Psychology of Underachieving Adults

Negotiation: The approach to negotiation taught in this course serves the parents' twin needs of preserving their own well being, and pursuing their desire to support their child in ways that are productive and worthwhile, according to their values and capacities. These negotiations can be an effective component of efforts to influence the adult child's behavior for various purposes.

These purposes include: 1) preserving the parents physical, emotional, and financial well being in the course of their relationship with their adult child; 2) supporting any efforts to help the adult child become more independent or less self-destructive, and 3) creating a harmonious and functional situation in the parents' home when the adult child is living with them.

The process of preparing for the negotiation can be very therapeutic. 1) It can be used to improve family structure, such as in strengthening the boundaries of the parents or eliciting a more adult role from the adult child, and 2) It can help the parents make more realistic and self-affirming decisions as the therapist helps them through their decision making, assessment of the situation, and understanding relevant information such as the nature of the adult child's impairments.

Challenge level: It is hoped that, after mastering this course, the reader will feel over-prepared to deal with most of these situations. To achieve this, there is a good deal of attention given to the more challenging situations and issues:

1) where the adult child has limited or no involvement in family therapy, particularly where he or she would have a difficult time playing a constructive role or where there would be a conflict of interest, and 2) where the parents are highly stressed or manipulated in their relationship with the adult child.

Theory: The course is written in practical and informative terms, with minimal references to theory, allowing the reader to integrate the approach into their theoretical perspective as needed. It draws on clinical experience and research more than it draws from theoretical thought leaders. For example, interpreting the behavior of the adult child as an expression of family dysfunction will often prove to be an overly broad generalization about family dynamics. Another example: The perception that family support for an impaired adult child constitutes enabling is premature without a full assessment.

Therapist roles: The nature of these situations requires a number of roles that the therapist can fulfill over the course of treatment. They include educator, mediator, case manager, advocate, and coach. These roles will be tied to very specific purposes commonly served with these families. Very often, the therapist will be working exclusively with the parents, balancing their desire to intervene in their adult child's behavior and choices with their own needs.

This course is based on the ethical understanding that family members must ultimately decide and take responsibility for their approach to their family and relationships. However, the therapist can play a strong role in helping family members make constructive and effective decisions. This is because family members may be so aroused, stressed, fatigued, and misinformed, that they may be making disastrous decisions that urgently require your intervention. There may be complicating factors such as medical conditions, children of the adult child, legal problems, crime, violence, and chemical dependence. The adult child may have comorbidities such as personality disorder, learning disability, attention deficit disorder, bipolar disorder, and schizophrenia.

Author background: I gained experience with such families in a variety of roles. I have served as a counselor and clinical coordinator in residential treatment facilities for older severely emotionally disturbed adolescents. I have also provided counseling and crisis response for many families as a licensed marriage family therapist working in employee assistance programs, a community counseling center, drug programs, and private practice. My experience in the mental health field began in the mid 1970's.

Treatment Planning and Psychosocial Aspects

Psychoeducational Interventions and Negotiation as a Component

A psychoeducational intervention involves educating patients and caretakers or other relevant parties regarding the nature of the illness or problems, treatment, self-care, and coping in order to improve well being and outcomes. Psychoeducation has been shown in numerous studies to benefit patients, most notably in schizophrenia (Ba?uml, Frobo?se, Kraemer, Rentrop, & Pitschel-Walz, 2006; Magliano et al., 2005; Pekkala, Merinder, 2002) and borderline personality disorder. (Dimeff, Koerner, K., 2007) Psychoeducation in schizophrenia has shown, "significantly decreased relapse or readmission rates," (Pekkala, Merinder, 2002), and additional improvements in areas such as, "knowledge gain, mental state, global level of functioning, expressed emotion in family members..." (ibid)

Ba?uml, Frobo?se, Kraemer, Rentrop, & Pitschel-Walz (2006) state that, "Since the mid 1980s, psychoeducation in German-speaking countries has evolved into an independent therapeutic program with a focus on the didactically skillful communication of key information within the framework of a cognitive-behavioral approach." For some issues, extensive psychoeducational materials are available as part of a programmatic psychoeducational approach, as is seen in dialectical behavior therapy, and in recovery-oriented programs for severe mental illness. (Copeland, 1997).

The therapist can use psychoeducation to assist parents in relations to their adult child. The negotiating approach presented in this course can provide a strong incentive and guiding structure for making use of psychoeducation. The psychoeducational components can include items such as 1) understanding the adult child's impairments and resulting behavior; 2) the services, benefits, and treatment available to the adult child; 3) the legal issues that may affect their options, and 4) the results that parents tend to get from various options.

Therapists can provide psychosocial information efficiently by using a focused approach that targets the most important areas that serve therapeutic aims. Research has shown that mental health center staff can learn to provide psychosocial education with brief training, and provide it in a cost-effective manner. (Magliano, Fiorillo, Malangone, De Rosa, & Maj, 2006) Parents can be directed to informative media for helpful information at a reduced cost.

Functional Family Therapy

The perspectives and structure of functional family therapy are very useful for this work. It integrates the systems perspective, family therapy, and practical sequencing of treatment. It was developed and researched for families with juvenile delinquents. (Sexton & Alexander, 2000) It is easily utilized for revolving door families for reasons given earlier regarding parallels between issues of adolescents and many impaired adults, and because its principles are not limited to the problems of families with delinquents. A family therapist should not find anything highly innovative or surprising in this approach, but will appreciate its organization and explication of the principles. This training is not designed to parallel its structure, but has strong resemblances. The biggest difference is that this training recommends dealing with community resources early in the work, rather than placing it in the "late" stage as functional family therapy does. Readers who do not have social work training or substantial case management experience are strongly advised to become familiar with this approach.

What is Realistic?

It is very important that the family and therapist not to base their plans on unfounded assumptions about the potential of the adult child, or the capacity of the parents to consistently enforce boundaries.

Underestimating the adult child: Factors such as criminal history, mental illness, or patterns of defaulting on agreements may tempt the parents or therapist to assume that negotiating with the adult child is pointless. While it is true that one of the best predictors of future behavior is prior behavior, there are two considerations of particular interest in this discussion. One is that we are learning that certain programmatic efforts have revealed previously unrecognized potentials in underserved populations such as the mentally ill. In a study on success in a housing program, it was shown that people with criminal histories were no less likely to succeed than were participants without criminal histories. (Malone, 2009) Many persons with mental illness are gaining much more independence as a result of treatment that includes psychoeducation from a rehabilitative perspective. (Copeland, 1997) The elements of this approach address a number of needs that are not unique to persons with severe mental illnesses.

Second, if the adult child has not received adequate assessment, social service linkage, and treatment, this may be a good reason to be skeptical about negative predictions regarding his or her potential for success.

Realistic timeframe and treatment: The adjustments that an adult must make in developing a more realistic assessment of their own abilities can be more challenging than parents and even professionals may recognize. This adjustment may require time to work through a number of phases. Young, Bramham, Gray & Rose (2007) discuss adaptation of adults to the diagnosis of attention deficit disorder (ADD). In their analysis, the authors described a, "six stage model of psychological acceptance..." that included: "(a) relief and elation, (b) confusion and emotional turmoil, (c) anger, (d) sadness and grief, (e) anxiety, and (f) accommodation and acceptance." (ibid) In their conclusions, the authors stress the importance of treatment, saying, "Cognitive behavioral techniques will help clients diagnosed with ADHD in adulthood cope with the adjustment process. Adults should be taught skills to anticipate future hurdles and challenges and apply appropriate coping strategies." (ibid)

Realistic level of support: Parents and some professionals may have difficulty accepting the kinds of support that chronic mild impairments such as ADD may require. Because the adult child's strengths give the impressions that such support is unneccesary, the needed accommodation can be counter-intuitive.

For example, a person with ADD may need to rely on external cues in order to stay organized, timely, and focused on priorities. This can be necessary for a person making the transition to college. With sufficient sophistication, a person with ADD may create systems that largely accommodate such needs. However, particularly early in grappling with the disorder, much external support may be required to maintain efforts at increased responsibility with sufficient consistency. (Parker, & Benedict, 2002)

Conditions that Justify Investment: The purpose here is not to create yet more concessions from the parents based on pipe dreams. Rather, it supports sober consideration of plans that will support success while protecting the parents from excessive loss or exposure to risk. The definition of excessive loss and risk must be derived from the parents' situation and values, with help from a therapist committed to helping the parents give sufficient weight to their own needs.

The following good examples of indications that the adult child's potential may be greatly underrealized, and that there is justification for negotiating with the child. All three conditions should be met.



Even a child with some antisocial personality traits may be able to benefit from negotiating with a parents that have intact boundaries and an adequate understanding of his or her issues.

Overestimating the adult child: Despite ample evidence to the contrary, some parents seem to have a limitless capacity to tolerate betrayals of their trust or optimism regarding the judgment, responsibility, and planfulness of their adult child. The reasons for this are discussed at various points in this course. It is the responsibility of the therapist to ensure that the parents have sufficient understanding of their adult child's impairments, that they can make objective decisions. Scenarios should be discussed that would constitute adequate reason for a more conservative approach such as pulling back from efforts to influence the child or provide certain resources.

Parents may need information regarding their child's impairments in order to adopt a more realistic view. The parents' ability to provide information covering the adult child's development can be very helpful. Parents are likely to have a poor idea of what to emphasize, so the therapist must educate the parent about the importance of allowing the therapist to focus the discussion with a series of questions.

Without diagnosing, the therapist can point out 1) the more common explanations for the current behaviors; 2) diagnoses that would probably be considered for an individual with the history given, and 3) likely progress or levels of success under various circumstances such as the provision of more treatment and support.

The therapist must explain the nature of the diagnostic process and its limitations, including the fact that individual people are not statistics; they may surprise even the most expert and well-informed clinician.

Overestimating the parents: The therapist should assess and monitor for two risks in parents that can undermine treatment. One is that the parents may have impairments that will limit their ability to understand their adult child's impairments (or their own). The other is that the parents may have impairments or emotional issues that prevent them from being adequately consistent in enforcing boundaries with their child. For example, they may have difficulty withholding some form of support when their child fails to meet a deadline for completing a resume. One of the concerns here is that the encroaching effects of stress or emotional manipulation may be impairing their judgment or stamina. Parents need to take the potential health effects of this situation seriously. This factor alone may be the one that gives them the permission that they need to give their own well being greater weight in their decision making.

Treatment should be molded to the parents' capacities to benefit and act on potential plans regarding their adult child and their own well being.

How Far Should Parents Go? How do They Benefit and Grow?

Although there is no set answer to this question, there are two considerations of special importance to this course. One has to do with the rights of the parents. The other has to do with creating a context for learning and change from which the parents can grow and benefit.

Parents' rights: First, parents have the right to go as far as they wish in giving their child second chances or additional opportunities or resources. They also have the right to withhold all contact and resources if they so choose. Parents will tend to have a bias in one direction or the other. If parents have come to see a therapist about how to more effectively relate to and help an impaired adult child, they are most likely biased in the direction of offering more, not less.

Learning and change: Second, the therapist must stay within ethical guidelines and refrain from telling parents where to draw the line, but can provide information and experiences that help them draw that line in a realistic and self-affirming manner. It is recommended that the therapist cultivate an experimental sensibility in sessions. That is, to get the parents to think like scientists. Then, it is easier to talk about how they will respond to potential outcomes of their experiments with the child.

For example, "If you send her to the Culinary Arts Program, you think the odds are about 70% that she will continue, so long as you provide sufficient support. Let's talk about what actions to take if she drops out, and what factors might cause that. This way, we will be prepared. Let's also talk about what factors might increase the odds that she will hang in there and complete the program." If the parents' "experiment" provides a surprising result, the frame is not so much one of failure, but of learning and change.

Treatment Plan Areas

1. Parents' Well Being

What aspects of parents' well being are affected or threatened? Examples include stress, health, and finances. Are the parents attempting to help their adult child in a manner that is in line with their values and capacities? What dynamics are preventing that? Has an unconscious agenda on the part of the parents sabotaged their boundaries? Has worry, stress, or concessions come to threaten the parents' health or finances? The therapist must work with the parents on their well being in this light.

2. Positive Family Structure

Evaluate the family structure. Can decision making be improved with changes in the balance of power? How intact is the parental subsystem? How effective is communication with other family members that can help? Are there additional family members that are realistic and can provide helpful understanding and information? Are other family members involved in a questionable manner? Is involving additional family members in therapy called for?

3. Adult Child's Well Being

What aspects of the adult child's well being are affected or threatened? Because many adult children have multiple problem areas compounded by personality factors such as denial, this could become a bloated area of the treatment plan. However, many factors may need to be taken into consideration here because the parents are basing decisions on them.

Contract items can include, for example, "Compliance of adult child with agreements with parents." Sub-items could include, "Adult child will continue to attend classes regularly and provide specified documentation of this on a weekly basis."

Unlike a treatment plan for an adult child who is a client of the therapist, this component has two purposes. One is to support efforts to help the adult child. The other is to help parents adjust their behavior and plans, and to become more realistic and to adjust emotionally.

Parents may need to form long-term plans that take into account the likelihood that their ability to provide support will lessen as they age.

Purpose and Philosophy of Negotiation

Purposes of Negotiation General purpose: The purposes of a negotiation between the adult child and his or her parents are to improve the choices that both the parents and the child are making. The parents want to see their child make choices for well being and success. The parents also want to reduce their stress.

View to motives: The adult child's motives may not be understood. For the purposes of negotiation, the adult child's motives are viewed from two perspectives: 1) From the perspective of their utility in creating a willingness to participate in negotiation and make concessions to the parents, and 2) from the perspective of positive underlying motivations that are masked by destructive behaviors. The term "concession" may sound, but it refers to offers or lessened demands made by any party. If the adult child accepts that a monthly stipend will depend upon the adult child providing access to the online record of performance available through the college she is attending, that is a form of concession.

A developmental view: This approach is a way to make the relationship between parent and adult child more adult. This is because it develops a negotiation done in free will between adults. Thus, it serves as a reframe for the parents, giving them a structure within which to process the reality of their child's being an adult and having adult options, even unfortunate ones. It would be a therapeutic metaphor, except that it is a reality.

This approach, with little modification, can also be used with mid to late teens. They are going through a transition into adulthood. The difference with teenagers, of course, is that the parents typically have more control and authority. However, many teens have developed levels of support outside of the immediate family, that they are not controllable. These teens may also be under the influence of a questionable peer group, or a more sophisticated individual or group. When this is the case, the teens are being influenced at a very malleable age. This adds urgency to the matter. Parents sense that their child is slipping from their grasp, possibly into great harm.

Balancing aspects: The therapist may emphasize one or more of the following aspects, and may change emphasis, depending on the circumstances:



Incentive for therapist to participat: The greater the importance and urgency of completing the negotiation, and the lower the capacity of the parties to negotiate, the greater the incentive for the therapist to help conduct the negotiation. This assumes that such involvement is appropriate, a matter that will be addressed.

Conditions that favor Negotiation

The more the adult child needs what the parents are prepared to offer, the more likely it is that the adult child will participate in a negotiation. The same goes for the quality of the relationship between the parents and their child, and the degree to which all parties have the capacity to negotiate and follow through.

However, even where the adult child is unable to follow through consistently, negotiation may be worthwhile. Examples include getting the adult child into an inpatient treatment setting, getting the adult child to transfer property into the name of the parents or others who can be trusted to preserve and manage it in the adult child's long-term best interest, and getting the adult child out of a highly destructive situation.

The less support the adult child receives from outside sources, the more likely the child is to participate and to make concessions. Adult children are less likely to negotiate with their parents when they are very successful at manipulating others, have a supportive peer group, have criminal sources of income, or have legitimate means of support.

Is this therapy?

Preparing parents to negotiate effectively with their adult child can be therapeutic. This is especially true for parents who are experiencing emotional distress in relating to their adult child, or whose poor judgment is causing harm. The results of these negotiations are sometimes matters of life and death. If the negotiating takes place in the context of family therapy, the clinical skills of the therapist will be used to benefit all parties.

Is this Mediation?

If the negotiation takes place in family therapy, the therapist will use some mediation skills. The use of mediation skills is commonplace in family therapy up to a point. However, the therapist is not functioning as a mediation specialist, and the work is not limited to mediation. There are mental health issues and power differences in the situation that are not commonly handled through mediation. The work exceeds the scope of mediation and takes advantage of the therapist's clinical knowledge and skill.

Is this an Intervention?

This process has more of a resemblance to intervention than mediation, especially where substance abuse is at issue. However, it exceeds the scope of intervention. This is because of the ongoing therapeutic relationships. Some interventionists engage in a good deal of psychosocial education of parents and others. This constitutes even more of an overlap between the roles, especially where the effort is primarily to convince the adult child to participate in an inpatient chemical dependency treatment program.

Is this Coercion?

There can be a resemblance between this process and a coerced or mandatory referral of an employee. In a mandatory referral from an employer, the employee has a motive for complying with certain demands from the employer. These demands include a visit to an employee assistance professional for assessment, and possibly for referral and monitoring of treatment compliance.

The employee receives a reprieve from the disciplinary process, and the employer has better odds of retaining the employee, and the investment that the employer has made in that employee. Employers consult with their employee assistance program as to how to approach a specific employee, and then make compliance with the mandatory referral a condition for temporarily halting the disciplinary process. If the employee fails to comply, he or she may lose their job immediately, or after another incident such as being late or aggressive, depending on the nature of the problem and the specifics of the employer's disciplinary policies.

The parallel between a coerced referral and this negotiation process is that the employer, like the parents, has things that the employee, like the adult child, wants. Further, the education of the employer has some resemblance to that of the parents. The main difference is that the parents are often the treatment unit. The employer would not be part of treatment.

Issues of Coercion and Monitoring

The issue of monitoring of treatment compliance is of interest here. In some cases, the parents may require their adult child to release a limited amount of information so that they may be assured that their child is complying with treatment. This can improve the odds that the adult child will participate in treatment and comply with recommendations.

The limited release of information allows the provider to inform the parents (or designated party) promptly if treatment compliance ceases or there is danger. Where treatment compliance is part of the contract between the parents and adult child, noncompliance will trigger the agreed-upon consequences. It can trigger additional support from the family and extended family where appropriate. It can also trigger the termination of support of some kind. The nature of the agreement depends upon the needs of the family and adult child.

Therapists who are not schooled in mandatory referrals may flub their role by failing to notify the parents of noncompliance, or by giving too much information, thus violating confidentiality. Research and extensive clinical experience shows that coerced treatment can be effective. However, the therapist treating the adult child, and the therapist working with the parents must intimately understand the meaning and nature of the limited release. It has clinical, legal, and ethical issues.

The therapist must be organized enough to react promptly to noncompliance. The parents' therapist must make sure that they have no unrealistic expectations as to what they will be told or what therapy can accomplish. They must clearly understand whatever role they are willing to play in a mandatory referral.

Potential problems with a therapist for the adult child: Many therapists do not have experience with some of the practices recommended for working with revolving door families. For example, they may not understand the idea of a limited release of information that allows the parents to receive verification of treatment compliance and timely notification of noncompliance or termination of the release. It is very important that the therapist attempt to use treatment professionals who are prepared to provide this information and who appreciate the importance of intervention that is sensitive to systems issues, as multiple systems are involved.

Parents are shocked and disappointed when they find that the therapist treating their adult child has not complied with such agreements. Although the parents are funding the treatment and have a verbal understanding, the issue simply did not take root in the inexperienced therapist's mind. Noncompliance, relapse, safety issues, or termination of release of information may have gone on for some time before the parents find out.

Preventing problems with the adult child's therapist: To help prevent this, the therapist or parents should initiate contact on a regular basis, asking one or two simple questions, most especially, "Is the release of information still valid?" "Is the adult child complying fully with treatment?" and, "Are there safety issues such as relapse, threats, or crime?" It may also help to remind the treating therapist of the contract specifying the conditions under which the therapist is obligated to communicate with the parents, and the release of information. A therapist with mandated referral experience, such as those who have worked as employee assistance professionals, is more likely to manage a situation like this effectively. They are already familiar with the legal and ethical issues.

Contracting with a therapist for the adult child: When parents are funding treatment, they should establish a written contract with the adult child's therapist. This contract should specify that the treating therapist will notify the parents of :

1. Any treatment noncompliance (including failure to show or return calls, or failure to follow treatment recommendations such as attending a twelve step program) or
2. Certain risks of harm (such as suicide threats, visible signs of injury, or positive urine screens).

Framing the referral for the adult child: For the purposes of this process, words should be used that will help the adult child feel better about cooperating. The therapist can omit words such as "mandatory" or even "treatment" that have a negative connotation. Instead, a phrase such as, "seeing a counselor who is really good with this," is desirable, especially with adult children who respond rebelliously to their parents.

Negotiation, Phase I: Alternatives, Assessment, Education, Agreements

Introduction

Opportunities, rationales and roles for negotiation: This section views the family situation as an opportunity for negotiation. Often, the parents cannot convince their adult child to participate in family therapy, but they can enlist him or her into negotiation, as will be described. In other situations, such negotiation may be a seamless part of family therapy. This course is emphasizing the situation in which the adult child is not a client, and the parents' needs are the therapist's primary responsibility.

As mentioned in the introduction, the therapist can assist parents in negotiating new agreements with their adult child. These agreements can help parents protect and enhance their well being and can help the parents improve the odds that their adult child will take successful and constructive actions. These negotiations can help families regain or maintain stability. Such negotiation can be useful in a variety of family constellations, and is not dependent upon the adult child living at home.

Parents often have meaningful, constructive reasons for wanting to influence the behavior of their adult child. At first glance, this may seem like meddling, but it is reasonable for parents to want to use what influence they can muster when their child is at risk for coming to harm because of impaired judgment. In addition, if the adult child is living at home or otherwise using parental resources, the parents have the right to impose conditions. Because of the issues of mental health, family dynamics, and well being that are in play, the therapist is in a good position to help the parents negotiate effectively with their adult child.

Designing negotiation: Artful judgment calls are called for in devising these negotiations. Although the therapist has no crystal ball, the therapist must have as clear a perception as possible of the bases of the negotiations. The therapist must have a good idea what boundaries and consequences the parents are willing and able to enforce consistently. If the parents are requiring the child to never come home drunk and loud, are they truly prepared to send him away if he does so? The therapist must have a good idea what the adult child is capable of. Are the parents acting on unrealistic expectations when they require their adult child to quit a serious methamphetamine addiction and gain employment in two months even though they can afford to send her to inpatient treatment?

At the same time, the parents must be assisted in putting this process into perspective. They must understand that they are working with odds, not guarantees. The therapist must help the parents understand the scope of assistance that the therapist can provide, and make sure that they don't perceive the therapist as a mediator.

Many parents have never completed the grief process that is involved in accepting their child's impairments or behavior, or to come to terms with their powerlessness over the risk of serious harm to their child. Parents often need assistance in letting go and in finding peace of mind. The therapist may be providing grief counseling and advanced stress management skills.

Alternatives: Are Other Treatments or Services Needed Prior to or During a Negotiation Track?

Parent Readiness

The therapist may determine that negotiation is not a good idea now, but could be if certain conditions are met. This may help to inform the therapy conducted with the parents, or referrals to other services. The parents may not be capable of negotiating effectively and may have a long track record of making serious errors. Even if they could negotiate, many parents are not capable of holding to agreements that they would make in good faith. These are usually boundaries and consequences such as requiring that the adult child uphold certain agreements in order to receive some kind of support.

The first work may be to help parents regain their mental clarity, stamina, or emotional stability by pulling out of living from crisis to crisis. This is an important area for parents to recognize and understand. The therapist can help the parents establish a vision of a more orderly and strategic approach that supports them in an emotionally healthy lifestyle. Means for achieving such stability include addressing any sleep problems, normalizing parents reactions as normal responses to an abnormal situation, and emphasizing the importance of the parents' well being and the seriousness of the threats to their well being. Parents may feel that the alternative to high anxiety is depression and bitter resignation or futility. The therapist can play an important role in helping the parents create a vision of strategic resolve and recommitment to their own well being and their other contributions in life. Resistance to this shift, if it appears, must be recognized and processed in a manner that is understanding of the difficulties of such a transition.

Parents must be prepared to create forms of monitoring, security, and accountability for their own peace of mind and financial well being. For example, if the adult child cannot be trusted with the computer unsupervised, it may be necessary to secure it with a pass code. Purchasing agreed upon items rather than providing cash will be necessary for some adult children. Checking the odometer on the car and using a key-logger on a computer are other examples.

Such monitoring and control can be framed to parents as a means of maintaining peace of mind and learning about problems that their child may not have revealed. Covert monitoring of this kind is not illegal or unethical if the adult child's behaviors have included manipulation or lying or there are reasonable concerns to this effect, especially where drug use is concerned. The purpose is not to catch the adult child, but to understand. Sometimes being above board about certain types of monitoring can help to prevent inappropriate behavior.

Adult Child Readiness

The adult child may be uninterested in negotiating with the parents, or be unable to do so effectively. In such a case, the therapist may need to educate the parents and help them understand what recourse they have, if any. Parents may have difficulty coming to terms with a situation in which they are helpless to get the information or changes that they desire. This can amount to a grieving process.

It is often the case that the adult child needs a number of services and resources in order to develop the capacity to negotiate with the parents. At the same time, negotiation must take place in order for the parents to feel good about providing such support. Strategic thinking and assessment must be used to untangle this knot.

One "cheat" that can be used to initiate some momentum is for the parents to make a unilateral move. For example, they might declare that a key resource will become available once the adult child has taken a specified step, such as having an initial appointment with the mental health center, or providing a urine screen.

Involvement of the Justice System

This topic deserves special mention. Although families may have serious reservations about how their adult child might be treated in the justice system, families should also consider the potential benefits such as court-ordered treatment and follow up. In a situation in which the family cannot take appropriate action without being threatened with harm or property destruction, the family may need to learn how to time a call to the police so that the situation and evidence will be as safe as possible, and lead to the arrest of the adult child. The possible need for this or other actions that the adult child will not perceive as being in his or her best interest exemplify the rationale for not attempting to be the therapist for the parents and the adult child.

Psychiatric Emergency Services

Where mental illness is involved, families should learn about the availability and services of the county unit that deals with psychiatric emergencies. Their presence can help improve outcomes where police are involved. Before there is trouble, the family should contact this unit and discuss how the situation may need to be handled. The family needs to know about the hours of availability, typical response times, what services are rendered, the qualifications of the staff, and how the police relate with this agency.

Hidden Issues

There are various ways that hidden issues may undermine the preparation or negotiation. For example, a resource that the parents are providing may be undermining the adult child's well being. In one case, the parents were allowing their mentally ill adult child to drink very large quantities of sugared, caffeine-rich soda. This contributed to disordered sleep on the part of the adult child, who then disrupted the sleep of the parents with his activities.

Drugs and Alcohol

Abuse of drugs and alcohol is pervasive, and occurs at much higher rates in impaired adults. Plans that do not address active substance abuse are easily torpedoed. Thus, evidence of abuse should be taken seriously. Measures such as drug screens may help. It can be a condition required in the negotiation. Overzealous concern about drug abuse should not mask a problem such as a mood disorder.

Collateral Information

The therapist should never underestimate the potential value of collecting information from collateral sources that may help with assessment and treatment planning. Whenever possible, having brief initial interviews with additional family members or even non-family members that the parents feel good about including may provide unexpected value.

Diagnosing and Legal Advice

The therapist must take care not to offer legal advice or to diagnose someone that they are not treating, such as the adult child. However, the therapist can provide a great deal of help based on history from the parents and diagnostic information from a current or prior provider. A referral for legal advice may be required.

Assessment: Detailed Guidelines

Introduction

These guidelines are intended to augment the therapists' assessment procedures. They are primarily an early phase assessment that emphasizes family members' perceptions. An understanding of these perceptions will afford the therapist much better odds of establishing rapport with the family, and determining what knowledge and perspectives the family members need in order to improve their outcomes.

Since much of the assessment involves understanding the impairments, development, motivations, and status of the child, parents may get the impression that the therapist is preparing to treat the adult child. It is important to put these questions into perspective, indicating that they are to help determine potential courses of action.

Most of the assessment guidelines are multiple-choice items, many of which cover a scale. In order to make use of each item, there must be some understanding as to the reason for the answer. For example, relationship may be cut off for a variety of reasons. It may be because the child has fled a situation in which he or she is being forced to discuss active drug abuse. That will require a very different approach to one in which the relationship has become cut off merely because the family cannot deal with moderate conflict over house rules.

Finally, in addition to the current status, each question should also be answered in terms of what status is realistic and desirable for the family. Each such answer suggests treatment interventions. If the relationship is cut off, is there justification for this, such as severe and real threats? Or, more likely, is engagement a desirable goal? If so, what are the obstacles and how can they be resolved? Do the parents need to have more realistic attitudes about their adult child's abilities, and additional skills for maintaining a connection despite their child's defensiveness? Can the child be included in family therapy, or is the therapist only able to help the parents modify their behavior and strategies for helping their adult child?

The answers to these assessment questions will prove to be very important in determining how to proceed with the negotiations described following this section.

Immediate Practical Considerations Threat Level

Immanent danger

Periodic danger, fights

Instrumental threats, damage

Risk factors are evident

No risk factors are evident

Status of Stressors and Resources Emerging or Occurring in All Family Members

Discuss these domains in terms of how they are being affected by the impaired family member as well as other factors. Discuss how this is affecting the roles and well being of family members, and what plans and efforts have emerged so far. What have been the results of the family members' attempts to cope with these issues.



Family Material Resources and Intention for Support

Bottom line: Learn about the family members' opinions as to what kind of lifestyle their impaired member should live. Some families have a level beneath which they will not allow the member to fall unless that individual violates certain codes of conduct. What are those codes and level?

Support: How far are family members willing to go at this point to ensure a certain level of well being or comfort. Paying rent on an apartment, paying for treatment, or maintaining a vehicle are typical examples.

Consequences: What are the members' current opinions as to issues of natural consequences, bottoming out, and what the impaired member deserves. How do they currently perceive the impaired individual's responsibility for their situation and the results of their behavior.

Emotions: What emotional reactions occur during interactions with the impaired family member? Are family members in repeating patterns of unproductive or harmful interaction? What is the current level of willingness of the members to alter these patterns and move toward new goals?

Material Resources: What financial and other resources does the family have to support the adult child? Finances may be used for anything from a disability attorney, to an inpatient drug program, to a car for a job search.

Social Service Level

Social services not accessed

Substantial obstacles exist

Partial access

Mostly accessed

Social services accessed as needed

Engagement, Dependence

Family Engagement Level

Entangled

Engaged

Re-engaged (Apparently, some important things happened to re-engage the parents and adult child. What were they?)

Cut off (What led to the cut off? Who initiated this and why?)

Adult Child's Level of Dependence on Family

Full dependence

Partial dependence

Dysfunctional independence

Full independence

Support and Engagement Factors

In what ways does family engagement and support appear to be excessive, inadequate, or appropriate, given the level of impairment and family resources? What cultural or social class factors are involved?

Impairments, Strengths, and Motivations

Nature of Impairment, Development, Motivations, Status of Adult Child

The therapist must attempt to understand the adult child well enough to provide helpful consultation and support for the approach that is settled upon. Most likely, the therapist is not in a position to conduct a full assessment of the adult child. However, the parents are probably a rich source of information, and they may have additional documentation from assessments that took place earlier for school, services, or independently. If the adult child is receiving mental health services, it may be appropriate to request that the adult child release the clinicians to speak with the parents' therapist.

The areas to explore include what is known about the adult child's:

Impairments and Motives of Parents and Other Family Members Involved

Problems such as entanglement, boundary crossings, bad judgement, fights, repeating the same errors without seeming to learn, may result from impairments in one or more family members. The therapist should look behind these behaviors for cognitive problems, substance abuse, impulse control problems, and other factors that may impair the parents. It is important to know what may trigger a family member to over or under-react.

What do the previous actions, judgments, and outcomes of the parents tell you about their strengths and needs? How well are the parents supporting their own well being? The therapist may wish to provide a great deal of psychoeducational information. The therapist may also wish to help the parents see the situation from the perspective of other stakeholders. To avoid overwhelming or alienating the parents, the therapist must learn how much information the parents can handle at one time, and the best form in which to provide it. The therapist must take the participants' impairments and strengths into account.

Recovery Level

What level of recovery has the adult child achieved, and what is anticipated under current circumstances? What changes may be necessary for this projection to improve? (And how confident should the clinician really be about any of this, based on the information available? It is important not to assume that limitations are permanent when recovery occurs in highly impaired people.) Chronic Problems Anticipated (Illness or Impairment-based)

Recovery Only Possible with Major Change in Motivation, Perspective

Relapsing Problems Likely (Course of Illness, Impairment)

Recovery Likely with Continued Learning, Treatment or Other Intervention or Support

Recovery in Progress with No or Minor Obstacles

Recovery Largely Complete, Work Toward Independence is Underway

Final Stage of Regaining Independence

Fully Independent

Regression Risk Level

What is the likelihood that the adult child will regress to a lower level of functioning, into relapse of substance abuse or another condition, or into risk behaviors? What conditions are relevant to this assessment? How great is the level of uncertainty? "Normal" uncertainty would mean that there are significant reasons for the ascertained risk level, but that the clinician accepts that people are not statistics and many of us make surprising changes of course. High Risk of Regression

Moderate Risk of Regression

No Risk Factors for Regression Evident

Awareness, Information, Perceptions, and Dynamics

Family Challenge Awareness Level

Full denial

Instrumental denial (manipulative, controlling)

Partial denial

Full Awareness

Child Challenge Awareness Level

How well has the adult child accepted the realities of his or her impairments?

Full denial

Instrumental denial (manipulative, controlling)

Partial denial

Full awareness

Family Information Level

How well informed is the family regarding the adult child's challenges?

Uninformed

Partially informed

Well informed

Child Information Level

How well-informed is the adult child regarding his or her own challenges?

Uninformed

Partially informed

Well informed

Family Members' Perceptions of the Impaired Member and the Resulting Dynamics

Discuss these perceptions in terms of how family members are affecting each other, and how these perceptions may be aiding or challenging adaptation and unity within the family and in terms of engagement with outside systems and resources.

Assessment: Creating the Scenario View From Scalar Questions

Introduction

In the assessment phase, there are questions of scale, such as in determining the current level of engagement between the parents and their adult child. Collectively, the answers to these questions constitute various scenarios that the therapist must take into account in determining where to start and how to proceed. Below are the questions from the assessment guidelines that are best suited to this scaling and basic scenario creation. This collection can help identify important problem areas. This is reproduced with fill-in blanks in an appendix to this course.

Immediate, Practical Topics

Threat: How high is the level of threat of violence or other harmful behavior?

Stress Effects: How severely have family members been affected by stress in domains such as medical, financial, etc.

Support Capability: How capable is the family of materially supporting the adult child

Social Supports Utilization: How well have social services and other supports been accessed and utilized, considering the level of need and qualification for services?

Obstacles to Social Supports: How problematic are any obstacles?

Appropriateness of Plans for Social Supports: How appropriate are existing plans for overcoming obstacles and using social supports?

Engagement, Dependence

Relationship with Family: To what degree is the relationship entangled, highly conflictual, functionally engaged, or cut off (or some combination)?

Dependence: How dependent is the adult child on the family or other systems for sustenance?

Appropriateness: How appropriate is the current level and form of engagement and dependence, given factors such as impairment and family resources?

Functioning in Independent Spheres: How functional is the adult child in his or her independent spheres of functioning, or in his or her relationship with systems upon which he or she depends? (E.g., Gets along with parole officer?)

Impairments, Strengths, and Motivations

Impairment of Each Member: How impaired is the performance of each family member that is involved?

Strength of Potential Family Support: How strong are the capacity, intentions, and current motivations of parents to support the adult child? (Consider financial and other resources, as well as types of support the parents are open to or rejecting.)

Likelihood of Progress in Recovery: How likely is the adult child to remain at the current level of impairment, get worse, or get better? How well supported is this contention? (How likely is it to be accurate?)

Awareness, Information, Perceptions, and Dynamics

Family Members' Acceptance or Denial: How well has the family accepted the reality of the adult child's impairments (as opposed to being in denial)? How about the adult child?

Family Members' Sophistication: How sophisticated is the family's understanding of the situation? How effective have their choices been in achieving their desired outcomes? How accurate have they been in predicting outcomes?

Family Members Readiness for Utilization: How positive and optimistic a view of the adult child's strengths does the family have? How strong is their sense of how these strengths can be reinforced and utilized?

Education and Initial Agreements on Treatment Plan and Focus

Purpose of This Phase

The therapist is to collaborate with the parents in generating a treatment plan that supports their welfare and has good odds of success. To achieve this, it is important strategically educate parents regarding a number of factors. For the purpose of this course, strategic education refers to the delivery of information in a sequence that is most likely to be accepted by the parents, and is most likely to have a positive impact that is in harmony with the current phase of treatment. In other words, the therapist uses care in providing psychosocial education because parents, as discussed earlier, may be inflamed, impaired, and feeling highly obligated or betrayed. These factors can eclipse the parents' effective commitment to their own well being and an objective assessment of the situation.

Therapist's Roles and Boundaries

As with any couples or family therapy, issues such as secrets and the identified treatment unit must be discussed. For these families, it is especially important to discuss the therapist's inability to provide legal advice, to predict the future behavior of their adult child or any external systems, and the free will of the adult child to disregard any attempts at influence by the family or external systems. The parents should have a good understanding of the therapist's roles and boundaries. The sections that follow will help to put this into perspective.

Regarding the negotiation between parents and adult child, the therapist can help the parents prepare for and follow up on these interactions.

Parents as Clients

The therapist should solicit an agreement from the parents to put their own welfare first. There may also be a need discuss the welfare of vulnerable family members such as any minor children in the household.

The parents should understand the kinds of methods that can be used to enhance their relationship with their child and how they may be able to improve their capacity to influence their adult child This information should include the strengths and weaknesses of such methods. The therapist should help the parents understand the difference between influence and entanglement, by discussing issues such as boundaries.

Parental impairments and other issues may need to be addressed. This may be as simple as helping parents understand how such issues factor into the situation and how to mitigate against further interference, or as complex as requiring treatment by the therapist or other service providers. Redirecting the parents' attention from their adult child to their own issues requires caution and rapport in order to avoid losing the alliance with the parents.

Couples that are Not Both Parents of the Adult Child

The therapist may need to determine how much sway a non-biological parent will have in decision making and negotiation. This will depend on the duration and strength of the bond, the contributions of the non-biological parent, existing agreements, the influence and involvement of an ex-spouse, and the abilities of each individual in the couple.

Other Family Members

Siblings of the adult child and other family members may be appropriate to include in one or more sessions. The purpose of such sessions may be to help them better support the parents in managing their boundaries and agreements with the adult child, and to better participate in providing support for the adult child that is in harmony with that of the parents. Conflict and misunderstandings may have arisen regarding these issues. Some extended families are much more intertwined than others are.

Case Management and Linking

The parents' needs may be at odds with the adult child's (as he or she perceives them) in ways that would compromise the therapist's work if he or she were to see the adult child as an individual client. However, the therapist may engage in case management in attempting to link the adult child with another therapist or other appropriate services, depending on the adult child's motivations and the resources available. Parents that are able and willing to do the footwork can fulfill much or all of this role. The therapist can educate the parents about the available resources. The therapist should maintain a list of information resources that can help to locate specific community resources or problem-specific information resources.

The Possibility of Including the Adult Child in Family Therapy

For cases in which the adult child is being considered for participation in family therapy, the therapist should take care to determine whether this is appropriate, given the possibility of a conflict of interest. All parties should understand the circumstances in which a member of the family would be referred for individual therapy, or in which the therapist would have to exclude the adult child from family therapy participation. These circumstances would include the adult child attempting to get the therapist to hold secrets, conflict of interest between the parents and adult child that is sufficient to impair the therapist's ability to be of service to all parties, and disruption of therapy by the adult child.

Although the therapist is not providing specialized mediation services, limited mediation can be an aspect of family therapy. For families for which it is appropriate to include the adult child, there may be good reason for the therapist to play a role in helping the parents and adult child negotiate and finalize their agreements. This would be when communication skills need to be improved. The behavioral contracting process can be an opportunity to practice such skills. It can also be a context for developing greater mutual understanding and collaboration.

If the therapist were to be present for negotiation between parents and adult child, a clinical relationship could be inferred between the therapist and adult child regardless of the position that the therapist takes on this matter. This brings up ethical and legal issues such as informed consent.

This course does not address this treatment constellation (family therapy including the adult child).

Seeing Individuals

The therapist should not function as individual therapist for the adult child in these scenarios. The therapist working with the parents as the identified treatment unit may see an individual parent when there is no indication of conflict of interest. This may occur during part of the entirety of the treatment process. One parent may have a greater need for focused work on stress management or understanding the negotiation process or enforcement of boundaries. One parent may have good reason to trust the other to bring home the information and ideas from the therapist, and be content with that because of a shortage of time due to work responsibilities. The therapist may, after the initial assessment, agree with such configurations. Only one parent may be available, as in a single parent family.

Charting the Course

The therapist should work collaboratively with the parents in settling on an initial treatment plan. This should come into focus within the first or second session, when possible. The parents should be able to walk away with the ability to describe the desired outcomes and some methods that may be used to achieve those goals. This should involve a discussion as to the risks and potential rewards of possible goals and approaches.

Preparation and Negotiation Phases

Preparation

Preparation for Negotiation

Objectives: To prepare for the negotiations between parent and child, the following objectives must be meet:

The therapist will almost certainly have to negotiate with and educate the parents so that these conditions are met. Parents generally have difficulty with what to expect from their child, or what to expect from themselves. The therapist has no crystal ball, but does have the ability to bring up issues that, if neglected, will sabotage the relationships and desired outcomes.

Handle parents' objections to following through: Parents may believe that withholding support will force the child to turn to crime or other dangerous situations or influences. You might respond that, "Without your influence, your adult child is using your resources to create danger. At least this way, you are improving your odds of creating a working relationship and pursuing meaningful goals. Your adult child, with some successful experiences, may come to think very differently than now. But this means that conditions must be attached to support." The circumstances will dictate the therapist response.

Plan is based on strengths: During the assessment, the therapist must become well acquainted with the adult child's history of interests and successes, and with the child's strengths. The proposed plans must be based on the adult child's interests and strengths.

Common Elements of the Negotiation

Some Common Wants of Parents

Better conditions at home when the adult child is living with the parents: This may include the noise level, the quality of interaction, and anything else that people living together might have issues about.

The adult child's efforts at independence or gaining more support: This may include efforts to get a job or go to school, or involvement in attempts to get social services and payments such as disability.

Money: The parents may feel that the child must provide funds while living at home. This may be out of need, or a desire to make realistic demands so home with the parents will not be too attractive an option in the long term.

Drugs: The parents may want proof that the adult child is not abusing drugs or alcohol. Otherwise, they may feel that they are wasting their support or enabling. They may wish to require random drug tests involving a local company that provides urine screens.

Treatment: Parents may feel that their child will not progress without some kind of treatment such as psychotherapy or drug treatment. They may require participation in treatment as a condition for support.

Some Common Offers of Parents

Adult children may be open to offers of a place to stay, being driven to appointments, work, or recreation, use of a vehicle, a monthly allowance, and use of a computer and Internet connection. The therapist can help the parents think of things that they might take for granted as obligatory, such as the value of food and the time involved in cooking, cleaning, or doing laundry. These items can be negotiating chits if the parents wish to offer them. This is not conditional love, this is using conditions to make love more effective.

The parents must create a list of everything they can think of that their adult child could possible want and that they are willing to offer. They must also put plenty of thought into their own wants.

When the adult child has an attitude of entitlement, what is offered should be presented as being very valuable in a way that highlights that fact that it is a sacrifice for the parents to provide. Rides to appointments can be referred to a chauffeur service. Staying in the guestroom can be referred to as private lodging with major amenities. Parents should be helped to feel very comfortable expressing limitations to these offers. For example, the adult child can be given to understand that neither parent will leave work or cancel important appointments because of a failure of the adult child to plan.

The Therapeutic Value of Learning to Negotiate

Parents may gain a great deal from learning to negotiate with their adult child. When in a therapeutic context, this can be much more than a skill-building experience, as it may bring up personal and family issues. It is also a way to create more flexibility in thinking and behavior, especially when a manipulative adult child has been dancing in circles around their less-flexible parents. When parents become less hide-bound in their own responses, they discover personal power and freedom in their new-found creativity that can be very rewarding in itself, and in helping them to preserve their well being and resources. And then there is the desire that may have brought the parents to the therapist in the first place: to be more effective in influencing their child.

Stopping the Cycle of Manipulation

Therapists and parents may feel sabotaged and frustrated when confronted with the endless ways that impaired, but manipulative, adult children color outside the lines, that is, violate their agreements. These adult children inevitably encounter (or create) situations that "force" them or their parents to alter or suspend their agreements. Therapists may be surprised by the symmetry of many parents' vulnerability to these situations. Such parents repeatedly fail to maintain boundaries that they passionately, and in very specific detail, agreed to uphold.

The situations that upend the parents' resolve include various kinds of emergencies or the adult child simply and suddenly deciding not to cooperate with an important element of the agreement. They may create an escape from accountability by manipulating others into providing support such as money or transportation.

Because these adults are impaired, their surprise moves often have bad endings. The car borrowed from the neighbor requires a new engine, because the adult child did not notice the heat gauge was redlined. The parents feel obligated to pay for repairs because the neighbor is their friend. The parents went to a great deal of trouble to get their adult child into an inpatient chemical dependency treatment program. Two days into treatment, the program reports that someone drove up to the front door, their new client hopped in, and they drove away. The parents sign their car over to their adult child because their attorney told them that they should not be exposed to the liability of their child driving it. Two weeks later the car is sold and the money used up in a weeklong meth binge.

These dramatic examples are often the ones that the parents least expect even though they are predictable. The therapist must look for such patterns during the assessment. The parents will be able to recall them. The therapist must ask about such patterns because the parents may not think to volunteer some of this information. This will enable the therapist to help parents make realistic agreements, and guard their own resources and well being more effectively. It is important to remember that events like these occur in all social classes. The more money parents have to spend, the more they seem to spend before they begin to question their own judgment or the advisability of these expenses.

Parents that are repeatedly manipulated will probably have to face a subconscious drive. They may be unconsciously maintaining the status quo with the adult child, although the pattern is harmful. This way, they avoid facing a grievous fact: If the parents maintain consistent boundaries, and maintain control of resources that their adult child would mismanage, then the adult child may have less (or nothing) to do with the parents. In other words, their adult child has been interacting with them because of the resources they offer. They are merely being manipulated. When this is the case, plan after plan will be sabotaged by either the parents, who give in, or the adult child, who finds a loophole.

Helping the parents surrender their illusions is a clinical challenge. If it is not handled with sufficient care, the therapist may lose the parents. The therapist will need to draw on a variety of skills that pertain to destructive acting out of subconscious defenses.

How to Solicit the Adult Child's Participation

The following are the elements that parents can be instructed to use in soliciting the participation of their adult child in renegotiating their relationship and the support the parents are providing.

1. The parent with the best relationship with the adult child informs him or her that there will be some changes happening in their relationship.
2. The parent provides a rationale for this. For example, they have been experiencing too much stress that is causing them to worry too much. The rationale should not be described in any detail. It is better to arouse curiosity is best, and to avoid making the adult child defensive. Impaired adults may readily project their insecurity and feel blamed at the slightest trigger. On the other hand, they may act that way because it helps to cow the parents.
3. The parent tells their child that they want to make sure that he or she has their say in this matter, because their opinion is important to them; they do not want to change the rules in a one-sided way. However, if the adult child prefers not to be involved, they will make their decisions on their own, but the adult child may not like the result and it may be too late.
4. A time is set, and the parent congratulates the child for stepping up to the plate. The parent does not thank the child; they congratulate. They close the conversation with a comment such as, "It will be good to have you involved."

Note: At no time are there to be any comments from the parent that attack the adult child's self esteem. Parents may be unconscious of these attacks, but they may contribute to defensiveness or depression that can cause further impairment or acting out that can derail the negotiations and perpetuate the status quo.

This is an example of having the parent establish and maintain a secure base in the child. Parents who have trouble being positive with their adult child may be able to do so if this is described as a game in which they are manipulating their child for their own good. The parents may find it helpful to get some explanation as to the value of secure base priming and other tactics that are prescribed.

This is an early test of the parents' capacity to follow instructions and resist manipulation, so the therapist must prepare the parent very thoroughly. The parent should follow the sequence very closely, and provide no additional detail, no matter how much the adult child complains, demands, or sweet talks. This is in service of the therapist's objective to disrupt and change negative patterns such as the cycle of manipulation.

The therapist is encouraged to become very intimate with theory and practices of persuasion for this purpose. This can help the therapist as well as clients.

Establishing a Contract

Introduction

The negotiation process may include the establishment of a contract between the adult child and the parents. This contract will help the parent maintain their understanding of boundaries that they have established, including the expectations they have of their child. It will also help to motivate the adult child to fulfill the expectations of the contract and honor the boundaries of the parents. It also gives the adult child some security in knowing what the limits are and what can be expected in areas such as financial support or living arrangements.

Steps toward responsibility: The therapist must assist the parents in seeing their adult child's path in terms of steps toward greater responsibility. This is usually true, even then there are chronic limitations such as developmental disabilities. From a strategic vantage point, the question is, "What next step will do the most to help this individual shift awareness, attitudes, habits, and skills toward greater responsibility?"

As a result of their struggles, impaired adults can be surprisingly self-absorbed. By itself, such self-absorbtion is not equivalent to an antisocial personality. The contract should include conditions that move the adult child in the direction of making contributions that build this practice of responsibility-taking. Since this is done in the spirit of meeting the adult child where he or she is, the first demands may be very small, and may be entirely focused on things that are for the adult child. However, if these are truly designed to habilitate the adult child, and are not underestimating the adult child, then they are a step in the right direction. This also reinforces the work of moving the adult child into a more adult identity and role in the family.

Below are some of the components that may appear in a family contract.

Contract Components

Requirements of the Adult Child

The contract may include the following elements that constitute concessions or commitments by the adult child:

Career or school steps: This may be for a small first step, such as talking to a counselor at the metro college about getting a career assessment. However, even small steps are tied to a long-term vision that has been developed fully in collaboration with the adult child.

Random drug tests: Include frequency, type, who will bear the costs, consequences of a positive test.

Remuneration: Payment by the adult child toward rent, groceries, utilities, car maintenance, gas, and other supplies or amenities. The consequences of failure to pay.

Prevention and control of liability and expenses: Measures parents may take to prevent adult child from creating expenses for which they may be liable, such as phone charges.

Financial and other management: Authority turned over to the adult parents or a representative regarding management of financial or other assets or activities. For example, parents may take over paying bills when an adult child is unable to regulate spending and fails to pay bills.

Signing over of assets: For example, if parents are paying the loan or insurance payments on a vehicle, the adult child may be required to sign the vehicle over to them as collateral and a sign of good faith.

Lifestyle and living conditions: Noise levels, order, cleanliness, visiting hours, curfew, control of computer or media such as television and other factors that affect the functioning or convenience of parents or other family members. Consequences.

Respect and safety: Language, insults, threats and consequences.

Responsibilities and chores: Laundry, cleaning, maintenance and other responsibilities. Frequency or schedule. Adjustments to be made if adult child fails to accomplish them. Consequences. Privacy: Room or other area or vehicle searches by parents. Consequences of finding prohibited things such as drug paraphernalia. Inspection of cell phone or cellular bills.

Participation in treatment: Participation in mental health or medical treatment that includes a limited release of information allowing parents to verify treatment compliance.

Progress: Achieving specified milestones toward employment, social services, or financial support according to a specified time frame.



Components Offered by the Parents

Financial support: Amount and conditions of financial support. Reasons for suspending or reducing support.

Logistical support: Favors or aid provided by the parents such as driving to work or assisting with organizing or managing certain affairs.

Living Accommodations: A room in the parents home, access to and use of other areas of the home, living in another home that is available.

Use of a vehicle: Ability to drive a vehicle owned by the parents, insurance paid by the parents

Other resources: The parents and adult child may agree on other resources.

Negotiating

Example Skills and Measures for Negotiating and Maintaining Boundaries

The following points are examples of negotiation and persuasion skills that parents can learn and practice. Any persuasion or negotiation skill can be helpful, and there is a great deal of information available on these topics.

Parents or Therapist? Parents who have trouble using these skills may be have limited abstract thought or learning problems. Throughout this section, any actions recommended for the parents can be done by the therapist when family therapy includes the adult child and the negotiation is conducted in that context. Some parents will need to realy a great deal on the therapist to get through this process if they are too poor at negotiating, or the situation is too urgent to wait until they have practiced enough.

If they are committed to learning these things, they may need to study and practice them with the therapist and with each other, and use mental rehearsal. Fortunately, impaired adult children usually have a limited number of typical manipulation strategies. The "antidotes" to those strategies should be the ones that the parents practice via drilling.

If the parents have trouble absorbing these skills because of subconscious issues, therapy should address those issues. These may include patterns or relating learned in childhood such as avoidance of conflict. The textbook scenario of avoiding marital or other issues by focusing on the child should be considered as a potential source of difficulty.

Therapists have many techniques and personal qualities that can be used to help parents prepare to interact effectively with their adult children. The following are examples of techniques that are especially helpful for parents to use in negotiation with adult children.

Limited moves: Parents will get off to a better start if they only need to employ a limited number of boundary-setting responses. This can be likened to the limited number of talking points that politicians have at any given time. No matter what the reporters ask, the politician finds a way to keep their responses focused on a few talking points. The parents may use a page or cards to remind them of their responses. The therapist can help them engineer these moves. They may be as simple and straightforward as classic assertiveness techniques such as the form of repetition known as "fogging" in assertiveness training. In fogging, the person repeats their position, rather than taking the bait from the other party that would frame the discussion in some other way.

Prepared for plan B: Parents, in the spirit of recognizing their adult child's adult status, must be prepared for the real possibility that their adult child will refuse to negotiate in good faith or walk out. This should be framed not as failure, but as practice for the parents in "owning their reality," that is, maintaining their boundaries. Plan B may be as simple as withholding support until the adult child resumes negotiations another time.

Commenting on manipulation: The parents can comment on manipulation that is sidelining the negotiations. This should be done either according to the secure base priming triad (below), or the behavior modification triad (also below).

Behavior modification: Behaviors that detract from the negotiation can be reduced or eliminated by using principles of behavior modification. The response to the behavior makes it unpleasant to persist in the behavior in some way. This is done by 1) causing the behavior to require more work to carry out; 2) causing it to feel embarrassing; or 3) ignoring the behavior. Whichever work best should be used. It is okay if the adult child notices and objects to being manipulated. Again, the behavior modification or secure base priming responses can be applied to such comments.

Secure base priming and identity shifting: The adult child is less likely to be defensive and manipulative with secure base priming. The keys to secure base priming are verbally, overtly recognizing the adult child's 1) suffering, endurance, and stress; 2) commitments and contributions; and 3) highest values and efforts to act on them. The behaviors of the adult child should be regularly reframed into one of those three categories.

The initial secure base move: It is especially important to employ secure base priming as the initial tone-setting step of the initial contact in which both therapist and adult child are present. All three elements should be employed as a brief commentary establishing the therapist's respect for the adult child, and appreciation for his or her presence. Most especially, the therapist should express respect for the adult child's negotiation abilities and willingness to participate in a constructive process that will support his parents' well being. These points help to encourage some subconscious identity shifting. They are drawn from classic persuasion techniques.

Adult identity-shifting: To further the identity-shifting element of the framing, all actions by the adult child that can be reframed as an effort toward a more responsible, constructive, mature, and adult way of living should be. However, directly evaluating behavior as "more adult" will offend most adult children. Instead, the parent, in a well-grounded, very sober quality, expresses some surprise or sense of being impressed by such moves, commenting on them very briefly. For example, referring to the adult child showing that he has circled want ads for jobs, the therapist might raise his or her eye brows and say, "Nice" in the tone that an adolescent might use in referring to an impressive move by a sports figure, yet while maintaining a cool demeanor.

What about the parents? If the parents have impairments that may affect their ability to participate constructively, the therapist will need to exercise much care in orchestrating the negotiations, and employ the methods in this section to the parents more liberally and strategically than would otherwise be necessary. The parents must role play successfully with the therapist before carrying out a negotiation session. The therapist must not assume that the parents will participate effectively.

Positive motivations in the negotiation: As much as possible, the parents should connect the adult child with all positive emotion-based emotions (emotional desires) that support movement in the direction of a constructive outcome. For example, "Yes, I can see you, walking into the shop, knowing those advanced tools and keeping those planes in the air. That's gotta feel good." Or, "That's definitely the place to clear out the toxins. One of my clients just went cold turkey in jail. What a mess. At this facility, they have meds that support the detox so you feel way better, and it's in a beautiful place."

Closing the negotiation via an appeal to pain, urgency, and reason: When approaching the end of the negotiation, connect the adult child the emotional discomfort of not being fully independent (or whatever condition the adult child is motivated to move away from). Follow this up by an appeal to what the adult child would consider rational, so that he or she can feel that they have made a final conscious "check off" or approval of the plan. For example, "I know that it's been a real fun ride in a lot of ways, but it's taken its toll, and you have been feeling it mentally and physically. And I know it's a real thing, watching other people your age getting the real good stuff in life; moving out ahead like that. This opportunity is really huge. You may never have a shot like this again. The fact that you've thought this through for so long and really wanted to pursue this line of education says a lot. Here's the pen, you can sign there." This started with discomfort with the status quo, and ended with triggering rational approval by reminding the adult child of previous decisions and declarations by him or her.

State management for momentum: Any state of mind that threatens the momentum that the negotiation is building towards an agreement must be managed. For example, if the excitement level is too high, refocus the participants on sober, rational analysis with questions such as, "What would you do in this situation; what did they miss. Now let him explain, you don't have to agree. Please, go ahead." If the life is draining from the deliberations, generate some excitement by refocusing the discussion on desires, fears, or urgency that lend themselves to moving toward some agreement, even a small one.

Postponing sticking points: If an issue appears to be a sticking point, do not allow it to get too much discussion right away. Find a reason to postpone it. The more small and easy agreements there are, the easier it will be to get the parties to resolve the issues left for the end. In addition, so long as they are not becoming irritable, they may be more agreeable to get it over with once enough time has passed. Appropriate food and drink should be available to help the parties maintain interest, focus, and stamina. Comforting, protein-rich foods can help here.

Motivational interviewing: Use motivational interviewing skills to reduce resistance. See the book Motivational Interviewing. An important element of this method is avoiding any "push pull." Every effort is made to avoid eliciting resistance in the adult child. Originally developed for substance abuse treatment, this method recognizes the tendency of people stuck at an adolescent level of development to be especially likely to reflexively resist ideas from authority figures. The more the adult child volunteers ideas, the less he or she will have to resist. Manage the negotiation so that the adult child might make concessions that are excessive, so that the parents can "give back" things and thus occupy more of a "good guy" role in the adult child's mind.

Respond to distraction: If the adult child uses distraction to absorb time and exhaust people as a means of getting their way, or of evading responsibility, the parents should respond. If the behavior modification or secure base priming triads are not sufficient, consider these strategies. 1) The parents can show that they are happy that the time will be up soon, and that the adult child must not be interested in negotiating, because that means that the parents can do whatever they want. The adult child may fear that outcome and become more focused. 2) Being crazier or more distracting that the adult child. This should only be used by therapists that have developed skill with this approach, or very intuitive parents. The parents must be aware in advance that the therapist may do this. In response, the adult child may take on the role of trying to get things back on track. However, an adult child that is very easily distracted or has very limited forethought may not make a corrective response.

Respond to legalistic tactics or red herrings: An adult child may use sophomoric argumentation to undermine the parents' positions. If the behavior modification and secure base priming do not work adequately, consider these responses. 1) Consistently tell the adult child that the argument supports the parents position, and make up a legalistic reason why this is so. 2) Say, "Let me think about that and get back to you," then approach the issue from a different angle. The adult child will forget the argument. If not, you can use any of the aforementioned responses. This should always be brief, and immediately followed by redirection away from the point for a short period of time. 3) Another approach is to agree while moving quickly to a higher level of abstraction, link to a high-level value, and descend into the real point at issue, and offer a specific instruction to do something that will further the negotiation. For example, the adult child says, "I'm frikkin' 22, I have the right to party!" To which the therapist says, "The constitution guarantees your right to pursue happiness. Of course, that applies to your parents and their home. Which, by the way, the are offering to you as long as you need to be here if you're willing to do these three things. Let's consider them now."

Respond to attacks on the parents' or your motivations: If the adult child attacks the motivations of the therapist or parents, the therapist can respond by normalizing the motivation in some way, and quickly redirecting. "Yes, I'm only in it for the money. If I were independently wealthy, I'd be... oh, never mind. What were we talking about? Oh yes. Your parents are offering you a stipend that will be available each month that you are on schedule with school. Now that's a real deal, isn't it?" Or, "Your parents are pretty selfish, controlling their cash like that, but then, I guess just about everybody is. What can you do? I mean, let's see what they're really asking for here..."

Never exceed anyone's attention span: Use the rhetorical methods of people who hold interest. This is a valuable area of study, and the materials on this subject are abundant. Break up ideas into small, concrete parts. Do not attempt to instruct. Rather, manage the participants with the objective of getting constructive, realistic agreements.

Navigate, do not drive: Do not try to control the outcome as you might a car. Function more like a sail boat racer. Use the forces in the environment to propel the negotiation in the right overall direction, maintaining as much speed as possible, even if it requires tacks that are not in a single straight line. Efforts to control are likely to create chaos. Seek ways to utilize the behaviors that appear most undesirable and symptomatic. Literature on Milton Erickson's method of utilization are helpful here.

Following Through

Introduction

The actions needed to follow through on a negotiation depend on the circumstances and the behavior of the parents and adult child. They also depend on the nature of the identified client or treatment unit, e.g., whether family or couples therapy is being conducted, and whether the adult child is involved as an ongoing member of the treatment unit, or is either not involved or receives some case management services.

This is a good point to remind the reader that various ethical and legal standards will apply to your relationship with the adult child, even if you are only doing limited case management on his behalf, and should be understood. However, if you are only working through the parents, the adult child may not be considered a client. The laws and standards in your location and professional association should be consulted for specifics. This may require consultation with an appropriate legal specialist.

Whatever goes wrong is grist for the mill and must be addressed in treatment with the parents or family. The various roles that the therapist may play have already been discussed.

What Can Be Expected?

Ideal outcomes: Ideally, the adult child cooperates and the parents come to feel very satisfied with the additional investment or support that they have provided their adult child. They may also feel that they have gained skills and freedom that benefits them in a wide range of situations. The parents may come to feel that now that they can respond appropriately to their adult child, they can handle any situation that demands creative assertiveness.

The level of support that the adult child receives should be appropriate to his or her degree and type of impairment. To minimize the demands on the parents, work is ongoing to secure appropriate social services or payments, and the adult child is dong whatever is necessary for that to take place.

Change: When the adult child breaks an agreement, the parents withdraw whatever support was tied to that agreement until the adult child comes back into compliance. If the adult child's needs or other circumstances change, the plan must change accordingly. The therapist is consulted as needed.

Rejecting and returning: If the adult child chooses to forgo the support offered, then the parents, who have been prepared for this possibility, are offered appropriate counseling. The parents must be helped to come to terms with this, and to refrain from harshly judging and second-guessing themselves. They should also be prepared to the possibility that the child will return because of emergent needs that make him or her open to negotiation.

If the needs of a returning adult child are urgent, the parents must only make concessions in a manner that addresses health and survival. As mentioned, parents must control the resources so that they are used in the manner intended, unless the adult child has a consistently good track record of managing such resources.

The parents must be prepared for the adult child to reach a greater level of dependency because of job loss or other reasons. Such dependence is sometimes the only way that the parents can resume having a constructive influence.

Termination: Termination of treatment is done in accordance with normal clinical standards. Parents should understand that the therapist is available for further consultation. Many of these cases periodically need additional assistance. Often, this need only be telephone consultation. These consultations are often to support the parents' decisions regarding boundaries or the need to understand the implications of a behavior. The therapist may want to have policies that take this into account, charging for fractions of an hour for intermittent consultations.

Final Comments: Keeping the Vision Alive

Just as many parents need to come to terms with an adult child's harmful behaviors, therapists need to maintain their vision and values in dealing with the parents. Even a therapist who is highly successful at promoting the ideas in this approach to parents will find that some parents are not prepared or willing to embrace it. They may have an obsessive and unrealistic agenda to control their child, they may be uninterested in the help that a therapist can offer in coping with their grief, or they may not have the capacity to negotiate with their child.

In any case, the therapist should keep a constructive vision in the forefront of their communications with clients and potential clients, and maintain the flexibility to meet them "where they are" whenever possible. At the same time, the therapist must be prepared to indicate that they cannot support the parent in doing something that is unrealistic, destructive, or would constitute an ethical or legal breach.

By the time most parents call the therapist, they will have enough experience with the situation to be open to the therapist's vision, values, and strategies. The therapist will then have the opportunity to guide the parents toward a productive approach that fits the parents' values.

Appendix: Assessment: Scale-Type Elements

The following questions are drawn from the assessment materials in this course. This can help to identify key areas or "red flags" for intervention. The clinician can place terms such as "high" or "low" in each space, and use this overview to organize and generate resources such as a more detailed assessment report, a treatment plan, and further questions for areas of concern. Immediate, Practical

Threat: __________

Stress Effects: __________

Support Capability: __________

Social Supports Utilization: __________

Obstacles to Social Supports: __________

Appropriateness of Plans for Social Supports: __________

Engagement, Dependence

Relationship with Family: __________

Dependence: __________

Appropriateness: __________

Functioning in Independent Spheres: __________

Impairments, Strengths, and Motivations

Impairment of Each Member: __________

Strength of Potential Family Support: __________

Likelihood of Progress in Recovery: __________

Awareness, Information, Perceptions, and Dynamics

Family Members' Acceptance or Denial: __________

Family Members' Sophistication: __________

Family Members Readiness for Utilization: __________

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