The Adolescent in Family Therapy Harnessing the Power of Relationship

by Joseph A. Micucci

Author Joseph A Micucci Isbn 9781606233306 File size 1MB Year 2009 Pages 368 Language English File format PDF Category Family and Friendship Rich with clinical wisdom this successful text and practitioner guide offers a comprehensive framework for treating adolescent problems in the family context Even as teenagers become increasingly independent Joseph Micucci shows they still need parental guidance and nurturance Download 1MB Still a Family A Guide to Good Parenting Through

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Author : Joseph A. Micucci

ISBN : 9781606233306

Year : 2009

Language: English

File Size : 1MB

Category : Family and Friendship



THE ADOLESCENT IN FAMILY THERAPY

The Guilford Family Therapy Series
Michael P. Nichols, Series Editor
Recent Volumes
The Adolescent in Family Therapy, Second Edition:
Harnessing the Power of Relationships
Joseph A. Micucci

Essential Skills in Family Therapy, Second Edition:
From the First Interview to Termination
JoEllen Patterson, Lee Williams, Todd M. Edwards, Larry Chamow,
and Claudia Grauf-Grounds

Doing Couple Therapy: Craft and Creativity
in Work with Intimate Partners
Robert Taibbi

Doing Family Therapy, Second Edition:
Craft and Creativity in Clinical Practice
Robert Taibbi

Collaborative Therapy with Multi-Stressed Families,
Second Edition
William C. Madsen

Working with Families of the Poor, Second Edition
Patricia Minuchin, Jorge Colapinto, and Salvador Minuchin

Couple Therapy with Gay Men
David E. Greenan and Gil Tunnell

Beyond Technique in Solution-Focused Therapy:
Working with Emotions and the Therapeutic Relationship
Eve Lipchik

Emotionally Focused Couple Therapy with Trauma Survivors:
Strengthening Attachment Bonds
Susan M. Johnson

Narrative Means to Sober Ends:
Treating Addiction and Its Aftermath
Jonathan Diamond

Couple Therapy for Infertility
Ronny Diamond, David Kezur, Mimi Meyers, Constance N. Scharf, and Margot Weinshel

Short-Term Couple Therapy
James M. Donovan, Editor

THE ADOLESCENT
IN FAMILY THERAPY
Harnessing the Power of Relationships
Second Edition

Joseph A. Micucci

The Guilford Press
New York   London

© 2009 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
www.guilford.com
All rights reserved
No part of this book may be reproduced, translated, stored in
a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording,
or otherwise, without written permission from the Publisher.
Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number:  9  8  7  6  5  4  3  2  1
Library of Congress Cataloging-in-Publication Data
Micucci, Joseph A.
The adolescent in family therapy : harnessing the power of relationships /
Joseph A. Micucci. — 2nd ed.
p. cm. — (The Guilford family therapy series)
Includes bibliographical references and index.
ISBN 978-1-60623-330-6 (hardcover : alk. paper)
1.  Adolescent psychotherapy.  2.  Family psychotherapy.  3.  Family—
Psychological aspects.  4.  Parent and teenager.  I.  Title.
RJ503.M495 2009
616.89′140835—dc22
2009014593

To
Dominick Micucci
(1920–1981)
for pointing me in the right direction

About the Author

Joseph A. Micucci, PhD, ABPP, received his AB in Psychology from
Cornell University and his PhD in Clinical Psychology from the University of Minnesota. In 1984, he joined the staff of the Philadelphia Child
Guidance Center, where he served as Director of the Adolescent Unit
from 1987 to 1993 and as Chief Psychologist from 1991 to 1993. Currently, Dr. Micucci is Professor of Psychology and Chair of the Division
of Psychology at Chestnut Hill College in Philadelphia, Pennsylvania. He
is Director of the PsyD Program in Clinical Psychology and has taught
courses in psychological assessment, adolescent development, and family
therapy. Dr. Micucci is a member of the American Psychological Association and the American Family Therapy Academy, and is an Approved
Supervisor for the American Association for Marriage and Family Therapy. He holds specialty board certification in Clinical Psychology from
the American Board of Professional Psychology. Dr. Micucci has a private
practice in Bryn Mawr, Pennsylvania.

vii

Preface

In the decade since the first edition of The Adolescent in Family Therapy
was published, my approach to working with adolescents and their families has continued to evolve. As in the first edition, I continue to stress the
importance of family relationships in promoting optimal developmental
outcomes for adolescents. While adolescents are certainly growing more
independent of their families, they continue to need the affection, attention, support, and guidance of their parents in order to negotiate successfully the challenges of the second decade of life. Problems may arise when
family relationships have not adapted to the adolescent’s changing needs,
or when parents have withdrawn their attention and support in ways that
leave the adolescent feeling abandoned or isolated.
In the first edition of this book I also emphasized that clinicians
who work with adolescents and their families must be familiar with the
trends and themes of normal adolescent development. A developmental perspective is essential so that normal and typical behavior can be
differentiated from atypical or abnormal behavior. Families sometimes
overreact to behavior that is typical of adolescents in our culture, and in
overreacting run the risk of exacerbating problems. On the other hand,
widespread myths about “storm and stress” during adolescence can lead
to reduced expectations and failure to provide the necessary guidance to
an adolescent who is off track.
My work continues to be guided by the fundamental ideas of family
systems theory. Symptoms tend to arise, evolve, and persist because of
particular interactional patterns that become attached to the symptoms.
Over time, the symptoms and the interactional patterns become inextricably linked, such that they tend to elicit and reinforce one another.
I have termed this interrelationship between symptoms and patterns of
interpersonal interaction the symptomatic cycle. Effective intervention

ix

x

Preface

requires an understanding of the particular form that the symptomatic
cycle takes in a family and a mastery of a variety of techniques that can
help replace these ineffective interactional patterns with more adaptive
and flexible patterns.
Questions and comments from readers of the first edition, my students, supervisees, and attendees at workshops have guided me in writing
this revised, second edition. The format of this edition follows that of the
first edition. After summarizing essential points about normal adolescent development, I present my basic framework for understanding how
problems arise and evolve in families. In the subsequent chapters, I apply
this framework to a variety of common presenting problems. All of the
chapters have been revised or expanded, some more than others. Some of
the features of this revised, second edition include:
• Addition of an entirely new chapter on anxiety (Chapter 7).
• Expanded treatment of attachment issues and how they can be
incorporated into family treatment.
• Expanded discussion of the development of lesbian, gay, and
bisexual adolescents in Chapter 2.
• Addition of a section on racial and ethnic identity to the chapter
on adolescent development (Chapter 2).
• Expanded discussion of techniques of intervention. Chapter
2 (“The Process of Therapy”) from the first edition has been
expanded into two chapters, one that reviews theoretical concepts,
and one that describes specific techniques of intervention.
• Addition of over 200 new and updated references.
• Addition of new case examples.
A word about the case examples in this book. My intention in presenting case examples is not to offer empirical evidence for the efficacy
of the principles and techniques I am advocating, but rather to provide
a concrete demonstration of how these principles and techniques might
be applied in situations commonly encountered by clinicians. The cases
in this book are not “case studies” in the strictest sense of the term. In
order to protect confidentiality, all of the cases have been extensively disguised and altered in important ways. Whenever I report dialogue from
clinical sessions, the words of the family members have been paraphrased
to protect their privacy and anonymity. Some of the cases are generic
cases. Many of the cases are composite cases, created from clinical situations cobbled together from several cases. A few of the cases discussed
in this book were not actual clinical families at all, but rather “simulated
families.” The latter refers to a procedure developed by my colleague
Scott Browning for the purposes of training students in family therapy

Preface

xi

(Browning, Collins, & Nelson, 2005). An experienced family therapist
trains actors to portray a family and to interact as if they are actual members of a family coming for treatment. The therapist meets this “family” for the first time when they are in character, and then proceeds to
conduct one or more sessions of family therapy with them as if they are
an actual family. Throughout this process, the coach continues to guide
the actors to remain in character and interact in ways typical of actual
families in treatment. When I have been the therapist in these situations,
I have found that my subjective experience is virtually identical to what
I typically experience when treating families in actual clinical settings. I
am grateful to Dr. Browning for his assistance in helping to create the
simulated families, and I am also grateful to the actors for the time and
energy they contributed to this project.
My editor at The Guilford Press, Jim Nageotte, has been a helpful
presence throughout this revision project. I am also grateful to Series
Editor Michael P. Nichols for his insightful comments on early drafts of
some of the chapters. Mike was intensively involved in critiquing drafts
of the chapters for the first edition of this book, and his influence continues to permeate this revised edition.
The ideas in this book germinated during my years at the Philadelphia Child Guidance Center (PCGC) in the 1980s and early 1990s. I am
especially grateful to John Brendler and Michael Silver for all that they
taught me during my tenure at PCGC. The spirit of other colleagues who
contributed to the first edition continues to be present in this revised edition: Molly Hindman, Steve Simms, John Sargent, Guy Diamond, and
the late Peggy Spiegel.
I am grateful to President Carol Jean Vale, SSJ, PhD, William T.
Walker, PhD, and the Board of Directors of Chestnut Hill College for
granting me sabbatical leave in 2005 to work on an article that evolved
into the ideas presented in Chapter 8 of this revised edition. My parents
and family provided me with a “secure base” that allowed me to become
all that I am today.
Finally, and most important, the companionship, devotion, and
encouragement of Jim Davis continue to nurture me and remind me that
our close relationships form the foundation for all that we are and all
that we achieve.

Contents

  1 Introduction

1

My Orientation and Influences  3
Diagnosis and Labeling  4
Biology, Medications, and Systems  5
The Paradox of Control  6
Harnessing the Power of Relationships  7
The ARCH  8
Adolescents Need Nurturance  9
The Plan of This Book  11

  2 Adolescent Development

12

Developmental Issues of Adolescence: An Overview  13
Early Adolescence  16
Middle Adolescence  29
Late Adolescence  45
Summary  56

  3 Basic Concepts

59

A Core Assumption  59
Family Systems and Family Therapy  60
The Symptomatic Cycle  62
Consequences of the Symptomatic Cycle  64
Common Patterns in Symptomatic Families  68
The Pattern Is the Problem  71
Summary and What’s Next  71

  4 How to Assess and Treat Problems
General Principles Guiding Effective Intervention  74
How to Build an Alliance with the Family  80
How to Identify Symptomatic Cycles  82
Setting the Course for Treatment  87
Techniques for Changing Patterns  89

xiii

73

xiv

Contents
When to Conduct Individual Sessions  101
Benefits and Risks of Consultations  105
Summary  106

  5 Eating Disorders

108

Perspectives on Eating Disorders  110
Principles of Treatment  115
Step 1: Negotiating a Treatment Contract  121
Step 2: Encouraging Parental Collaboration  125
Step 3: Addressing Unresolved Conflicts  127
Step 4: Handling Relapses  132
Step 5: Supporting Individual Development  136
Step 6: Supporting the Transformation  139
Pitfalls and Complications  141
Summary  145

  6 Depression and Suicide

146

The Role of Gender in Adolescent Depression  147
Assessment of Adolescent Depression  150
Treatments for Depression  151
The Role of Family Dynamics in Adolescent Depression  153
Common Family Patterns Associated with Adolescent Depression  154
Helping Suicidal Adolescents  162
Case Example: The Crying Father  172
Summary  183

  7 Anxiety

185

Anxiety and the Family  186
Cognitive Factors in Adolescent Anxiety  189
Anxiety and Abandonment  191
Freeing the Family from the Grip of Anxiety:
  A Detailed Case Example  198
Summary  216

  8 Defiant and Disruptive Behavior

217

How Common Is Problem Behavior during Adolescence?  220
Developmental Perspectives  221
Factors Related to Adolescent Defiance  222
Assessing the Severity of the Problem  225
Interventions When the Problem Is Mild  228
Interventions for Moderately Severe Defiance  232
Interventions for Severe Defiance  238
Summary  253

  9 Psychosis
Theoretical Perspectives  255
Psychosis and Isolation  258

255

Contents

xv

Reducing Isolation in Psychotic Systems  261
Summary  267

10 Underachievement and Other

School-Related Problems

269

Factors Contributing to Adolescent Underachievement  271
Strategies for Intervention  279
Identifying and Avoiding Triangulation  291
Summary  293

11 Leaving Home

295

Perspectives on Leaving Home  297
Assessment  299
Intervention  302
Summary  304

12 Families with Multiple Problems

306

Principles for Working with Overwhelmed,
  Low-Income Families  310
Case Example: Two Tokens  318
Summary  321

Epilogue:  The ARCH

323

References

329

Index

359

1
Introduction

Louis (age 16) is locked in a bitter battle with his father. Every discussion turns into an argument. Meanwhile, Louis’s grades continue
to slip and the relationship between his parents is becoming tenser.
Caleb (age 13) can’t go to bed until he performs an elaborate ritual
that is taking more and more time each night. His parents are afraid
to stop him because he becomes terrifyingly agitated if his ritual is
interrupted.
Tina (age 16) has lost over 20 pounds in the past 6 months because
she won’t eat. Her divorced parents, Bill and Rose, seem more interested in fighting with one another than in finding a way to help their
daughter.
Jenny (age 15) ingested a handful of acetaminophen tablets minutes
after what both she and her mother described as a pleasant conversation over dinner.
Keith (age 15) is staying out all night and using drugs. He threatens
his parents with violence if they try to impose any restrictions or
consequences. As a result, his terrified parents shrink from confronting him.

e

This book is about adolescents like Louis, Caleb, Tina, Jenny, and
Keith. Along the way, we will meet other young people like them: Bart
(age 16), whose intractable abdominal pain allowed him to say “no” to
his overbearing father; Tyrone (age 17), on the verge of leaving for college, who can’t seem to follow his mother’s simple rules about curfew;
and Tammy (age 14), whose sexual promiscuity terrified her parents. If

1

2

THE ADOLESCENT IN FAMILY THERAPY

you are a therapist who works with adolescents, the stories I tell will
have a familiar ring. If you are a therapist who is looking for a compass
to orient you through the sometimes frustrating journey of working with
teenagers and their families, I hope to provide one in this book.
In one sense, working with adolescents is no different than working with any person who comes to us for help. The basic principles of
family systems thinking that guide my work can be applied to problems
that arise at any point in the human life cycle. On the other hand, work
with adolescents poses particular challenges because of the developmental processes that are occurring during this period of life. For this reason,
I believe that therapists who work with adolescents must be familiar with
the typical developmental changes that are occurring during adolescence.
In Chapter 2, I review the basics of normal adolescent development and
provide guidance on how to differentiate normal adolescent behavior
from atypical or problematic behavior. One of the major trends that is
at the forefront during this phase of life is the push–pull between dependency and independency. How the parents and the adolescent negotiate
this balance is a critical factor to determining how successful their passage through adolescence will be.
I discuss and illustrate many techniques that are useful in work with
adolescents and their families. However, techniques must be embedded in
a clear map for what the therapist hopes to accomplish. Techniques are
like tools: The more you have, the more options for getting a job done—
but you have to know what you are building first. Familiarity with a variety of techniques can give a therapist security in versatility, but relying
on techniques without a formulation can lead to haphazard and reactive
treatment that frustrates both the therapist and the family.
Many therapists find theories too abstract and therefore not particularly relevant to what they are trying to accomplish in their work with
families. Seeing the merits in a number of different schools of therapy,
many therapists consider themselves “eclectic,” which usually means that
they have refrained from committing themselves to a particular model.
Unfortunately, eclecticism can breed hopeless confusion, leaving the practitioner a “jack of all trades, master of none,” with no guidance on how to
weave together ideas from a variety of theories into a coherent whole.
I hope to address this dilemma in this book by striking a balance
between theory and technique. What I hope to offer are pragmatic solutions for common clinical problems. I have tried to spell out my rationale for my suggestions, and illustrate their use in clinical case examples.
Sometimes, I recommend a step-by-step approach. I trust that readers
will realize that steps and phases are rarely discrete or invariably sequential in all cases, and so will exercise sound clinical judgment in applying
these ideas.

Introduction

3

My Orientation and Influences
The fundamental guiding beacon for my work is family systems theory.
Thus, my focus is not on the individual alone, but on the network of relationships in which individuals participate. A basic premise of the family
systems perspective is the idea that problems and symptoms occur in
an interpersonal context. These problems are not internal to any single
person, but rather arise and are maintained by particular, repetitive patterns of interactions among those who are in close contact with the person who exhibits the symptom or problem. I elucidate on these ideas in
Chapter 3, when I discuss the concept of the symptomatic cycle, and in
Chapter 4, when I describe a number of techniques derived from a family
systems perspective.
There have been a number of important theoretical influences in my
work and my thinking about adolescents and families. From structural
family therapy (Minuchin, 1974, 1984; Minuchin & Fishman, 1981;
Minuchin, Nichols, & Lee, 2007), I borrow many of the concepts that
describe how a family is organized: subsystems, boundaries, hierarchy,
and alignments. I also borrow from structural family therapy many techniques associated with this model, including joining, enactment, using
complementarity, and unbalancing. I discuss these techniques in more
detail in Chapter 4.
From Jay Haley (1987), I borrow the basic framework for conducting an initial session. From models of therapy termed “strategic” I borrow the idea that people get caught up in cycles that keep a problem
alive, and that their efforts to solve the problem often make the problem
worse (Fisch, Weakland, & Segal, 1982). From narrative therapy, I borrow the insight that language shapes our experience of reality, and the
value of talking about problems as if they were external forces influencing all family members rather than defects or deficiencies within individuals (White & Epston, 1990).
My work has also been influenced by ideas that were originally
developed within the context of psychodynamic theory. In particular, I
find value in the work that has explored the importance of emotional
attachments during the lifespan (Ainsworth, 1989; Bowlby, 1988). In
particular, I believe that the emphasis on promoting adolescents’ independence from parents has paid insufficient attention to the ways in which
adolescents continue to need parental support and nurturance (Mackey,
1996). In this vein, I appropriate some of the ideas and methods from
emotionally focused therapy (Johnson, 2004), particularly the emphasis on uncovering and emphasizing the “softer” emotions such as hurt
and sadness that are often obscured behind angry interactions (see also
Micucci, 2006). Also relevant in this context is the importance placed by

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