Online Family Therapy with a Teenager Engaging in Risky Behavior
Online Family Therapy with a Teenager Engaging in Risky Behavior
In this article I will illustrate the case of a family therapy with an adolescent with risky behavior that I conducted online through the Skype platform. The goal is to describe the therapeutic process in order to help readers understand how it is possible to work with families even at a distance. This approach was unthinkable until some time ago, when the therapist specialized in family and systemic-relational psychotherapy carried out sessions exclusively at the professional practice.
In this popular article, I would like readers to understand the effectiveness of this therapeutic approach, to give undecided families who feel the need the possibility to consciously choose whether to work in person or online. This path allows both parents and children to be helped in moments of crisis when a reorganization of family roles and rules is necessary, especially in cases of families with adolescent children presenting acute symptoms with risky behaviors.
Online support for families with children with risky behaviors
It is important to premise that the symptomatic child or the one with risky behavior is signaling, through their distress, a blockage that involves all members of their family context and that causes discomfort and communication problems. In other words, the son or daughter in question is taking on the suffering of the family system members, using the symptom as a communicative vehicle to request a family reorganization that is more adequate to the life cycle phase in which the family finds itself. Online family therapy is aimed not only at families with married or cohabiting parents, but also at families with separated parents, especially in those cases where the separation was conflictual and the former spouses have been unable to resolve disagreements lasting several years and in which at least one child shows acute symptoms and/or conduct disorders. In both cases it is possible to address the family crisis with the same effectiveness by working in family therapy either in person or online.
The first approach with the family
The family was referred to me online by one of my patients whom I had followed at my practice in Pescara. The patient, Maria, is a 24-year-old university student living away from home, worried about her 16-year-old sister Roberta, an adolescent who had shown risky behaviors. In the phone call, Maria explained to me that her sister, after a phase of protesting against her parents about negotiating evening outings, expressed with aggressive and uncontrolled emotions, went to a party that ended dangerously for Roberta, who ended up in the hospital due to severe substance intoxication. The parents, frightened by the event – fortunately resolved positively for their daughter who did not suffer serious consequences – immediately asked Maria to intervene to resolve the difficulties related to Roberta’s risky behavior. So Maria decided to contact me, asking me to take her family into online therapy, since they live in another city.
The family is composed as follows: MOTHER, Cecilia, 48, homemaker; FATHER, Paolo, 51, worker; FIRST DAUGHTER, Maria, 24, university student living away from home; SECOND DAUGHTER, Roberta, 16, third-year high school student.
The therapy lasted one year and at present we are in a phase in which the online sessions are only with the parents, for follow-up meetings, very useful in maintaining the results achieved. In the first session I decided to see only the adolescent, Roberta, to build a therapeutic alliance with her, given that the meetings were not in person but online. This decision proved advantageous when I later decided to involve the whole family.
The phases of online therapy
For the first interview I built the reading grid, which serves as the compass on which to orient myself in my clinical practice as a family and systemic-relational psychotherapist. It provides for different stages in the development of the session:
WHERE: The family was referred to me for an online family therapy by my patient Maria, followed at my practice, who reported the episode involving her sister Roberta, who, after a previous turbulent conduct towards her parents about negotiating evening outings, ended up in the hospital for substance intoxication after a party. The adolescent’s risky behavior shook all members of the family system, who immediately wanted to start an online family therapy path, entrusting themselves to me on Maria’s recommendation.
WHEN: The family’s life cycle, according to author J. Haley, is the phase “The difficulties of the middle period of marriage,” in which the second daughter is an adolescent with conduct disorder in the process of separation who increasingly demands greater autonomy. The first daughter, although apparently separated from the family context by studying at university away from home, is still actually involved in family dynamics despite the physical distance.
WHICH SYSTEM: In in-person family therapy, during the first therapeutic interview the whole family is always called together. In this case, having received a request for online family therapy, I decided to see only Roberta for the first four sessions. In adapting the method, I considered it fundamental for the success of the intervention to establish a therapeutic alliance with the adolescent, which would be indispensable when I had to work with all the other family members. After the first four sessions, I called the whole family, but the father refused to participate until the tenth session, when he finally accepted the invitation. From the fifth to the ninth session, I worked therapeutically with Roberta and the mother. In a “task or prescription” I gave at the end of the eighth session, to the mother and daughter, the “joint family drawing,” in which I asked all family members to represent their family graphically on an A3 sheet, I also requested the father’s collaboration, and he participated with amusement in completing the task. This therapeutic move probably allowed Paolo to reflect on his parental role and to begin, from the tenth session, to participate in the sessions to reorganize family roles and rules.
WITH WHOSE EYES?: The therapist at first sees through Roberta’s eyes, since for four sessions she will establish a therapeutic alliance with her. Then, from the sixth session onwards, she will see through the mother Cecilia’s eyes and finally, from the tenth session onwards, also thanks to the father Paolo’s participation, she will be able to see through the eyes of the whole family. At last, the therapist is able to see the suffering and unhappiness of all members of the family system. Author G. Bateson states: “The lack of systemic wisdom is always punished.” Authors M. Tommasoni and L. Solano: “Thinking in systemic terms means dealing with relationships, structure and interdependence between elements rather than attributes and characteristics of objects, understanding systemic theory as a transversal theory, as a grid to read events, as a theoretical framework that contains other theories.”
TITLE: “Help me manage my emotions”
The family’s requests:
Examining the demand analysis, there are two requests the family submits to the therapist:
EXPLICIT REQUEST: The parents ask the therapist to resolve Roberta’s risky behavior, to manage her angry and hysterical reactions when she receives a “No” from her parents in negotiating evening outings, and to work on the lack of trust towards their daughter after the critical episode.
IMPLICIT REQUEST: The family asks the therapist to work on parental disagreement due to certain resentments that have built up over years of marriage and that have led over time to a rigid division of roles between the spouses: father spending much time outside the home due to work commitments and having delegated to the wife, a homemaker, the upbringing of the daughters. When the daughters were small, however, Cecilia worked in a company. Both spouses agree that when Cecilia was working, the family organization was more stable and there was greater agreement between them. This aspect is useful to understand how a family crisis can also arise due to difficulties related not only to internal stresses (relational dynamics between members) but also to external ones, such as the change in Cecilia’s status, which caused a family reorganization based on the rigid division of roles between the spouses.
Tools used and therapeutic goals
With regard to the analysis of the tools used in online family therapy, I had to select tools that would allow me to work even through the use of the technological medium, seeking to successfully achieve the same therapeutic goals as in in-person family therapy.
So, after careful reflection, I decided to proceed in this way:
-
Clinical interviews
- Reading grid
- Demand analysis
- Therapeutic contract
- Use of tasks or prescriptions
- Drawing of how Roberta perceives herself and how she is perceived by her mother Cecilia (sixth session) – Attachment 1 –
- Joint family drawing (ninth session) – Attachment 2 –
- Teamwork of the parents collaborating together to reestablish new family rules
- Work to reestablish collaboration and renewed dialogue between the spouses (two sessions were conducted only with the parental couple)
- Work on reestablishing trust between the respective members of the family context
- Teamwork of the parents in managing the daughter’s angry and aggressive reactions to “No’s” about negotiating evening outings
- Follow-up only with the parental couple to maintain the results achieved (still ongoing).
Allegato 1
Allegato 2
Conclusions
In a digitalized society, it is necessary to make family therapy available online as well, while ensuring the same results as a traditional approach. Until recently, individual and couple psychotherapy conducted online had already shown validated results supported by scientific literature, but very few had ventured into carrying out online family psychotherapy, without knowing what outcomes it could produce. I am pleased to present in this article the therapeutic goals that were achieved with a family in online therapy.
Therapeutic goals achieved:
- A strong alliance with Roberta which later allowed, thanks to the work with the whole family, the elimination of risky behaviors;
- The restoration of parental roles to Cecilia and Paolo, united in their collaboration in establishing new rules useful for the emotional and behavioral management of their daughter;
- The inclusion of the father in online family psychotherapy, who had initially shown resistance to providing his contribution in helping his daughter, once again delegating the education to his wife;
- A renewed collaboration and communication within the parental couple, which gradually led to the elimination of the rigid division of roles, replacing it with cooperation;
- The release of the first-born, Maria, which today can be considered completed, as she, although physically distant, was still involved in family dynamics;
- A regained sense of well-being for individual members and a renewed dialogue within the family.
Online psychotherapy to act promptly
I hope that this work may be helpful for many families who would like to embark on a path of family psychotherapy and who, for some reason, are still undecided or in disagreement. To them I strongly recommend not postponing the decision and to also consider the option of online family psychotherapy in order to act immediately on resolving the family crisis.
From the analysis of this case, it emerged that the technological medium seems to have the great advantage of breaking down resistance even from the most skeptical family members, as happened with Paolo, and of engaging the most difficult adolescents in therapy, as in the case of Roberta. This is thanks to the fact that online psychological therapy reaches directly into the home, making it more accessible and capable of involving all members of the family system.
I would like to conclude this article with a beautiful quote from Mahatma Gandhi: “Take care of the means, and the ends will take care of themselves.” In my clinical practice I can affirm that I have come to a conclusion: with the right means, the greatest human works can be achieved.
Bibliography:
- Bateson G., Verso un’ecologia della mente, Milano, Adelphi, 1976;
- Caillè P., Rey Y., Gli oggetti fluttuanti. Metodi d’interviste sistemiche, Roma Armando Editore, 2005;
- Cancrini L., La Rosa C., Il vaso di Pandora. Manuale di psichiatria e psicopatologia, Roma, Carocci, 1991;
- Cancrini L., La psicoterapia: grammatica e sintassi, Roma, Carocci, nuova ediz. 2008;
- Haley J., Terapie non comuni. Tecniche ipnotiche e terapia della famiglia, Roma, Casa Editrice Astrolabio, 1976;
- Minuchin S., Famiglie e terapia della famiglia, Roma, Casa Editrice Astrolabio, 1976;
- Tommasoni M.; Solano L.; Una base più sicura: esperienze di collaborazione tra medici e psicologi, Milano, Franco Angeli, 2003;
- Watzlawick P., Beavin J.H., Jackson D.D., Pragmatica della comunicazione umana. Studio dei modelli interattivi delle patologie e dei paradossi, Roma, Casa Editrice Astrolabio, 1971.
