Coming Together to Move Apart: Family Therapy for Enhancing Adolescent Development

Introduction

While there is wide agreement that adolescence is a time for emotional separation from family of origin, and that the process of individuation must be successfully accomplished in order for the adolescent to become a healthy independent adult, there is no consensus about the process of achieving this developmental advance. Freud (1909) recognized that intergenerational relationships were critical in the case of Little Hans, and he treated the child through the father. Most experts in treating adolescents have acknowledged the need for a healthy relationship between parents and young adults in the fostering of this developmental stage. Widely different views are expressed, however, as to how to achieve this goal. Anna Freud noted the impact of parenting on adolescent development and wrote that “the closer the tie between child and parent has been, the more violent will be the fight against them in adolescence” (1971, p. 86). Child analysts dating back to Anna Freud have believed that the therapist should work with the adolescent in a confidential relationship separate from parental involvement. A “team approach was instituted in which a family was treated in the clinic, but never together in the same room” in the Child Guidance movement in the United States (Offer and Vanderstoep, 1974, p. 257). The definition of family therapy varies according to the orientation of the therapist. “Quite often, when child psychiatrists refer to family therapy with an adolescent, they mean that they actively involve the mother and the father in the total treatment program (but separate from the adolescent’s individual therapy)” (Williams, 1973, p. 324) While in some cases this separation is beneficial and necessary, in others it does not help, leading parents to prematurely disconnect from their teens. This paper will demonstrate how involving families either in conjoint family therapy or in individual therapy sessions with adolescents can be invaluable. Further, familial involvement can facilitate more effective means of enhancing separation and individuation necessary for progress toward adult independence and autonomy.

Family therapy with some or all members present in the same room is a relatively recent modality, dating back only to the late 1940s and early 1950s. Family therapists are proponents of the idea that the family operates as a system that seeks homeostasis. Patterns of interactions in families that have become entrenched are difficult to change and these patterns are maintained by all members of the family (Minuchin, 1985). A move toward separation by the adolescent has a reciprocal impact on parents and siblings who must also change to accommodate the developmental shift in order for the family to progress and grow. “Open and flowing communications were seen as an essential ingredient for the functioning of a relatively healthy family” (Offer & Vanderstoep, 1974, p. 257). Family therapy is a diverse field encompassing a number of different treatment models. However, the relationship between adolescent and family during adolescence is well represented by the notion that “functional separation requires leaving without alienation, and this is one of the key goals of family therapy. To encourage a functional breaking away, the therapist must help not only with the separating adolescent but also with those people from whom he is separating. All of these individuals must gradually let go and then reconnect” (Fishman, 1988, p. 11). The concept of connecting family members to promote healthy family development is controversial. In fact, one family therapist has described family therapy with adolescents in the following way: “In a culture that promotes the values of autonomy and independence as relentlessly as European-American culture does, it is a political act for a therapist to see parents and adolescents together” (Weingarten, 1997, p. 307).

The choice of how a particular therapist proceeds with treatment of adolescents is related less to his/her understanding of the tasks of adolescence and more to comfort in working with parents, the ideological position a therapist holds, and his/her approach to treatment. Therefore, it is first important to define the goals of adolescent development. Different schools of therapy and different therapeutic models generally are in agreement about the tasks of adolescence. Blos (1979) views adolescence, from the psychoanalytic perspective, as the “second individuation process” during which an important task becomes the “shedding of family dependencies, the loosening of infantile object ties in order to become a member of society at large, or, simply, of the adult world” (1979, p. 142). Consistent with object relations theory, for the adolescent to reach the next developmental stage, he/she requires a stable, consistent presence similar to how the two-year-old child [needs guidance] going through the practicing sub-phase of separation–individuation on the way toward rapprochement (Mahler, Pine, Bergman, 2000). From the family therapy perspective, Carter and McGoldrick (1989) defined the key principles of the life cycle phase of the family with adolescents as leaving home and accepting emotional and financial responsibility for self. Necessary to achieving this goal is differentiation of self in relation to family of origin. However, this should not be accomplished by cutting off from family, which involves physical separation but not emotional differentiation and thus leads to problems (Bowen, 1978). In fact, recent research indicates that the development of autonomy facilitated by retaining close relationships with parents and family promotes individuation. Further, parents’ ability to remain close to adolescents without threatening their independence leads to the transformation necessary in the transitional period toward adulthood. (Grotevant & Cooper, 1986; Hill & Holmbeck, 1986; Youniss & Smollar, 1985).

Many factors influence this phase of development so that the single event of leaving home does not determine successful navigation toward adulthood. For example, development is stalled in the case of serious mental illness (the onset of which often occurs at the time an adolescent would be separating from family). As the illness creates isolation and difficulty in functioning, the adolescent with serious mental illness needs to rely on his/her parents at a time when he would be breaking away from the family. At the same time, parents of the ill adolescent need to become engaged with supporting their child and securing resources for him/her. The involvement should not be viewed as dysfunctional but, rather, as a consequence of the illness. All too often in these situations, parents are blamed and families are labeled as “enmeshed”. The whole family suffers, and this negative view intensifies pain and isolation.

The concept of separation-individuation as defined by leaving home is culturally bound. In many cultures, it is expected that adolescents will remain at home until they marry. In fact, a youth wishing to leave may create problems for the family. So too, is the idea that leaving home should occur at a particular time culturally bound. In fact, separation-individuation is a process that occurs gradually and at different times for different people. Some young people need to remain at home longer than others for many reasons, and this is not necessarily a sign of pathological development (Micucci, 1998). Even those adolescents who do leave for college return home for frequent, and sometimes lengthy, school vacations. Society has shifted significantly in recent years. For example, since the national economic situation has led to a decrease in availability of jobs and stable incomes, many young adults have either stayed at home or have returned home for economic reasons rather than as a sign of unresolved developmental issues. In fact, the stage of adolescence has been extended from the teens to the twenties for a number of social and economic reasons. Recent research has even indicated that neurological development continues into the twenties rather than stopping in the teens (Dobbs, 2011). Physical separation, therefore, must be distinguished from emotional separation.

Leaving the family home to move thousands of miles away does not mean that someone has successfully individuated; conversely, it is possible to accomplish emotional separation while still living at home. It is important to see adolescent development as a continuum rather than an abrupt event. Daniels (1990) has described the various poles of separation-individuation ranging from successful separation, leading to a sense of self while remaining connected to the family, to dysfunctional, leading to becoming “stuck,” which manifests in behavioral disturbance, emotional symptoms, or problems with relationships.

Micucci (1989) proposes four principles for treating problems of leaving home. They include:

It is in this context that I have seen a number of adolescents having difficulty moving to the next stage of development, manifested by poor relationship choices, substance use, and/or failure to progress academically. Some adolescents suffer a decline in school performance, problems in relationships with parents and other significant people that threaten their ability to progress, to leave for college, or to find a career. Family therapy can be a useful way of making systemic changes. Alternatively, an effective treatment is to work with the young adult individually but, in addition, include the parents in family therapy. In some cases the family therapist and the therapist treating the adolescent are different people. A significant explanation for the reason that many therapists separate individual therapy from family therapy is a belief that the adolescent’s individuality should be reinforced in the process of therapy. I have found it beneficial, when possible, for the individual’s therapist to be the family therapist as well. Although confidentiality with the adolescent is maintained, frequently the adolescent appreciates assistance and support from the therapist in saying important things to parents (conversely, the parents may need help in communicating with the adolescent). This paper will demonstrate how, in many cases, the individual is not able to achieve autonomy without first working through separation issues with the family. Thus, parents and adolescents need to come together so that moving apart can be successfully navigated.

Case Illustrations

Part 1

The following case illustrations are examples of psychotherapy with adolescents that progressed because of the involvement of parents/family members in the individual treatment of the adolescents.

An Adolescent with Unresolved Early Childhood Family Traumatic Separations

Wendy Murdock, age 15 years, was referred for therapy by her mother, Mrs. Murdock, who was very concerned about Wendy’s lapse in grades and acting-out behavior, including staying out past curfew, drinking alcohol, and suspected sexual activity. Wendy attended a prestigious high school from which mother and older brother had graduated very successfully. Wendy’s brother was now in college and was considered to be a high achiever in all ways. When Mrs. Murdock tried to talk to Wendy about her behavior, Wendy would lie, get angry, and continue the behavior. When I met with Mrs. Murdock to gather history, she was at her wit’s end; she recounted how she had had a life-threatening illness and was away from the family for a long time receiving hospital treatment when Wendy was five years old. During that time Mr. Murdock cared for their four children and took them to visit her frequently, but no one knew whether Mrs. Murdock would survive. No discussion or treatment had followed this experience, and the family eventually returned to normal functioning. When I suggested to Mrs. Murdock that this history might be relevant to Wendy’s behavior, her reply was that the events were over and that had nothing to do with the current problems. She did not want to be involved. She wanted me to see Wendy and to fix her.

At the beginning of treatment, Wendy presented as a sweet girl, very receptive to our meetings. She was eager for the opportunity to be able to talk about the many things in her life that made her sad and angry. She felt neglected by her parents who, she felt, constantly criticized her and did not see anything positive about her. With little denial, she acknowledged responding to them by getting herself in trouble. She was very open about her behavior and felt that it did not matter how she acted since they would not value her even if she tried. In addition to the problems at home, Wendy was also having difficulty with peer relationships and felt very isolated and unloved by friends, extended family, and a boyfriend who rejected her. She felt that her extended family rejected her because her mother had said bad things about her. Clearly, she was asking to be heard and understood, but she was going about it in a self-defeating manner. At first, she did not want her family involved in her treatment, so that I met with her individually with an eye toward helping her to deal with her family in a more constructive way. We worked on improving her grades (a goal both of Wendy and her parents) since it was her junior year in high school and she was damaging her chances to get into a good college by failing to perform adequately. With the support she needed, she was a person who was capable of progressing. In the course of our work together, we discussed the experience of her mother’s illness.

Wendy described the separation from her mother as being very traumatic. She was scared and confused and lonely. Her primary coping mechanism was the presence of a caretaker with whom she became very close. When her mother returned, the caretaker was let go, so that Wendy suffered yet another traumatic loss. She felt that she had not been permitted to discuss her feelings or question anything that had happened. Consequently, she continued to be in great pain silently. In fact, she expressed her ongoing worry that her mother might die. A turning point occurred in Wendy’s senior year. She was trying to do better, and both her school and home performance was improving, but Mrs. Murdock continued to call me to complain about Wendy’s behavior. Mrs. Murdock reported that Wendy was not changing rapidly enough and she constantly let her know how disappointed and angry she was. During our next session, Wendy was very distraught; she had overheard her mother tell someone that it was possible for her illness to recur at any time. This revelation was a confirmation of Wendy’s deepest fear. Wendy finally agreed that we invite her mother to begin to meet with us. Mrs. Murdock used the first joint meeting as a forum to discuss all of Wendy’s troublesome behaviors. Wendy listened and defended herself a little. In her next individual session with me, she was very angry and hurt about what her mother had said. I encouraged Wendy, with my support, to tell her mother in the next joint session about how she felt and about her fears. Wendy was able to let Mrs. Murdock know that she was very hurt that her mother did not recognize her efforts to improve, and that it made her feel hopeless. Moved by Wendy’s candor, Mrs. Murdock was able to talk about her feeling that Wendy’s behavior meant that she didn’t care about her. Wendy let her mother know that, in truth, she cared very much about her, and revealed her fear of losing her mother and her unexpressed pain. Mrs. Murdock understood and was able to be supportive to Wendy. We, thus, began the process of reconciliation. In subsequent meetings, we discussed specific behaviors that Wendy needed to improve while also talking about ways the mother could be less critical of Wendy and more supportive of her progress. While the situation was far from perfect, they had a new appreciation for each other and a better relationship and Wendy’s school performance improved.

All of this worked to help with Wendy’s college selection. She settled on a good school that was three hours away from home. This decision was relevant, since earlier she had been saying she wanted to go to a school 3,000 miles away, but had been scholastically performing in a way that would have prevented her acceptance and forced her to remain at home. The communication was open so she knew she could express her worries if she had them. Mrs. Murdock agreed to be open with Wendy about her condition. The relationship felt more secure and Wendy did not have to stay home to be certain her mother was in good health. I continued to see Wendy on school vacations and she was progressing well in college. Her relationship with the entire family improved.

An Adolescent Fulfilling Parental Needs and Ambivalence

Jennifer Langdon, age 16 years, in her junior year of high school, was referred because of overwhelming anxiety about the idea of leaving home to go to college. She was afraid that she would not be able to go, and yet she wanted to be able to leave since it was an important value in her family. The Langdon family was a very traditional, conservative one. Her parents had high expectations about academic performance, morality, and proper behavior. Jennifer had a very competent, active brother, Scott, a year her senior, who took a leadership role in their relationship. Jennifer felt she could do nothing without Scott. She had social anxiety and tended to isolate herself; Scott was gregarious and popular. In fact, Jennifer would only go out if she were going somewhere with her brother and his friends. While Scott exhibited more typical adolescent behavior, challenging rules and values, Jennifer was too perfect, never rebelling against her parents or doing anything wrong. She was unable to stand up for herself in any situation. The therapeutic goals were to help her to have a voice, to become more independent, and to be able either to leave home or to accept her need to stay home longer.

Family sessions alternated with individual sessions. The parents were very concerned about Jennifer, yet they reinforced her perfect behavior because of their own values. I would not have been able to help her become more assertive and reduce her anxiety without Mr. and Mrs. Langdon being able to allow this to happen by dealing with their anxieties. Mrs. Langdon, in particular, was very fearful about Scott’s behavior and his negative influence on Jennifer. While on the overt level, Mrs. Langdon wanted Jennifer to be more social, she was unconsciously communicating the dangers of social behavior by using Jennifer as a sounding board for her concerns about Scott. Work consisted of supporting Jennifer to be more outspoken about her needs and opinions to her parents and for the parents to be able to listen and lessen their anxiety about her competence.

A pivotal moment occurred when Mr. and Mrs. Langdon went on an overnight trip, leaving their children alone for the first time ever. Jennifer made an emergency appointment to see me. She told me that Scott was planning a party while they were away, and this was putting her in a bad position. Although she knew it was wrong, she was afraid to confront Scott. I met with the two siblings, and Jennifer was able to tell her brother that she would tell her parents if Scott had the party. This confrontation was a major step forward in Jennifer’s feeling empowered. Gradually, she developed more independence and was able to tell her parents what she wanted, even when she knew they might not approve. Further, she began to make some friends separate from Scott, and she felt good about having independent activities. She remained ambivalent about leaving home up until the summer after graduation from high school. Finally, she was able to make the decision to leave for college and feel comfortable about it.

Because Jennifer initially was unable to make decisions or engage in activities separate from Scott or Mr. and Mrs. Langdon, I believe that alternating individual therapy sessions with family sessions enabled Jennifer to gradually practice self-assertion in her family in an environment where she was supported and encouraged. Mr. and Mrs. Langdon learned how to limit their anxiety and to respond to Jennifer in a different way, thus allowing her to become more mature and confident. Currently, Jennifer, now in her twenties, is living in another city and doing well in her career. She maintains a good relationship with her family.

Part 2

The following are illustrations of family therapy with adolescents leading to the ability to move forward in development. Included is a treatment failure.

An Adolescent with Too Much Power in His Family

The McGregor family was referred for therapy when Sean was 16 and a junior attending a suburban high school. He had been diagnosed with bipolar disorder and both he and his parents were struggling with how to manage the illness so that he could progress in his life. The relationships in the family were conflictual, with Sean fighting with his parents, refusing to cooperate with them, and having problems at school. Sean did not show up to the first session because he told Mr. and Mrs. McGregor that he had a prior engagement. However, he gave a note to his parents to give to me. The note included his cell phone number and an invitation for me to call him for information even during the session. When I did call Sean, he advised me that I should work with his parents because they needed it and that there was a problem between his mother and father, and that he would come with them next week. Thus, therapy began with Sean’s assertion of control and so it continued for a while. Mrs. McGregor initially expressed much helplessness while Mr. McGregor revealed a more contentious relationship with Sean. Family therapy consisted of the family, Sean and his parents, who were really very close but in constant conflict. They needed to be able to talk about issues in a better way and resolve conflicts. Sean repeatedly made allusions to the fact that Mr. McGregor behaved in similar ways towards Mrs. McGregor that Sean did and that the real problem was in the relationship between Sean’s parents. The parents were not prepared to address this, but Mr. McGregor was able to discuss how, based upon his own family of origin experience, he understood what Sean was experiencing. Considerable work involved helping the parents to set firmer, more realistic limits while allowing Sean to develop independence in appropriate ways. For example, we established that it was not acceptable for Sean to disappear overnight, but if he let the parents know where he was and called them at particular intervals, it satisfied them and him. Mr. and Mrs. McGregor felt more relaxed when they were not so helpless, and they were less overtly angry with Sean. Concurrently, Sean appreciated the clarity and was comforted by his parents creating a better holding environment. As Sean’s behavior improved, the family was able to discuss emotional issues, including the fear and pain associated with a diagnosed mental illness. Strengths, of which there were many, were reinforced. Sean showed greater responsibility by finding not only summer jobs but also a job he found during the school year. Mr. & Mrs. McGregor were able to discuss their ambivalence about Sean’s leaving for college, and this helped them all to move forward. Eventually, he was able to go out of state to college. Many ongoing issues remained, both because of the mental illness and family relationships, but it was important for all of them to experience success and hopefulness in the situation.

Ruiz et al. (2013) studied the impact of parental attachment and separation attitudes on parent-adolescent conflict resolution. One finding was that the relationship between the parents was an important factor. In this case, the parents and the adolescent would have benefited even more had Mr. and Mrs. McGregor been willing to consider couples therapy.

A Treatment Failure Based on Challenging a Parent’s Readiness for Individuation

The Marsh family was referred for treatment because Mr. Marsh had recently left Mrs. Marsh, and she wanted to help her two children cope with the divorce. During the several sessions I had with the family, it was clear that Mrs. Marsh was still very angry with her husband. While she stated that she wanted the children to have a good relationship with their father, her behavior made it clear that she also wanted them to be angry and to reject him. In the sessions, she was controlling of her children, often speaking for them and defining the issues to be discussed. During the course of the treatment, the 16-year-old son, Tyler, began to have severe problems at home and at school. Mrs. Marsh was unable to help him no matter what she tried. She asked me to see him individually to assess the situation. When I met with him, he was quite open about what was upsetting him, including that he felt controlled and suffocated by his mother. He stated that he wanted to return to see me. With Tyler and Mrs.

Marsh in the room, I asked Mrs. Marsh whether it would be all right if I were to see Tyler individually again. Immediately, I realized that this was a serious mistake. Challenging her control at a time in her life when she felt a loss of control further disempowered her. She said yes at that moment, but the next day she called me and advised that she was planning to take Tyler to her individual therapist. The lesson was very clear. The son wanted to work on the separation process, but the mother was not ready. The loss of her husband was still too new for Mrs. Marsh, and she had not yet been able to work through her own grieving process. I ought to have included her in the plans, better understood her ambivalence, and gradually helped her to be able to move to the next phase.

A study of family cohesion by Dzukaeva (2014) looked at different patterns of separation according to family cohesion. The recent abandonment by the father was likely a factor both in the distress of the adolescent and the difficulty of the mother to deal with the adolescent’s moves toward autonomy.

An Adolescent Not Ready to Leave Home Due to Parents’ Premature Disconnection

The Walters family was referred for therapy because Ilene, age 17 years and a senior in high school, was depressed and stated that she would be unable to go to the college to which she had already been accepted on early decision. Ilene’s individual therapist made the referral for family therapy because he felt stuck. Ilene could not explain what was wrong and the therapist believed that separation issues were significant. Ilene presented as depressed, withdrawn, and angry. Mr. and Mrs. Walters were energetic, very supportive of each other, and worried about their daughter.

History revealed that Ilene had been a very good student and that she had been very involved with peers and activities. Early in the year, Ilene had requested therapy because she was having a difficult time, but would not explain what was bothering her to her parents. The Walters had complied. They were concerned, disturbed, and confused about Ilene’s recent behavior, which consisted of being withdrawn to the point of being almost mute. For the first few sessions, Ilene was almost unable to speak. Her parents were prodding her, asking what was wrong, and trying to make her talk. I suggested that we let Ilene listen and whenever she was ready to join in the discussion, we would welcome that. I asked Mr. and Mrs. Walters to tell me about the family. They reported that Ilene was the younger of two children, their older son was a junior in college. The parents had been high-school sweethearts and were extremely close, frequently vacationing as a couple (without their children). In sessions they showed obvious love and affection. Both Mr. and Mrs. Walters’ families of origin were having difficulties with aging, and recently the Walters were involved with helping them. Thus, there were some family concerns, but nothing that explained the dramatic change in Ilene. The parents spoke in an animated way about the life of their nuclear family. The four family members were clearly a tight and mutually supportive unit. Gradually, Ilene began to join in the conversation, talking about various extended family members and asking questions. She asked her mother about a family member with mental illness, a topic they had not discussed before and about which Ilene did not know. As they talked more, it appeared that the parents had talked to each other about many of the issues, but that the children had not been included in the discussions. That, in fact, became the focus of Ilene’s upset. With encouragement, she told her parents that she felt very left out of their close relationship and that she thought that they were eager for her to leave for college so they could be alone together. This feeling was reinforced by the fact that they had planned a trip for themselves after they were to drop her off. She discussed this with her brother, just home from college, and the brother asked to join our sessions. Together, the two siblings told their parents that they felt that the parents only cared about each other. For example, both Ilene and her brother believed that as youngsters they were made go to summer camp so that their parents could be alone. Now out in the open, the parents were able to address the concerns of their children and reassure them. They were even able to say, with help in seeing that it would not be devastating, that if Ilene felt she was not ready to leave for college, she could stay home longer. For a couple of months, it was uncertain whether Ilene would go to college or stay home, but eventually, the family worked through the emotions, and Ilene made the decision to go. Therapy was set up for her at school, and she was able to successfully physically separate. We were aware, however, that she would need ongoing assistance, support, and dialogues with parents if college was going to work for her.

Conclusion

The above cases illustrate that being able to stay connected with family throughout the separation process during the transitional phase of adolescent development is a protective factor, and it enhances rather than stifles growth. Working with the parents and adolescents on the conflicts and other problems that interfere with ability to navigate this turbulent time can prevent their resurfacing in adulthood. Family therapy, either with the family as a defined unit or with family members being invited into the individual treatment of an adolescent, is an effective method for opening lines of direct communication and problem solving leading to an improved individuation process. In the case of Wendy, both she and her family were stuck in unresolved traumatic separations from the past that were impeding Wendy’s ability to move forward in her life as well as preventing her from having satisfying relationships with family members. Jennifer and her family members suffered from severe separation anxiety that threatened Jennifer’s capacity to attain her goals. They were caught in an ambivalent connection, and all were suffering. Sean exerted control over his parents by worrying them and rendering them powerless. They, in turn, were afraid to take a stand for fear of dangerous consequences. The goal of therapy was to help the parents take control while allowing Sean to assume more real responsibility for his own life. The treatment failure with the Marsh family highlighted the need to begin the process where all members of the family are emotionally and to recognize the impact of other losses on the process of development. Finally, the Walters family illustrated how essential it is for parents to be a stable, secure presence for the adolescent in order to facilitate a healthy separation. The resulting depression and inability to take a step forward in development occurs when the adolescent cannot count on the parents to remain connected. It was not until Ilene could feel secure in her relationship with her parents that she could move on.

As society evolves, the need for new ways of managing the transition from adolescence to adulthood presents itself. Not only is the world culturally diverse, incorporating many different values, but also the structure of families is changing. Because of economic and social factors, young adults have complicated relationships with parents that extend into their twenties and even thirties. Class distinctions have become more pronounced and impact family organization thus affecting the adolescent generations of the future (NY Times, July 15, 2012). It is in this context that adolescent separation and individuation issues need to be addressed in flexible ways. Improving family relationships by fostering communication and connection between the generations is one way to assist in the young adult’s development of the ability to form positive adult relationships, to achieve education and career goals, and to prepare for the next generation.