a peer-facilitated low intensity cognitive-behavioral intervention for mild to moderate depression and anxiety in older adults. Aging & Mental Health, 21(9), 968-974. doi:10.1080/13607863.2016.1186152

Solomon, J. (n.d.). Gender Identity and Expression in the Early Childhood Classroom: Influences on Development Within Sociocultural Contexts. Voices of Practitioners, 11(1). Retrieved June 15, 2017, from http://www.naeyc.org/publications/vop/gender-identity-and-expression

Stein, M. L. (2017, January 20). HealthDay. Retrieved June 16, 2017, from https://consumer.healthday.com/encyclopedia/aging-1/misc-aging-news-10/sex-and-seniors-the-70-year-itch-647575.html

U.S. Department of Health and Human Services. (2016). Trends in Teen Pregnancy and Childbearing. Retrieved June 15, 2017, from https://www.hhs.gov/ash/oah/adolescent-development/reproductive-health-and-teen-pregnancy/teen-pregnancy-and-childbearing/trends/index.html

Veselska, Z., Geckova, A. M., Gajdosova, B., Orosova, O., Dijk, J. P., & Reijneveld, S. A. (2009). Socio-economic differences in self-esteem of adolescents influenced by personality, mental health and social support. The European Journal of Public Health, 20(6), 647-652. doi:10.1093/eurpub/ckp210

Woodhead, A. D., Blackett, A. D., & Hollaender, A. (2013). Molecular biology of aging. Place of publication not identified: Springer-Verlag New York.

Zwiauer, K. (2003). Nutritive factors influencing the development of childhood obesity and possible preventive approaches. Montasschrift Kindereilkunde, 151, 88th ser., 84-88. Retrieved June 15, 2017, from http://eds.a.ebscohost.com.libproxy.chapman.edu/eds/command/detail?vid=7&sid=0fc1a4b0-12cb-4f2c-96c4-e52bffabeb70%40sessionmgr4006&hid=4202&bdata=JkF1dGhUeXBlPWlwLHVpZCZzaXRlPWVkcy1saXZl#AN=000186520900017&db=edswsc

Childhood and Adolescent Depression

Childhood and Adolescent Depression

John R. Stafford

Brandman University

Abstract

Depression affects individuals for a variety of reasons and manifests in both physical and mental dysfunction that impacts the daily lives of adults and children, sometimes with debilitating results. Although age is not a major factor in determining depression, there is evidence that certain age and gender groups are more likely to suffer the dysfunction. Individual personality, moods, societal influences, and biological aspects aid in determining how and individual will react to various triggers and symptoms.

Keywords:  Depression, Childhood Depression, Depression in Adolescents

Childhood and Adolescent Depression

Clinicians and researchers continue to pursue studies on how depression affects adults and children, often in the same household. Rapid changes in societal influences and variations in the home environment are both fundamental aspects of how parents and their children develop depression (England, et al., 2009). Although numerous studies indicate a genetic and biological influence, environmental factors also affect how adults and children perceive their inner-self and how they will react in stressful situations (England, et al., 2009). John Bowlby (1907-1990), a well-known British psychologist studied the interactions between biology and environmental effects on childhood depression and asserted that a well-adjusted child requires affection, guidance, and a feeling of equality and independence.

Cytryn (2003) states “Prior to 1970, childhood depression was not considered a valid clinical entity by American psychiatrists” (p.1). Before formal recognition, depressive symptoms observed in pre-adolescents and children suffering from chronic illness, or another recognized dysfunctions was associated with the perceived dominant physical or mental condition (Crytyn, 2003). One problem with the history of depression in children and young adults, especially those diagnosed with major depressive disorder is the timeframe of the original diagnosis. Around the 1980s child abuse started to become a major area of concern, both in the medical and psychological fields, but also in the general public. Many children and young adults diagnosed with depressive disorders during this time, may have been diagnosed without a complete understanding of the underlying causations of the dysfunction; abuse or sexual assault in particular (Hynes, & McCune, 2002).

Other factors in children diagnosed during this time were other conditions that are now fully
recognized, and treatments that were used in part to treat young patients. During this time, ADHD and hyperkinetic disorder was not fully accepted or diagnosed, which most likely resulted in many young patients receiving incomplete or inaccurate diagnosis and treatment  (Hynes, & McCune, 2002). Furthermore, antidepressants prescribed to young patients suffering from depression at the time was omitted for young patients displaying comorbid conduct disorder over concerns that the patient may overdose on the medication (Hynes, & McCune, 2002).

Human Development1

An important aspect of a person’s mental well-being is how he or she develops. Childhood development is a consideration in how well adjusted a person will be as an adult. Children raised in loving, supportive and emotionally stable environments are usually able to adapt to situations easier (Conway, Rancourt, Adelman, Burk, & Prinstein, 2011). In contrast, children raised in less stable, abusive, or emotionally unsupportive environments are prone to suffer higher levels of difficulty adjusting to conditions in adolescence and adulthood. Depression is just one of adverse outcome for people raised in environments in which alcoholism, mental and physical abuse and neglect are prominent. Experiences like a loss in childhood, the death of a family member, a personal tragedy like sexual assault, and other mental or physical traumas also serve as triggers for depressive episodes.

Socialization.

The study of social influence on depression helps clinicians understand how social forces affect people suffering from depression. Considering depression is one of the most common diagnoses in the Untied States, it is fair to note that many previous studies were focused more on adults than young children or adolescents (Conway, et al., 2011). Established models of cognitive-interpersonal influences continue to produce research data emphasizing the understanding of developmental variances and social processes related to depressive episodes and various methods used in treatment and maintenance (Conway, et al., 2011). Data gathered from ongoing research indicates that the transition from childhood to adolescence presents a concern of vulnerability to contexts of depression; noted as being more prevalent in girls than boys. Naturalistic clinicians continue to examine the depression socialization hypothesis to shed more light on the integrational transmission of depression and the temporal association between mothers and children with depression (Conway, et al., 2011).

Previous research primarily focused on how socialization affected adults suffering from depression. However, newer studies are emphasizing the importance of socialization in adolescents and young children diagnosed with depression (Conway, et al. 2011). The study conducted by Conway, Rancourt, Adelman, Burk, and Prinstein was carried out to examine and identify the connection of an individual’s depression to specific friendship groups, and average levels of depressive symptoms within the group. This study asserted that the mean levels of depression socialization effects in a peer group as a predictor of an individual’s depression symptoms over time (Conway, et al., 2011). The study found that peer influence and the child’s unique position in a social group might affect the degree of socialization induces depression. The study also indicated that adolescents with fewer friends or social circles had a higher risk of developing depression (Conway, et al., 2011).

Risk Factors.

Recognizing the risk factors for depression in children and adolescents is imperative when trying to assess and treat the problem. Some recognizable risk factors include poor peer relationships, difficulty in coping with situations, a history of depression in another family members, conflicts in the home, and negative thoughts or behaviors (Clark, Jansen, & Cloy, 2012). Some figures indicate that approximately 2.8 percent of children under the age of 13 and 5.6 percent of teenagers suffer from some form of depression, and about 60 percent will have recurring symptoms during adulthood (Clark, Jensen, & Cloy, 2012). Furthermore, adults who suffered depression during childhood or adolescent years are more prone to have suicidal ideations than adults that did not suffer from depressive symptoms (Clark, Jensen, & Cloy, 2012).

Diagnosing, Treating, and Red Flags

Diagnosing, identifying red flags, and providing proper treatment is essential in addressing depression. Left untreated, the symptoms of depression become more severe, which can lead to extreme situations of withdrawal, declining social activities, educational detriment, and even suicidal ideation. Parents, teachers, and other adults that interact with children or adolescents need to be aware of particular behaviors and temperament changes potentially associated with depression and address their concerns accordingly.

Diagnosing

A primary issue of diagnosing children and young people with depression is the determination of the classification of depression the patient is suffering. Initial observations from parents, teachers, or other adults may not be sufficient because these individuals lack the proper training and understanding of the investigative techniques clinicians use to make appropriate assessments. The information provided by those who observe the behaviors is valuable to a clinician will provide a solid starting point.

The criteria for diagnosing depression begin with a detailed exploration of risk factors, family history, and gaining an understanding of the potential causations. This explorative process will aid in determining the level of severity, and identification of the proper DSM classification of depression that patient is experiencing. Persistent Depressive Disorder was chosen as the example for this paper and associated vignette. The criteria for Persistent Depressive Disorder include notable depression or irritability lasting the majority of the day (American Psychiatric Association, 2013). These symptoms must be recurring for the majority of the time for a period no less than one-year. The patient must also display at least two other symptoms like poor appetite or overeating, insomnia or hypersomnia, a lack of energy or low self-esteem, difficulties in concentration or decision making, and feelings of hopelessness (American Psychiatric Association, 2013).

Treating

There are various methods used to treat patients with depression. However, the classification of depression the patient is suffering is a major factor in making the proper treatment plan (Castro, & Garthright, 2013). A treatment plan for patients with symptoms of mild depression is not appropriate for a patient suffering from a major depressive disorder. Estimates indicate that approximately 70 to 80 percent of children suffering from depression will experience positive results with proper treatment (Clark, Jansen, & Cloy, 2013).  Effective treatment methods include Interpersonal Therapy [IPT] and Cognitive Behavioral Therapy [CBT]. Other methods include pharmacotherapy using SSRI’s to enhance positive results. A combination of Cognitive Behavioral Therapy and Pharmacotherapy treatments usually lead to higher efficacy of long-term treatment plans (Clark, Jansen, & Cloy, 2013).

Red Flags

Red flags are also warning signs of the severity of depression a person is experiencing. People suffering mild depressive states are likely to display more clement symptoms that may not be immediately recognized as red flags, whereas an individual suffering from severe depressive states is apter so show recognizable critical behaviors (Clark, Jansen, & Cloy, 2012). Some key red flags to take note of are parental loss or separation, suicidal ideation, biological factors, and cognitive distortions. Other risk factors associated with family, environment, or societal like the history of depression in other family members, discord in the household, childhood neglect or abuse, bullying from peers, drug or alcohol abuse (Clark, Jensen, & Cloy, 2012).

Conclusion

There is no magical solution to treating depression. Multiple classifications, treatment options, and individual factors of the patient inject complications for any clinician. However, proper exploration of the patient’s history, family situations, and social interactions all serve as fundamental aspects of determining the severity and classification for assessment and treatment of the patient. Using proper treatment methods enhances the patient’s ability to overcome many, if not all, of their symptoms and resume and healthy lifestyle. However, left untreated the patient is at higher risk of developing worsening symptoms and recurring depressive episodes later in life.

References

Diagnostic and statistical manual of mental disorders (5th Ed). (2013). Washington DC: American Psychiatric Association.

Castro, J., & Garthright, M. M. (2013). Depression in Children and Adolescents (pp. 1-28, Working Paper No. 4600016732). The University of Arkansas For Medical Sciences. doi:https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwiTvLqqhqXTAhVByVQKHTuYAfkQFggxMAE&url=http%3A%2F%2Fpsychiatry.uams.edu%2Ffiles%2F2009%2F07%2Fdepress.docx&usg=AFQjCNFWdM0ff3g4-8IPTSpgpfm2oL-aoA&sig2=yity6qpEQnKw0oIBhmswsQ&bvm=bv.152479541,d.cGw

Clark, M. S., Jansen, K. L., & Cloy, J. (2012). Treatment of Childhood and Adolescent Depression. American Family Physician,86(5), 442-448. Retrieved from http://www.aafp.org/afp/2012/0901/p442.html

Conway, C. C., Rancourt, D., Adelman, C. B., Burk, W. J., & Prinstein, M. J. (2011). Depression socialization within friendship groups at the transition to adolescence: The roles of gender and group centrality as moderators of peer influence. Journal of Abnormal Psychology,120(4), 857-867. doi:10.1037/a0024779

Cytryn, L. (2003). Recognition of childhood depression. Journal of Affective Disorders,77(1), 1-9. doi:10.1016/s0165-0327(03)00048-x

England, M. J., Aguilar-Gaxiola, S., Barnard, K. E., Beardslee, W. R., Cabral, H. J., Finley, P. R., . . . Scott, K. (2009). Depression in parents, parenting, and children: opportunities to improve identification, treatment, and prevention. Retrieved April 12, 2017, from http://eds.b.ebscohost.com.libproxy.chapman.edu/eds/ebookviewer/ebook/bmxlYmtfXzk5MTAyMl9fQU41?sid=1174c4e1-a370-4252-9e92-c9494e68279f@sessionmgr120&vid=1&format=EB&rid=2

Hynes, J., & McCune, N. (2002). Follow-up of childhood depression: historical factors. The British Journal of Psychiatry,181(2), 166-167. Retrieved April 12, 2017, from http://bjp.rcpsych.org/content/181/2/166

Vignette

1A 14-year old adolescent boy is brought for assessment by his mother. The patient reports of having feelings of worthlessness and irritability for most of the day. His appetite is poor, and he states that he can go without eating anything for certain periods of time and that he has difficulty sleeping at night. He states that he has a constant feeling of fatigue and has trouble focusing on his school work and chores. He mother interjects that most of his symptoms have been manifesting for the past year and states that she doesn’t understand why his mood has changed so dramatically. 

Structural and Strategic Family Therapy Comparison

Structural and Strategic Family Therapy Comparison

John R. Stafford

Brandman University

Abstract

Family therapy is not a single theory solution for new family therapists. Although it is common for a young therapist to pick a model that he or she may feel most comfortable with, it is a manner of limiting the scope of learning in the early stages of education and even practice. Gaining a full understanding of the four primary constructs of family therapy can assist a young therapist in not only selecting a model that feels right but also in the ability to employ aspects of multiple models when working with various clients and their diverse spectrum of issues.  Although each model has significant differences, they also share some similarities. This paper will examine the differences and similarities of structural and strategic family therapy models. 

Keywords:  Structural Theory, Strategic Theory, Family Therapy Models

Structural and Strategic Family Therapy Comparison

Understanding the differences and similarities of the different family therapy models enhances the ability of a therapist to determine if a particular model or combination of models are best suited for their practice and the individual needs of the client[s] (Silva, et al., 2003). This paper contrasts and compares the Strategic and Structural models of family therapy by discussion the constructs of both models. By careful examination of the different approaches, development, and intervention styles associated with the two models, we can better understand the core concepts, intervention techniques, processes, social contexts, and outcomes represented in each model.

The Creation of Each Model

Salvador Minuchin and his colleagues at the Wiltwick School residential facility in New York developed Structural family therapy base don their experiences working with inner city delinquents (Issitt, 2013; Gladding, 2007). Pulling from their experiences, Minuchin and his colleagues asserted that passive and historical approaches to working with families posed difficulties in working with families in lower socioeconomic and racial minority families (Gladding, 2007; Nichols, 2013). Based on his observations, Minuchin asserted that the households in this demographic tended to display more aggressive behaviors and place blame on other family members or influences when troubles within the family were present (Issitt, 2013; McAdams et al., 2016). Minuchin further surmised that when a dysfunction within the family arose, that it was the result of an inability for the family structure to adjust to changing conditions and that families incorporate subsystems that establish individual roles and responsibilities (Issitt, 2013; Gladding, 2007). Based on these observations and assertions Minuchin developed the concept that therapists should engage families directly to aid in changing the family structure to facilitate change, and that the particular type of clientele they were working with required active and dramatic interventions to be successful (Issitt, 2013; Gladding, 2007).

In the 1960’s and 70’s Minuchin and his associates expanded on the social context that formed the basis of structural family therapy mainly because the clientele of inner city tended to display a heightened level of crude characteristics (Israelstam, 1988; Issitt, 2013). Structural family therapy also assumes that problems arise when family boundaries are not clear and when difficulties are present within the family hierarchal structure. Furthermore, cross-generational influences like coalitions and alliances add additional challenges within the family (Isrealstam, 1988; McAdams et al., 2016). Sequentially families with diffused boundaries are more likely to be enmeshed while families with rigid boundaries are more likely to be disengaged than households with a healthy set of boundaries and hierarchal structures (Isrealstam, 1988; Gladding, 2007; McAdams et al., 2016).

Gregory Bateson (1904-1980) of the Palo Alto research group developed strategic family therapy in the early 1950’s. His primary focus on treating schizophrenic patients and the problems their families experienced as a result of the illness, and he surmised that schizophrenia was a result of discrepancies in various levels of family communications and interactions (Isrealstram, 1988; Nichols, 2013). Strategic family therapy is primarily composed of two subgroups. The first being Haley’s structural-strategic group and the second being the MRI group (Israelstam, 1998). It is fair to note that while both of these subgroups share much in common, they have strong fundamental differences. One aspect of strategic family therapy is that therapists working with families take a lead role in defining the process fo treatment and design the strategies required to aid families in changing their system (Israelstam, 1998). Also, D. Jackson (1920-1968) and John Weakland (1919-1995) expounded on Bateson’s concepts by describing various communicational strategies as processes an individual uses to escape or define intrafamilial relationships (Israelstam, 1988; Sheehan, & Friedlander, 2015). Based on the focus on specific strategies for intervention aimed at changing the current problem within the family, Jackson and Weakland’s theories also became known as strategic family therapy (Israelstam, 1988; Sheehan, & Friedlander, 2015). The process involves a complete assessment of the family interactions and developing a strategy to disrupt the cycle by providing straightforward or paradoxical interventions. The therapeutic process focuses on changes, and the therapist is responsible for the successful outcome of these processes. It is fair to note that strategic therapists do not make interpretation of current interactions of the therapist themselves or exploration of the past when addressing the family’s current interactions.

The strategic family therapy model significantly impacted by social context, combined ideas, accumulated research, and writings of all the theorists at the Mental Research Institute [MRI] established a strong presence in the psychotherapy community. Although there were various therapists and schools of theory involved in the creation of strategic theory, the collaborative research and shared objectives of all concerned defined the theme used to form the model into a modern family therapy technique.

Mechanics of Each Model

The structural theory asserts that changing the structure of a dysfunctional family will enable the family to interact in a positive manner and overcome the pressing issues. Structural family therapy assumes that problems and solutions develop on a series of hierarchal, subsystem, and architectural influences within the household that affect the behaviors of individual family members (Israelstam, 1988). A further assumption is that people interpret issues like social interactions as patterns of interaction that occur on a repetitive basis (McAdams et al., 2016). The dynamics of a family network or structure ranges from dysfunctional to supportive and based on the level of cohesiveness will either promote negative or positive household interactions (McAdams et al., 2016). The structural interpretation of problems versus solutions provides a systemic comprehension of the family unit as an operational network and provides insight into the routine functionality of both the family system and individual components. If the therapist determines a dysfunction in family operations, he or she assists the family in changing the issues to encourage more positive interactions (Israelstam, 1988; McAdams et al., 2016).

The underlying assumptions about problems in strategic family therapy focus on the family system and how it interacts with a problem instead of identifying the problem itself (Gardner, Burr, & Wiedower, 2006; McAdams et al., 2016). Strategic family therapists attempt to change the household interactional processes by focusing on individual communication patterns and developing strategies designed to aid the family to recognize and change actions and interactions associated with the dysfunction (Horigan, Anderson, & Szapocznik, 2016). Strategic family therapists believe that this manner of intervention will aid in the restoration of active family function and the dysfunction will cease (Lindstrom, Filges, & Jorgensen, 2015).

Model Core Concepts

The fundamental concepts of structural family therapy emphasize a systemic and organizational process where the therapist analyzes the family structure to determine how the household interactions maintain the dysfunction without identifying the solution (McAdams et al., 2016). A primary assumption of Minuchin is that a family network core function centers on functional expectations that establish individual interactions and affect household homeostasis (Issitt, 2013; Lindstrom, Filges, & Jorgensen, 2015). Besides the inner workings of the family itself, the therapist also reviews external social influences that potentially affect the dysfunctional behaviors in a negative manner. Another area of focus is subsystems intertwined with the primary system and hierarchal processes identified as potentially harmful influences, hence allowing the therapist to aid in modifying how individuals relate to one another and create a positive rebalance of the primary system (Issitt, 2013; McAdams et al., 2016).

The fundamental concepts of strategic family therapy emphasize systemic process, hierarchal structure, and understanding the intricacies of individual and family communication patterns (Horrigan, Anderson, & Szapocknik, 2016; Sheehan & Friedlander, 2015). The process includes analyzing invisible and visible family guidelines [rules], family function, and repetitive behavioral patterns that appear to reoccur within the family Israelstam, 1988). Emphasizing that problems are inherent to dysfunctional hierarchies in the family structure; therapists seek to aid families to correct the problems by modifying personal interactions to change the family structure. Other concepts of strategic family therapy include the household’s behavioral sequences and the processes that potentially exacerbate or maintain the dysfunction (Szapocznik, Schwartz, Muir, & Brown, 2012).

Model Interventions

Applying unbalancing techniques, aiding individual family members to reframe perceptions, family mapping, joining with the family during sessions, and presenting the dysfunction as a metaphor are core intervention methods employed in structural family therapy (Nichols & Tafuri, 2013). Applying these techniques, a therapist can diagnose the dysfunction and aid the family in restructuring, which allows the process to develop structure and improved esteem within both the individuals and family network (Nichols & Tafuri, 2013). For example, if a therapist is working with a family that has an addiction problem, he or she may choose to use a family structure map to analyze various coalitions to interpret the underlying cause of the addiction (McAdams et al., 2016; Nichols & Tafuri, 2013). The therapist, in this case, objectifies the addiction to detach it from the affected family member and realigns the spousal coalition to strengthen the family’s center of power to combat the influence of the dependency (Nichols & Tafuri, 2013).

Strategic family therapy focuses on a set of planned, practical, and problem-focused strategies to address dysfunctional behaviors and familial structures that are associated with or contribute to the underlying problems (Lindstrom, Filges, & Jorgensen, 2015; Szapocznik, Schwartz, Muir, & Brown, 2012). The unique or core fundamental approaches of strategic family therapy include providing directives, assessing ordeals, and therapeutic paradoxes during interventions. A Therapeutic paradox is a tactic used to engage family members to evaluate unfavorable interactions and to redirect efforts into different interactions or behaviors (Lindstrom, Filges, & Jorgensen, 2015). Directives serve as precise instructions for the family members to enact to facilitate change, whereas ordeals are behavioral prescriptions that direct the family to engage in pernicious behaviors when maladaptive interactions return (Lindstrom, Filges, & Jorgensen, 2015; Szapocznik, Schwartz, Muir, & Brown, 2012).

         Considering that both models were primarily developed to treat addiction problems in young family members and provide assistance to the family unit to restructure the family network either by changing the structure or the strategy of the household dynamic, the benefits of both models apply in other therapeutic settings. For example, the application of both models in long-term care facilities and addiction rehabilitation for adults are both viable use-case scenarios. Hybrid models like brief strategic family therapy have combined elements of structural and strategic family therapy models of effecting changes in family networks troubled with dysfunctional addiction and behavioral problems. Using this hybrid model, a therapist can apply proper treatment to a family with an adult member suffering the same dysfunction. Although the primary applications of these models remain to treat families with children suffering from addiction and dysfunctional behavior, the transition to intervention programs for adults is beneficial and practical. Considering the systems and structures of families with dysfunctional children and dysfunctional adults are similar, if not identical, therapists only need make minor modifications to the intervention process to adapt the treatment to fit the needs of the family.

            A key factor of consideration in adapting these models to adult therapy is the effect addiction has on the mental state of a patient. Chronic addiction modifies and even retards human maturity, and therefore adult addiction patients may, in fact, have reduced mental capacity, or immature behavioral attributes. In cases of adult addiction or dysfunction, there are factors of treatment that remain relevant. Treating the parental structure or system would be considered a primary aspect of treating the dysfunction or an adult family member. The core processes of joining the family system, providing an in-depth evaluation of dysfunctional personal relationships, and aiding in the adjustment of the family structure or system are all viable approaches when providing therapy to families with dysfunctional adults.

Model Goals and Outcomes

In comparison, the goals of structural and strategic family therapy share similarities of altering the family network via methods of behavior modification, communication enhancement, and disruption and restructuring dysfunctional interactions. In both models, the desired outcome is a change in maladaptive patterns that affect both the individuals and family unit. Assuming that changing the structure to recognize and disrupt dysfunction within the person and the family structure, a proper balance will be achieved and family homeostasis returned. Therapists are usually not dedicated to a particular model. Hybrid therapies like Brief Strategic Family Therapy, which incorporates both structural and strategic theories along with intervention are sound methods to engage families coping with adolescent substance abuse and behavioral dysfunction (Robbins et al., 2012; Szapocznik, Schwartz, Muir, & Brown, 2012).

The strategies for structural and strategic therapy model interventions applied to brief strategic family therapy shifts slightly to focus on reconfiguring the overall strategy to emphasize the transformation of family relationships for dysfunctional to an efficient, mutually supportive process. Therapists using this technique concentrate on helping families develop and enhance conflict resolution skills, behavior management skills, parenting and leadership skills, and blocking, directing or redirecting communications within the family network (Robbins et al., 2012).

The evolution of structural family therapy has made advancements in how therapists understand how relational issues affect areas like attachment theory and evolved the original concepts into new practices. For example, ecosystemic structural family therapy focuses on a systemic process (Lindblad-Goldberg, Jones, & Dore, 2004). Ecosystemic structural family therapists concentrate on an evidence-based process that focuses on families with adolescents and children suffering behavioral dysfunction. The primary goal is to aid families in addressing dysfunction and restore household homeostasis (Lindblad-Goldberg, Jones, & Dore, 2004).

Brief strategic family therapy models incorporate the core concepts of strategic family therapy and structural family therapy. The combination of both core models provides an evidence-based model designed to deliver treatment to families with young addicts (Robbins et al., 2012). By combining aspects of both strategic and structural therapy models, brief strategic family therapy increases therapeutic retention, and aids families comprehend and combat the dysfunction (Robbins et al., 2012; Szapocznik, Schwartz, Muir, & Brown, 2012). It is fair to note that although the model itself has undergone extensive research, there is still question as to the effectiveness on actually combating the actual addiction problem (Robbins et al., 2012).

Models Contrasted and Compared

            Structural and strategic family therapy models share numerous similarities in the foundational concepts of practice. A unique identifier of each of these models is the systemic approach employed to understand pathology and by redirecting efforts from a psychoanalytic approach to focus on the individual in conjunction with the family network. In doing so, both models emphasize the importance of understanding how the intrapsychic world affects an individual’s health and integration into the family structure, and how changing interpersonal interactions aids the family in achieving successful outcomes in therapy. Further similarities include the target market [clientele] that both models cater to servicing. Both models emphasize understanding and treatment of dysfunction in family communications and interpersonal relationships that contribute to significant problems in young family members and continue to expand with emerging hybrid therapy models like ecosystemic structural family therapy and brief strategic family therapy (Robbins et al., 2012). A fair comparison of the theoretical approaches of both models is the intervention strategies both employ. In both models, key therapeutic techniques include joining with the family system and assisting the family in restructuring the family dynamic. It is important to state that although these models were developed to combat families with dysfunctional youth, therapists have successfully applied both models to clients outside this demographic.

            In contrast to the similarities both models share, there are also fundamental differences. A primary difference between structural family therapy and strategic family therapy is the method in which each model applies changes to the family system. Structural family therapy models assert that relational interactions become altered by focusing on changing the dysfunctional family structure, whereas strategic family therapy models state that family structure will change organically once the relational strategies become modified.

            Both models share unique strengths and weaknesses, and although these attributes exist in the similarities of the models, it is appropriate to separate them for comparison. Both models emphasize the importance of systems inside and outside the family structure by exploration, interpretation, comprehension, and modification of dysfunctional relation to environmental factors. Secondarily, the therapeutic objective of assisting the younger family member[s] and the entire family to change the dysfunctional systems and structures are the most important aspects of resolving family conflict and dysfunction. Although these issues are considered shared strengths, they also present weaknesses in therapy. Those weaknesses being the fact that both models focus highly on intrapersonal relations within the family system, they often fail to investigate and address the intrapsychic and emotional factors of individual family members involved in the dysfunctional network. A reasonable assertion of both models is the roots fo where they started. Both models were developed to focus on sociocultural and socioeconomic populations most commonly overlooked (Israelstam, 1988). For various reasons, both models have provided a looking-glass view of these communities by emphasizing the importance of diversity of race and class structure (Nichols, 2013).

Conclusion

            In conclusion, one can quickly take note that structural and strategic family therapy models have made revolutionary advancements in the field of family therapy. The emphasis on evaluating and addressing the dysfunction in the family structure or system that allows the structure to operate outside of standard tolerances has not only opened the door to successful treatment of addiction in young family members but also applies to the treatment of adults suffering the same issues. Emphasizing focus on interpersonal relationships, communication, and hierarchal power struggles as a core aspect of family dysfunction and aiding families in implementing proper solutions to address these issues is a critical factor in successful treatment.

         References

Gardner, B. C., Burr, B. K., & Wiedower, S. E. (2006). Reconceptualizing Strategic Family Therapy: Insights from a Dynamic Systems Perspective. Contemporary Family Therapy,28(3), 339-352. doi:10.1007/s10591-006-9007-x

Gladding, S. T. (2007). Family therapy: history, theory, and practice (4th ed.). Boston: Pearson.

Horigian, V. E., Anderson, A. R., & Szapocznik, J. (2016). Taking Brief Strategic Family Therapy from Bench to Trench: Evidence Generation Across Translational Phases. Family Process,55(3), 529-542. doi:10.1111/famp.12233

Israelstam, K. (1988). Contrasting Four Major Family Therapy Paradigms: Implications for Family Therapy Training. Journal of Family Therapy,10(2), 179-196. doi:10.1046/j..1988.00311.x

Issitt, M. (2013). Structural family Therapy (SFT). Salem Press Encyclopedia. Retrieved February 15, 2017, from http://eds.b.ebscohost.com.libproxy.chapman.edu/eds/detail/detail?sid=a9a9e471-bdd0-4ddb-8791-90d91204a4bd%40sessionmgr101&vid=3&hid=103&bdata=JkF1dGhUeXBlPWlwLHVpZCZzaXRlPWVkcy1saXZl#AN=89677644&db=ers

Lindblad-Goldberg, M., Jones, C., & Dore, M. (2004). The Ecosystemic Structural Family Therapy Model. Retrieved February 21, 2017, from https://books.google.com/books?hl=en&lr=&id=Ks2z9zkHrVwC&oi=fnd&pg=PA3&dq=ecosystemic structural family therapy&ots=efqsNTaj7A&sig=tkqqeVafzVa3xHydBWFVHy3I5aw#v=onepage&q=ecosystemic%20structural%20family%20therapy&f=false

Lindstrom, M., Filges, T., & Jorgensen, A. K. (2014). Brief Strategic Family Therapy for Young People in Treatment for Drug Use. Research on Social Work Practice,25(1), 61-80. doi:10.1177/1049731514530003

Mcadams, C. R., Avadhanam, R., Foster, V. A., Harris, P. N., Javaheri, A., Kim, S., . . . Williams, A. E. (2016). The Viability of Structural Family Therapy in the Twenty-first Century: An Analysis of Key Indicators. Contemporary Family Therapy,38(3), 255-261. doi:10.1007/s10591-016-9383-9

Nichols, M. P. (2013). Family therapy: concepts and methods (10th ed.). Boston: Pearson.

Nichols, M., & Tafuri, S. (2013). Techniques of Structural Family Assessment: A Qualitative Analysis of How Experts Promote a Systemic Perspective. Family Process,52(2), 207-215. doi:10.1111/famp.12025

Robbins, M. S., Feaster, D. J., Horigian, V. E., Rohrbaugh, M., Shoham, V., Bachrach, K., . . . Szapocznik, J. (2011). Brief strategic family therapy versus treatment as usual: Results of a multisite randomized trial for substance using adolescents. Journal of Consulting and Clinical Psychology,79(6), 713-727. doi:10.1037/a0025477

Sheehan, A. H., & Friedlander, M. L. (2015). Therapeutic Alliance and Retention in Brief Strategic Family Therapy: A Mixed-Methods Study. Journal of Marital and Family Therapy,41(4), 415-427. doi:10.1111/jmft.12113

Szapocznik, J., Schwartz, S. J., Muir, J. A., & Brown, C. H. (2012). Brief strategic family therapy: An intervention to reduce adolescent risk behavior. Couple and Family Psychology: Research and Practice,1(2), 134-145. doi:10.1037/a0029002