Breaking the Cycle of Adult Underachievement

The topics include:

Revolving Door Families: The Issues and Clinical Concerns from a Biopsychosocial Perspective



Sister Course: Revolving Door Families: Assessment, Treatment, and Negotiation for Parents with 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.

Focus on challenging situations: 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.



Topic Introduction

This course addresses the problem of families with one or more adult children that have impairments that their parents or caretakers have not been able to cope with. (For brevity, this course will refer to parents throughout, although other family members or caretakers may be involved.) These adult children have been unable to leave home, wish to return home, or place significant demands on their parents.

The greatest confusion often comes with impairment levels that are not so great as to require a high level of ongoing dependency, and not so mild as to allow the child to establish ongoing stability. Drug or alcohol abuse is often occurring. There may even be self harm, threats, crime, or violence. Problems are often worse when the adult child is impaired in ways that the family or society stigmatizes or has difficulty understanding or acknowledging as valid, especially when the adult child is a poor self-advocate, has some level of cognitive impairment, has immature social skills, or is in denial, manipulative or impulsive. The needs of grandchildren (children of the adult child) may complicate matters greatly.

However, the problems of the adult child, for this course, are viewed primarily in terms of the needs of their parents. Though the parents may come to the therapist with a strong focus on the adult child, the usually need treatment or consultation for their own symptoms and impairments. There may also be difficulties with access to or relationships with social services, benefits, or the justice system.

The Parents' Condition

A key to helping the parents is often helping them shift their perspective on the situation. This may occur through better understanding of the clinical issues of the impaired adult child. There may also be a strong emphasis on the attitude of one or both parents to the situation.

There are countless ways that family dynamics may prevent resolution of conflict or enabling. The parents' difficulties may be compounded by conflict over what to do, especially when it comes to the question of where to draw the line on providing support and intervention. The therapist will encounter such parents at an early, middle, or late stage in coping with their adult child. Parents may be in denial or na?ve, fresh or burned out, confident or hopeless, unified or in conflict, and skilled or hapless. The parents may have any number of financial, community, cognitive, or emotional problems of their own. Such problems may have a great deal to do with the parents' inability to establish effective means of coping with their adult child.

Varying Circumstances and Roles

Pushed to extremes: The situation may have progressed to the point that the parents are highly stressed, financially harmed, or even physically injured or afraid. The parents may need substantial recovery of their own in order to think effectively about problems such as these. The child may be at any level of functioning and may have gotten into complicated problems.

The circumstances may vary a great deal. The relationship with the adult child may be calm, but with parents fearing disaster or excessive demands. The relationship may be highly conflictual, or it may be emotionally cut off with one or both parents wanting to engage and help the child, but on terms that the adult child finds unacceptable. These adults may have never left their parents' home, or may repeatedly return, may be returning for the first time, or may be presenting needs and desires to the parents without returning home.

Complicated dynamics: The dynamics of such situations can be quite complicated, and families can place great expectations on the therapist to predict the child's behavior and guarantee that a particular strategy will work. This thrusts the therapist into roles that are similar to those required for working with families with impaired or drug abusing teenagers, but with the added challenges of the adult child being legally an adult, but being out-of-step with social and family expectations. Grand children, a marriage, child support payments, criminal behavior, and additional legal issues are more likely to be in the picture as well.

Efforts to engage the services of government agencies may be fraught with problems. Bad experiences with police or knowledge of negative experiences of the mentally ill in the justice system may discourage parents from contacting police. Obstacles to gaining social services or other benefits may seem insurmountable. The child's unwillingness or inability to follow through may sabotage extensive efforts on the part of the parents and others to acquire additional support. The adult child's behaviors may finally alienate the parents to the point that they decide to cut the cord, but later vacillate.

Impaired capacity for independence: Typically, family therapy focuses on improving boundaries in a family so that older teens and young adults are allowed to become more independent. In revolving door situations, however, the adult child has limitations that prevent normal maturation and independence. This calls for careful assessment and flexible adaptation on the part of the therapist.

It is important not to obscure the fact that family therapists routinely deal with couples or families in which one member is significantly out of skew with the rest of the family or with their spouse. This problem can range from mild personality problems or cognitive deficits, to extreme acting out or drug abuse. In therapy in which that family member is included as a member of the treatment unit, the therapist must take into account that fact that the other family members have a much better grasp of nuances or issues. Where the impaired member is highly impaired or in denial, this can be an extreme schism. For this reason, family therapists already have training and perspectives for dealing with impaired family members.

Scope of this course: This course is not intended to duplicate that knowledge. It has the practical purpose of carving out a narrower range of situations, and emphasizing the aspect of negotiating support and boundaries where the parents or caretakers are usually the treatment unit. Although this course refers to parents throughout, the material may apply to foster parents who are continuing to be concerned about an adult who was in their care, siblings who are invested in the well being of an impaired sibling, or other family members or caretakers who can benefit from this material.

Through the Parents' Eyes

A good way to develop an understanding of the experience of parents in revolving door situations is to read the following typical experiences of the parents themselves. A notable feature of their experiences is that they are usually prevented from gaining closure or making decisions that they can feel confident about by one or more factors. This binding greatly amplifies the parents' distress.



Dysfunctional Responses

The parent experience in the revolving door situation can be quite functional or dysfunctional, but people outside of the family may have biases that make it difficult to be supportive of a good outcome. Below are several examples of parent and service provider responses. Stigma/moralism: Without an appreciation for the biological nature of the impairment, many parents take a moralistic stance. The parent may write off the child as not caring, sabotaging, and being a fundamentally bad person. The parents may not be able to see past the adult child's attitude to recognize the child's underlying needs or impairments. This can result in withholding assistance or support that the adult child could benefit from, or can lead to serious family conflict or aggression. The result can be endless conflict or emotional cutoff. Service providers such as case managers and teachers may take a moralistic stance, perplexing parents who do have a more sophisticated understanding.

Natural consequences and hitting bottom: It is prevailing wisdom in some circles that a person who is abusing substances or making bad decisions must hit bottom in order to turn their life around. However, some people do not have bottoms to hit. Instead, they may lose their lives, or be so damaged by the consequences that they are less able than before.

Parents or service providers may be unable to see that the child is unable to learn from certain negative consequences. They may take a "more is better" approach that leads to more severe consequences that result in harm rather than learning. Where to draw the line on natural consequences, or how to intervene to shape such consequences, can be a very difficult judgment call, even with a thorough assessment.

It is very important to learn as much as possible before making this call. Parents may need education on this issue, but have difficulty understanding it because of their own impairments or because of ingrained moralistic thinking. The therapist must understand the parents well enough to maintain rapport and build understanding when dealing with topics that are fraught with deeply held beliefs. Whenever a therapist is dealing with material that is driven by semantic memory, such as clients' religious, moral, and psychological beliefs, it is important to be very cautious and strategic.

Failure to learn: Parents may repeat the same mistakes many times, bailing out an adult child who does not benefit, and bailing them out in ways that compound the child's or the parents' problems. This may be explained by normal human internal pressures from bonding, guilt, or being manipulated. It may be from impairments of the parents that make learning from life experiences a challenge. Substance abuse, trauma history, dissociation, and attention deficit disorder may contribute to codependence. It may result from subconscious resistance to facing the fact that the relationship is based on manipulation by the child.

Driven to control: A parental drive to control the adult child may be expressed in a variety of ways. This may result in insulating the child from life lessons or eliciting rebellion that exacerbates the problem. The ongoing drive to control by stem from obsessiveness or anxiety on the part of one or both parents.

Chasing losses: After making an extraordinary level of emotional, financial, and time investment in their child, parents may be unable to objectively assess the likelihood of success of further efforts, and be unable to see better alternatives.

Burnout: After spending too much effort and enduring too much stress for too little reward, one or both parents may experience burnout. This can muddy the waters to the point that it is very difficult to determine what actions to take. While parents may be very concerned about what may happen if they back off, it is generally a good idea to advise parents to consider taking a very protective stance regarding their own well being. Parents can usually understand that if they become impaired themselves, they will be of no use to their child. The therapist can discuss the causes and results of burnout, including the mental and health issues that may arise.

Dysfunctional cognitions: The assessment may reveal variations on the classic dysfunctional cognitions. For example: "My child must not experience adverse circumstances." This may sound like a perfectly reasonable parental attitude. But in actual practice, the "must" is what controls the parent. For many parents, once the adult child is exposed to sufficient trouble, the parent "must" rescue the adult child. This kind of "must" must be resolved in order for the parent to consistently apply appropriate boundaries. Such boundaries may be established in negotiation with the adult child, or because the parent realizes through treatment that the he or she has been providing support in dysfunctional or excessive ways. The therapist may provide information and treatment that helps the parents decide where to draw the line on such a "must."

Family dynamics: The family therapist can include these factors in their assessment of family dynamics. Problems in areas such as emotional cutoff, boundaries, and power will be more richly understood. The subject of negotiation will be discussed in terms of its potential positive effect on family dynamics.

Multigeneraltional or genetic issues: The adult child's problems may be part of a genetic cluster of problems, some of which affect the parents. For example, there is a high concordance for ADD. Multigenerational problems relating to attachment and psychosocial issues may affect parents and children.

Misapplied consequences and negotiation: The parents may want to consequence or negotiate to influence behaviors that are not under adequate control of the child. For example, the parents may be attempting to motivate a child suffering from depression in faulty ways that result in conflict, withdrawal, failure to get treatment, or worsening of symptoms that are strongly affected by parents' attitudes. Negotiating to get compliance with a visit to an appropriate provider of mental health services would most likely be more appropriate than threatening to withdraw support if the adult child doesn't get to school on time during major depression.

Perceived conflict of interest: In many of these situations, the adult child will be highly adverse to decisions by the parents that are actually quite appropriate and constructive; even life affirming. Often, the adult child will see the therapist's role in an adversarial light. This perceived conflict of interest can prevent the therapist from ethically including the adult child in a family therapy constellation.

Fulfillment and Personal Growth

Moderate to severe impairment: Parents who care for adult children with exceptional needs such as severe mental illness may experience great rewards, even with that care is demanding. According to Gidron (2002), who conducted a study of parents of mentally ill adult children, "Caring for their mentally ill child has led some parents to personal growth and a deepening sense of self-awareness. They felt they had become stronger, more tolerant, less judgmental, more sensitive, and empathetic toward others and were more assertive in their demands on welfare services." The authors stated that, "the parents who participated in our study scored the gratifications gained from fulfilling their parental duties and from learning about themselves higher than receiving everyday assistance and support from their child." and that "Some parents describe caring for their child as a 'calling' or a 'commitment' that gives their life content and meaning." (ibid) The authors found that the objective factors such as, "...parents' gender, age, health state, years of education, and religiosity..." and "the child's age, gender, and employment status" did not correlate with the rewards assessed. The factor that seemed to have the most impact on the overall stress of the situation on the parents was the severity of the child's mental illness, because parents experienced less stress with they received more support at home and a better emotional connection with their adult child. (ibid)

Mild to moderate impairment: For adult children that do not have this kind of chronic disability, parents report additional factors to clinicians. When parents learn enough about milder impairments that affect their child's success, they are better able to come to terms with the situation, and to settle on strategic responses that make sense to them. This enables them to reduce their stress by experiencing less anger and resentment, worrying less, efforting less, and building confidence while reaping the rewards of functional strategies.

Zero, temporary, or mild impairment: A number of factors improve parents experience of rewards and hope when their child is experiencing a transitional difficulty such as being laid off or experiencing a period of sever grief. Below are some of these factors:

Incentives to Leverage Dependence

Limited research: There is very limited study of parents attempting to help adult children, except where impairments are more severe, particularly in the areas of developmental disabilities and chronic mental illness. Aside from limited research, there are case reports that appear in journals and books written by family therapists. These usually demonstrate a particular approach to family therapy. As the rehabilitation approach to mental illness gains favor, mild to moderately impaired adults with mental illnesses will most likely receive more attention from researchers. There are

Resemblance to adolescence: However, experience indicates that there is much to be applied from the study of a population that has received more attention: families with juvenile delinquents and other mild to moderately impaired adolescents. This is a relevant area because 1) adolescents are emerging into adulthood; 2) impaired adults have delayed development in one or more areas of life, and 3) these delays and resulting problems place them in roles of dependence and social control that bear a resemblance to the roles and experiences of adolescents.

Incentives to influence: These issues, along with the adult problems that impaired adult children experience, give parents strong incentives to attempt to influence the decisions and actions of the adult child. Their intentions are to help the adult child live a more rewarding and independent life, and to minimize the harm that may result while that adult child is (in so far as possible) developing into a more responsible individual.

In many cases, there may be ways to utilize the dependence of the adult child upon the parents as leverage to influence them in constructive ways. While this may sound like infantilization or a negative kind of manipulation, this course will cover the rationale for making constructive use of dependence when possible.

Unrealized Potential and Stability

Enabling vs. stability: Parents may have gotten the impression from many sources that they are enabling adult children with chronic problems, especially where drug or alcohol use are concerned. It is imporitant to recognize that there are many legitimate reasons to console parents about this.

There is good reason to support parents in attempting to build stability into their adult childrens lives. Research is showing that chronic alcoholics who are provided with stable housing and ongoing availability of medical and counseling services are less costly to support over time, and will reduce their abuse of alcohol. (Cassels, 2009)

This research is about programs, but it is evidence of the value of stability. Also, clients of methadone programs are estimated to take two years to achieve sufficient stability that they can begin to make significant progress in their lives in areas such as career development. (Kleber, 2008)

Rehabilitation and recovery: Our understanding that drug and alcohol abuse as well as many mental health conditions produce brain injury that must heal is very important. Not only can it be a slow process to gain this healing, but the rebuilding of any skills and knowledge that have been eroded by this damage can also be time consuming.

Nonetheless, evidence of the positive influence of a rehabilitative approach even where severe mental illness is concerned is mounting. (Dimeff, Koerner, Eds., 2007) So long as excessive expectations are not placed on the parents, and genuine, vigorous efforts are made to bring additional support and services into play as needed, great strides can be made. Two ingredients are critical, however. Patience and a greater concern for positive directions and results must supplant standing on principle and making moral judgments.

Proper structure: The reason is based on observations that properly structured, ongoing support of an adult child by his or her parents can be beneficial, despite conventional wisdom regarding enabling and bottoming out. To support this approach, this course ties together an outcome philosophy, a psychosocial education approach, a rehabilitative mindset, and a systematic approach to boundaries and negotiations.

The following are examples of the sources of stress of these families.

Manipulation

The adult child is taking advantage of the family members' tolerance and gullibility.

Uncertainty

The family members do not know what to expect of their impaired member. Because the adult child is an adult, the family members may not be able to get information from professionals and social service systems that have had contact with their child.

Bad experiences may have made the family feel hopeless about their adult child ever receiving the help they need.

Last Option

The family may feel obligated because their impaired member has no options left, and the family is convinced that the child will suffer serious consequences without aid.

The child may have been marginalized and have difficulty finding employment because of personality, criminal history, visible tattoos, and other factors.

Habit, Accommodation

Family members may be so habituated to their patterns with the adult child, that they will have difficulty venturing outside of their comfort zones in order to get a meaningful change.

Hope

It is human nature to be optimistic, and the extreme emotional and financial investments that some parents make can cloud their judgment. The therapist may feel that they are dealing more with a gambling addiction and "chasing losses" than parenting.

Guilt

If the parents withdraw support and something terrible happens, they fear it will be their fault. They feel unable to live with that prospect. The parents may even feel responsible for the adult child's behavior because of a factor such as prenatal drug exposure or a car accident in which a parent was driving.

Promise vs. Trust

Parents may be on the razor's edge between viewing progress with optimism, and feelings of anger and hopelessness at the many betrayals and disappointments that they have experienced from their child and social systems.

Responsibility Paradoxes

Parents tend to feel responsible for their children. However, they feel torn when they are told on the one hand that they must let their child "hit bottom," while, on the other hand, they are aware of the extreme dangers of this approach. Family and social pressures may be conflicting and confusing. The feeling that others do not understand can be isolating.

Family Issues

Family members may take different tacks. This can cause breaches in relationships. The stress may be exacerbating existing issues in the family or causing new ones.

Being Cut Off

An adult child who keeps the rest of the family in the dark may be going on terrible misadventures, or simply struggling to do the right thing with limited abilities. The family members, with things left to their imaginations, may feel very concerned, and even be angry at being cut off from communication. The adult child may have distanced because of the amount of concern, conflict, and coercion coming from the family, even if they are justifiably concerned. The adult child may be choosing drugs and druggies over the family or just laying low for a while. The adult child can prevent social services agencies and mental health professionals from providing information to family members by withdrawing or not providing a release of information to them. Family members, still relating to the adult child much like he or she is still a minor, may become fearful and frustrated when this happens.

Potential Harm to Family Members

Family members may not be adequately considering the harm or potential harm that they are exposed to in accommodating their adult child. The following describes some of them. A discussion of such factors may help family members make decisions that they have previously felt too guilty or manipulated to make. It may also give them the words that they need in order to assert themselves effectively in setting limits with their adult child or with others. This section could appear to be fear mongering, but it is a realistic assessment of outcomes in actual situations that many family members face. Families should be able to make informed decisions regarding their exposure to risks.

Legal and Financial Jeopardy

It seems as though there are countless ways that people can experience legal or financial problems. There is added risk with an impaired adult child under some circumstances. Family members should mitigate for such potential issues.

Destructive Acts in the Community or at Home

Although the impaired child is an adult, there are ways that their actions can affect the family. The family may now have to make a decision as to whether to post bail or bear the cost of damage that their adult child has done. They may have allowed him or her to use the car and crash it.

Parents may fear the hiding of illegal drugs in the home, property destruction, unseemly characters knowing where the parents live, and other threats.

Finances and Credit

The therapist should directly ask about financial exposure and caution parents to consider the risks involved and to get appropriate financial or legal advice. Situations such as a family business, a credit card, or use of a property comprise a few examples of risk. Families report that attorneys have advised them against allowing an impaired family member to drive a vehicle that is in another family member's name. This has convinced some families to put a car in the child's name. Such cars have been sold for methamphetamine or lost to bets.

Accusations

Parents may be at risk for being accused of something they did not do. Even if they are vindicated, the cost and stress of such situations can be difficult to bear when the family is already highly stressed. An adult while with a very sympathetic and manipulative personality can be especially dangerous, because of the feelings they arouse in others.

Police

Because of actions by the adult child, or people that he or she has met, the police may show up and even get physical or shoot before understanding the situation. Anyone in the house could be at risk if this happens. The police may become aware of drug involvement and do a great deal of damage while inspecting the house during a no-knock raid. Policies such as the use of SWAT teams with paramilitary training and equipment and placing those teams in escalated circumstances, and the use of questionable informants has contributed to the number of disturbing and fatal situations. (Balko, 2006) Police are not always adequately trained to deal effectively with persons with mental illnesses or cognitive disabilities. This can result in maltreatment or unnecessary fatalities. (ibid)

Pregnancy and Children

The adult child may have or be responsible for the care or financial support of a child. This can result in time demands on the family to assist with legal issues, child care, medical care, and legal problems that result from mismanagement of issues such as child support, neglect, or abuse.

Parents may feel tremendous pressure to curtail the activities of an adult child who may be poor at using contraception. This can lead to conflict and fear.

Assault Allegations, and Coping with a Violent Outburst

In conflict turns to violence, even if it is merely visible damage to property, police may arrive and need to make a judgment call as to whom to arrest. An innocent family member may have to cope with an arrest and even court-ordered program involvement.

Forms of Violence and Destructive Emotional Manipulation

There are many forms and directions that violence can take, and destructive emotional manipulation can be as harmful as physical violence and as coercive as physical threats. Harm to Children, an elder, or another dependent adult.

Parents may need to consider the risk to other family members, especially the most vulnerable ones, and be encouraged to take the safest and most conservative approach.

Emotional Manipulation and Harm

Family members may need help in putting this behavior into perspective and in recognizing the connection between the behavior and their own difficulties. They may be able to be more objective about it if they learn about how such behavior develops, how it can be an expression of deficits and dysregulation, and how it can be inadvertently reinforced.

Threats

Family members may be stressed by threatening behavior, but unsure how to interpret it.

Physical Violence

Family members may be fearful because of signs of risk or because of a history of violence. They may need encouragement to take this seriously, and to get assistance in establishing a plan. They may need coaching on how to communicate effectively with the police.

Stress

Harm to the Adult Child

Parents can be plagued by fears regarding the well being of their child. Potential incidents involving drug abuse, violence, and trouble with the law produce fearful imagery along with great frustration and helplessness.

Emotional Harm and Stress

The physical toll of emotional harm and stress, whether it is the byproduct of the situation or because of direct manipulation, has real effects on family members. Members may downplay this, but can be encouraged to take it seriously.

Sleep Deprivation

If family members are not sleeping effectively, then they may be unable to think things through or tolerate the stresses involved in taking effective action. Traumatic experiences, fears, and feelings of loss of control can all interfere with effective sleep. This increases the likelihood of poor judgment, accidents, outbursts, and even job loss in the sleep-deprived parent.

Solutions and Well Being

The many overwhelming factors discussed so far can make it very difficult for many parents to turn their attention to their own mental, physical, and financial well being. The therapist must carefully assess and plan to take the approach best suited to such parents. Mere advice is unlikely to work. Therefore, using skills such as those of motivational interviewing can help. Getting overt agreements to spend designated portions of the sessions on stress management that will reconnect the family members with what it feels like to breathe more easily can be a good strategy. The details of your process may be used to convince parents to get treatment for specific problems such as PTSD. It may help to point out areas where further loss of function could result in severe problems such as unemployment.



Introduction

This section is intended to put some common problems that prevent adult children from maintaining independence into perspective for the purposes of this course.

In the section "Therapist Ethics, Roles, and Boundaries," this course will cover the question of what the therapist can do with this information in more detail. However, in this section, the material is presented from the perspective 1) that the parents can provide much historical information, and 2) that the therapist is in the role of helping to interpret this information for the parents and to put it into perspective for them so that they can make more effective decisions.

Situational Factors

It is important to determine whether apparent situational factors such as economic hardship is a reflection of underlying problems such as substance abuse or poor impulse control. Assess the motives of the parents for the responses that they have historically made and are considering for this problem. Also, inquire as to the motives of the adult child for seeking or not seeking financial aid from the parents and other sources.

What issues are causing ambivalence or preventing any of the parties from seeing all of their options? To what degree to they need information or financial consultation? How much of the problem is one of boundaries and psychodynamics? To what degree is impairment affecting the abilities or judgment of any of the family members? If there is impairment, is it the transitory impairment of an adjustment disorder making it difficult to cope with a job loss or other financial impact, or is it a long-term impairment such as attention deficit disorder? Do the circumstances indicate impairment in the ability to plan and predict the results of one's actions?

Transitional Impairments

Response to Stress, Loss, or Life Transition

If the adult child is so impaired by a stressful situation, loss, or life transition that he or she becomes dependent for a period of time, the therapist must determine what vulnerabilities exist that may need treatment. This includes pre-existing vulnerabilities as well as transitory symptoms. Knowledge and effective strategies can help all family members experience less stress. Family members may not have been exposed to a traumatic grief reaction or an adjustment disorder with depressed mood. They may not know the typical course or duration of treatment for panic attacks that have delayed independence of a young adult. The therapist may need to assess for and educate family members about problems such as toxic relationships and learned helplessness.

One Time or Relapsing Condition

The first experience of an impairing condition such as a mood disorder can create confusion and difficulties with adaptation in the family of origin. Family members may have clumsy ways to attempt to motivate the adult child. The therapist can educate family members as to how to respond. Families that understand the risk and nature of relapse of a condition such as bipolar disorder can be better prepared to responed constructively.

Cognitive Problems

A Very Common Problem:

Cognitive difficulties often play a role in mental disorders and poor adaptation. They are very often an important factor in revolving door families. Cognitive deficits often go undetected and untreated. A large percentage of prisoners and homeless persons have cognitive deficits that have contributed to their problems. Cognitive deficits can impair the ability of individuals to benefit from psychotherapy, consultation, and other interventions.

According to Wongvatunyu & Porter (2008), traumatic brain injury affects a large number of people. They write that, "Persons with TBI can have difficulty initiating and planning activities, organizing the day, recalling information, and staying on task." They may have, "Behavioral problems that are difficult to manage, such as irritability, aggression, and disinhibited behavior..." The authors state that such problems, "...can become major sources of stress for family members...all members are likely to be affected." and that the family may experience, "higher levels of family dysfunction than families with psychiatric patients."

For this course, where brain injury is mentioned, the injury to the brain may be the result of physical impact, illness, or iatrogenesis.

Often Misunderstood and Mistreated

Because of widespread poor understanding or acceptance of this problem, people with cognitive disabilities often meet with moral judgment while lacking insight into their own impairment. In severe mental illnesses positive symptoms such as hallucinations are the most obvious and arouse the most concern in most people, but negative symptoms as they are called such as cognitive impairment are often the greater threat to functioning. This is especially true when the individual has sufficient insight into their illness that they can ignore hallucinations. When this capacity is absent, cognitive deficits are a contributory or explanatory factor.

Helping People Understand

Parents usually need help in understanding their adult child's cognitive deficits. It is important that people involved with an impaired adult child understand that the brain has parts that do different jobs, and that one or more parts may have trouble working well, while others do just fine. The good abilities of the impaired person cause people to think that when they fail or use bad judgement, that they are purposely sabotaging, that they don't care, or that they should be punished for moral failings.

Erroneous responses to these cognitively impaired individuals often stem from the faulty belief that they will learn from natural consequences. However, persons with cognitive issues often are not well equipped to learn from some natural consequences. This means that they are likely to recur and get attention from the family. Controversy or misunderstandings then arise as to the significance of these consequences. The therapist can play an important role in helping the family understand that more assessment or treatment is needed. It should be determined what kinds of experiences will be most restorative. Neuropsychological assessment may be advisable.

Miscues

Many, if not all, of the symptoms of cognitive impairment can be misinterpreted as permanent when they are not, and reflecting negative motivations and intentions that the person does not have. Two reasons for this are particularly persuasive:

1) Such deficits may wax and wane, depending on factors such as stress, substance use, a medical condition, a relapsing mental illness, or a sleep disorder.

2) The disorder may be all the more mysterious because there may be no history suggesting that such an impairment should have occurred. Many people have deficits that occur later in life because of innocuous causes such as undetected "whispering" or "silent" strokes or blows to the head that are not considered serious. Many medical conditions and treatments can worsen cognitive performance. These include chemotherapy, fibromyalgia, and multiple sclerosis.

3) Unaffected aspects of brain function can yield strengths or even gifts that make it very difficult for people to believe that the person has a brain impairment. This is especially true when the deficit is focal (limited to a narrow range of brain functions).

4) It is easy to take many of the manifestations of brain injury personally.

Extreme Results of Even So-Called Mild Impairment

The degree of impairment caused by even so-called mild brain injury can be sufficient to cause loss of a job, a marriage, and other roles. Many suicides result from untreated cognitive impairments. The incentive to reduce costs can cause managed care and military staff to create pressures to underdiagnose disorders such as cognitive impairment that can be costly and long lasting. Recovery from cognitive impairment, when possible, can require years and still leave a person with residual symptoms such as memory difficulties and trouble with mental focus.

Enduring Deficits

After recovery from brain injury, it is not unusual for some deficits to continue, particularly in the areas of memory and attention. The earlier in life that deficits occur, the greater the likelihood there may be developmental problems. Such problems can impair judgment, identity, and social functioning in ways that pose greater problems than the deficit itself.

Helping Parents Understand

Parents can be assisted in understanding cognitive impairment by comparing it to a sports injury. Degradation, strain, and even tearing of fibers and nerves in the brain can be compared to the damage to tendons that affect the performance of famous sports figures. However, it must be pointed out that, after the tissues heal, there is the added problem of restoring skills and habits that have been disrupted. In addition, some conditions such as schizophrenia may involve recurring harm to brain tissue.

The Power of Rehabilitation

A positive perspective that comes from education, peer support, and rehabilitation efforts can make a tremendous difference for a cognitively impaired individual. The therapist should link families with resources to this end. A shift in perspective can make all the difference as to whether such an individual thrives or is lost.

Developmental and Personality Problems

Developmental Deficits

Developmental deficits that do not constitute the severe, chronic impairment of a developmental disability such as downs syndrome, can be very confusing to families. These adult children are in the twilight between the normal population and people recognized as having a disability. Parents usually need a great deal of help putting their adult child's behavior into perspective. There can be significant problems with social skills, judgement, maturity, and skill level that puts these individuals out-of-synch with society.

The earlier a person acquires limitations such as cognitive difficulties or learning disabilities, the more severe they are, and the more negative or neglectful the reaction from peers and adults, the greater the likelihood of developmental problems.

Treatment of such individuals is much more likely to need to be of a long-term and mentoring form, and great care must be taken to help such individuals develop a career path that will not be too demanding.

Also, the deficits may obscure gifts that can be harnessed for increasing independence. Those concerned with such an individual's well being may need to take up the slack by making sure that he or she can complete their education or other efforts at increasing their independence.

Personality Disorders

It is nearly impossible to walk in the shoes of a person with a personality disorder. It is even harder for parents who have spent many years accommodating for their child's difficulties. Parents are often prone to trying what would work with a person who does not have a personality disorder, but trying much harder and for a prolonged period of time.

A striking example is that of antisocial personality disorder. Some parents have attempted to be found guilty of murder or child abuse rather than have their child held accountable for such acts. Such parents can have good educations and be functioning very well.

Therapists can help parents make realistic judgments and plans by showing parents the profile and name of the disorder, and give examples of how such personalities function in various circumstances. In the sections that discuss parents defenses against such realities, and on risks for physical and emotional violence, there is additional relevant material.



Introduction

We are not recommending that families take on a violent family member as a co-resident, but many families make judgment calls as to how much interaction to have with a potentially violent or otherwise harmful family member. The adult child may have some history of violence that the family is aware of, but does not feel poses a sufficient threat to prevent them from having the adult child at home. Violent behavior may emerge, and it is important to be aware of risk factors and educate the family members as needed.

It is also important to know ways that the likelihood of violence can be reduced. Psychotherapy, couples, or family therapy, medication, managing the adult child's environment, and social services can help. Parents can be trained in communication methods that prevent escalation or de-escalate.

The therapist must not give the impression that violence is predictable, but the family should understand the risks involved and signs to look for, as well as ways of interacting that may help them prevent violence.

Potential for Violence: Focus on Mental Illness and Brain Injury

Parents need to include their safety in considerations regarding contact with or living with their adult child. Researchers provide conflicting opinions as to whether adults with mental illnesses have an increased likelihood of violence. It appears that rates of violence in the mentally ill are only elevated in certain subpopulations. Some of these subpopulation have identifiable risk factors for violence. (Elbogen & Johnson, 2009; Nestor, 2002; Swanson, et al., 2002) Although there is some controversy, a number of researchers believe that severe mental illness does not independently predict violent behavior. (ibid)

In order to understand the link between violent acts and mental disorder, we must consider, "its association with other variables such as substance abuse, environmental stressors, and history of violence." (ibid) Steadman, et al. (1998) studied individuals recently released from hospitalization for a mental illness. These individuals were no more likely to engage in violence than members of communities they lived in were, except where substance abuse was involved. The authors state that, "Among those who reported symptoms of substance abuse, the prevalence of violence among patients was significantly higher than the prevalence of violence among others in their neighborhoods during the first follow-up." (ibid)

However, those communities tended to be in lower socioeconomic strata that were more prone to crime. Mentally ill individuals, like their neighbors, were more likely to be violent if they had certain substance abuse problems. However, mentally ill individuals, including those in the study, were more likely to have substance abuse problems. Like others in their neighborhood, the violence was usually, "...directed at family members and friends, and took place at home." (ibid) The likelihood of violence "varies considerably according to diagnosis and, particularly, co-occurring substance abuse diagnosis or symptoms. (ibid) Although violence took place in a variety of locations, patients were more likely to be violent in their homes, while other community members were more likely to be violent in a bar.

Hope for Recovery

The researchers were pleasantly surprised to find that the rates of violence declined a great deal over time after release from the hospital. They hypothesize that this may be because clients may have residual acuity even post release. They speculated that this may be because of stays being too short, and because aftercare may account for the reduction of violence over time. This is because aftercare services help to build additional support from the family and other sources. (ibid) This lends credence to advocates of recovery-oriented treatment of persons who experience severe mental illness. In addition, most of the violent incidents occurred in the ten weeks prior to hospitalization, presumably because violence often leads to hospitalization. (ibid)

Serious Violence, Substance Abuse, Brain Injury

Of those patients or community members who were seriously violent (likely to cause serious injury or death), they averaged 1.6 violent incidents during the ten-week follow up period. (ibid) In discussing the impact of substance abuse, the authors state that, "...the 1-year prevalence was 17.9% for patients with a major mental disorder and without a substance abuse diagnosis, 31.1% for patients with a major mental disorder and a substance abuse diagnosis, and 43.0% for patients with some other form of mental disorder and a substance abuse diagnosis." (ibid) Regarding substance abuse and violence, Wayne, Dinn, Gansler, Moczynski, & Fulwiler (2009) state that, "research on large population samples of individuals with major mental disorders has consistently indicated that the most important risk factor for violence in this group is substance abuse."

Elbogen and Johnson (2009) found no elevation of violence in persons with severe mental illnesses, except in connection with specific variables. In this study, "Data on mental disorder and violence were collected as part of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a 2-wave face-to-face survey conducted by the National Institute on Alcohol Abuse and Alcoholism." (ibid) There was a statistically significant increased rate of violence only, "...for those with co-occurring substance abuse and/or dependence." (ibid) In attempting to predict violence, they authors state, "Multivariate analyses revealed that severe mental illness alone did not predict future violence; it was associated instead with historical (past violence, juvenile detention, physical abuse, parental arrest record), clinical (substance abuse, perceived threats), dispositional (age, sex, income), and contextual (recent divorce, unemployment, victimization) factors." (ibid) However, they point out that, "Most of these factors were endorsed more often by subjects with severe mental illness." (ibid)

In a longitudinal analysis, Crocker, et al., (2005) found that, among persons with severe mental illnesses and substance abuse, "ASPD, thought disturbance, negative affect, and earlier age at psychiatric hospitalization were predictive of aggressive behavior." However, "the SRP-II did not predict violence or criminality in this population. The antisocial lifestyle factor, which demonstrated good internal consistency and convergent validity, also did not predict violence." (ibid)

In keeping with the conclusions of Steadman, et al., Nielssen and Large (2008) conclude in their meta-analysis that the fact that, "almost half of the homicides committed by people with a psychotic illness occur before initial treatment suggests an increased risk of homicide during the first episode of psychosis." Their study found 1.59 homicides per 1000 presentations during first episodes of psychosis, and only 0.11 homicides per 1,000 patients after treatment per year (a ratio of 15.5:1). (ibid) They suggest that, "Earlier treatment of first-episode psychosis might prevent some homicides." (ibid)

Bearing in mind that persons with mental illness suffer from damage to various regions of the brain (Wayne, M., Dinn, W. M., Gansler, D. A., Moczynski, N., & Fulwiler, C., 2009), it is no surprise that individuals with poor affect or impulse regulation are at increased risk of violence, and that persons with mental illnesses would have increased rates of other risk factors. This puts into perspective the statement by a forensic psychiatrist (Hodgins, 2008) that, "The largest group of violent offenders with schizophrenia show no antisocial behaviour prior to the onset of the illness and then repeatedly engage in aggressive behaviour towards others." Also, perhaps because of accumulated damage from repeated episodes, there is, "A small group of individuals who display a chronic course of schizophrenia show no aggressive behaviour for one or two decades after illness onset and then engage in serious violence, often killing, those who care for them." (ibid)

Of persons with severe mental illness convicted of murder in Indiana between 1990 and 2002, "Subjects were primarily suffering from a mood disorder...and, to a lesser degree, had significant intimate and familial relationships." (Jason, Matejkowski, Cullen, & Solomon, 2008) Most of the murders were motivated by rage or anger, and involved, "the use of a firearm or sharp object..." (ibid)

Assessment of 63 referrals to inpatient psychiatry units found four times as many persons with a history of closed-head injury in violent patients. However, it also found that 50% of the head injuries may have been accounted for by substance abuse, and that this could statistically account for the violence. (Wayne, M., Dinn, W. M., Gansler, D. A., Moczynski, N., & Fulwiler, C., 2009) This study found no neuropsychological deficits that distinguished violent from nonviolent patients, but discussed previous studies in which such deficits were found. (ibid) However, their paper posed the idea of serotonergic-mediated pathways and frontal lobe dysfunction are likely explanations for violence, and that both of these may be caused by a history of drug abuse or depression. In support of this, the authors state that depression and substance abuse is much higher in individuals with post-head-injury aggression. (ibid)

Gender, Personality Factors, and Psychosocial Context

Looking at gender differences in violence and mental illness, Krakowski and Czobor, (2004) studied men and women in psychiatric settings and after release. They found that, in the community, men were more likely to be violent, but this was, "associated with substance abuse, property crime, and a history of school truancy." Women were more likely to be verbally or physically assaultive, especially during the first ten days of admission and when positive psychotic symptoms occurred.

Nestor (2002) evaluated personality dimension associated with violence, concluding that problems with impulse control and affect regulation were risk factors. However, risk was substantially elevated when the individual had schizophrenia as well as a narcissistic or paranoid cognitive personality style and was reacting to a narcissistic injury. This was found whether the subjects were college students or persons with personality disorders.

Swanson, et al., (2002) explored the psychosocial roots of violence in a population of persons with mental illness in and out of inpatient settings who were clients of mental health systems in four states. They found that, "Three variables-past violent victimization, violence in the surrounding environment, and substance abuse-showed a cumulative association with risk of violent behavior." This population had a one-year violence rate of 13%.

Psychopathy and Antisocial Traits

As mentioned earlier, parents can have great difficulty understanding and accepting the realities of an adult child with antisocial or narcissistic traits. Before learning to protect their assets, parents may suffer extreme financial harm that may include identity theft.

Psychopathy: Psychopathy is a combination of antisocial and narcissistic traits. It is a profile used primarily in forensic psychology, and does not appear in the DSM-IV as a diagnosis. Forensic experts disagree with the statement in the DSM -IV that antisocial personality disorder and psychopathy are synonymous. According to Hare (1996), psychopaths are not, "simply persistently antisocial individuals," who meet DSM-IV criteria for antisocial personality disorder. He describes psychopaths as, "remorseless predators who use charm, intimidation and, if necessary, impulsive and cold-blooded violence to attain their ends." (Hare, 1996) It has been estimated that 1% of the public are psychopaths. (ibid) Psychotherapy for psychopathic individuals is questionable, because is appears that psychopaths learn to be more effective at manipulating and harming others as a result of psychotherapy. (ibid)

Misinterpreting the adult child: In cases of psychopathy, parents tend to misinterpret their child's behavior according to standards of normalcy. Despite ample evidence to the contrary, parents will perceive learning experiences and changes of heart where none exist. They will apply tough love, limit setting, and rescuing to a child that cannot benefit from such strategies. Such misinterpretation requires parents to assume that their adult child has motives and capacities that they have not demonstrated (but may be skilled at feigning), and can be influenced in ways that cannot be expected. It is difficult for a parent to percieve their own love and caring through their child's eyes as vulnerabilities to be exploited.

Dangerous change of strategy: A special concern here is what happens when the parents change their approach to a psychopathic adult child. The adult child with antisocial traits will change strategies in order to counter their moves. This can include dramatic escalations in emotional manipulation, threats, and even violence.

This could be mistaken for something akin to an extinction spike that can occur when a reinforcer is removed and a behavior increases in an attempt to get the reinforcer. However, in the case of antisocial personality disorder, the behavior can be far more intentional, strategic, and skilled.

Since many people with antisocial personality disorder have overinflated estimations of their capacity to succeed and avoid punishment, and have impaired foresight, this is not to say that their strategies will be effective from a long-term perspective. It is only to say that they will act out intentions that come from life-long practice in manipulating people. It is fueled by a very strong investment in maintaining something such as a lifestyle, public perception, sense of control over others, fraud, or criminal enterprise.

Red-collar criminals: The more impaired person with ASP may be very limited in their scope, engaging in petty acts. Less impaired individuals may have grander schemes. A profile that one forensic expert refers to a red collar criminals, is "a sub-group of white-collar criminals who are capable of vicious and brutal violence against individuals, namely murder, whom they believe have detected their fraudulent crimes." (Perri, Lichtenwald & MacKenzie, 2009)

In the case of parasitic adult children, it applies, "...to an adult child who is perpetrating fraud schemes against his parents and kills them (known as parricide) once they have detected his fraud. Although parricide accounts for less than 2 percent of all homicides in the United States, cases have emerged that appear to counter the popular perception that children who kill their parents only do so because of parental abuse or mental illness." (ibid)

Tarasoff warning: The authors discuss circumstances in which there may be Tarasoff reporting and warning requirements. A therapist may be justified in warning parents and authorities of risk of violence when the individual is committing fraud against the parents, especially where there is a psychopathic profile. This has not been tested in the courts. There may be no other indications of risk in such parricides. The logic used by the authors could possibly be extended to non-familial situations.

Risk signs and scenarios: In some cases, there is an escalation of antisocial behavior prior to violence. However, there may also appear to be a "lull before the storm" during which the psychopathic individual develops the intent to kill and prepares to act. During this time, the individual may be out of contact, or may be acting in a manner that is intended to quell fears and create an opportunity. Where a confrontation is sufficiently damaging from a narcissitic point of view, the individual may fly into a narcissistic rage and harm the other party.

Protective strategies: The authors also stress that parents should take protective strategies at the earliest signs of antisocial thinking or behavior. At the minimum, they should secure personal financial information and pass codes. If there is any reason to fear violence, parents should have home security measures that would prevent unannounced entry to the home, and should not meet with the adult child in a private location. They should not confront the child about fraud prior to alerting appropriate authorities and institutions. This eliminates most of the incentive to kill the parents, because murder will not prevent disclosure.

When a potentially violent adult child is in the picture, the therapist should discourage the parents from triangulating the therapist and antisocial adult child. They may be tempted to do so in a misguided attempt to influence the adult child. They might attempt to use the therapist as an authority figure or a motive for taking action the adult child would see as hostile to his or her desires. This could prompt an attack on the therapist.

Therapist Roles

In addition to the material on therapist roles in psychopathy above, the following are more general guidelines pertaining other populations.

Where there is significant risk of violence, the therapist may need to encourage parents to be more objective and informed about these risks. Where there are minors, disabled adults, or seniors in the living situation, there may be a reporting requirement.

Parents should be helped to understand how threats, property destruction, or nearly an intimidating attitude may be unduly influencing their decisions, and may need to be taken more seriously in terms of the stress caused and the risk imposed. Parents may need to learn behavior modification and communication techniques to help extinguish such behavior where possible. As is conveyed throughout this course, this is not an obligation of the parents, but many parents are more than willing to commit to such roles. Although the therapist does not want to encourage parents to take on risk, there are also situations in which threatening language or behavior is a chronic part of a disordered repertoire that does not include violent physical acts.

Violence from a higher-functioning family member may occur. Efforts at coercion and control may escalate into one-sided or mutual violence, especially where alcohol is involved. Family members should be educated about the risks and costs associated with being arrested for domestic violence, and how easily this can occur.



When the Adult Child is Not a Client: Counseling the Parents

In many revolving door families, the adult child will not be involved in family therapy and is not a client of the therapist. It is a conflict of interest and violation of ethics to work with parties whose interests may be at odds. According to the AAMFT Code of Ethics (2001) 3.4 "Marriage and family therapists do not provide services that create a conflict of interest that may impair work performance or clinical judgment."

Of course, family therapy often works with family members who are in conflict. The difference here is that the child in question is now an adult, is impaired, and is making decisions of concern to the parents. The adult child's decisions and behaviors may require the therapist to assist the parents in taking actions that the adult child will not consider to be in his or her best interest.

At odds: For example, it may be necessary to cut off support or call the police for an arrest. The therapist may need to emphasize ways that the parents can manage the adult child, and this may involve withholding information from him or her. At the same time, the adult child may need to discuss secrets that would compromise the therapist's role with the parents. Also, it is commonplace for such adult children to be unwilling or unable to effectively participate in family or even individual treatment. The adult child can be referred to another therapist or agency for services. Even when the adult child is getting needed treatment, the parents' issues with the adult child may continue.

Parents' symptoms and issues: Although the parents may be quite occupied by the problems of their adult child, the parents and possibly other family members usually have problems that need treatment. These may include the following problems:

For the problem of functional boundaries, family members do need to know what to do about the adult child. However, if it were a simple matter of making a good decision, they might have already gotten it from daytime TV or a single consultation with you.

Treatment unit, clients: Ethics require that the therapist clearly identify with the family who the clients are. Family therapists generally take the position that the family is the client, and they explain what this means at the outset of treatment. For example, the therapist cautions that he or she will not hold a family member's secret such as adultery. In this situation, where the adult child is not participating in family therapy, the parents and possible additional family members are the treatment unit.

Case management, sharing information: The therapist may find that it is advisable to discuss the adult child's clinical issues with other systems or treatment providers.

The family will provide a great deal of clinically useful information about the adult child. The adult child may not share some of this with treatment providers. This may impair the effectiveness of treatment. However, this information can help the therapist make appropriate referrals. The therapist can share the information that will help to ensure relevant treatment. In communicating with other providers, the therapist can avoid confusion by explaining his or her fole, and by disclosing that the information is second-hand, that the therapist is not treating the adult child.

From the perspective that the parents are the clients, these efforts would be part of a set of interventions intended to reduce stress on the parents. Many parents are so unskilled at navigating social systems and communicating with insurers, treatment providers, or police officers, that they require assistance in order to achieve a good outcome.

Clarity on roles and fees: Because of the potential additional time demands, the therapist must make it clear up front what roles, fees, and time may be involved, and must assist the parents in making decisions that are in their own best interest. This can include providing sufficient coaching and information that parents can engage in better advocacy or coordination on their own when this is a realistic expectation. Independent action by the parents can build their skills in working with these systems and being advocates.

Similarly, there are circumstances in which the therapist might need to speak to other systems, as when helping parents navigate in order to get benefits such as Social Security Disability Income for their adult child. Some parents may be sufficiently impaired or na?ve that the therapist will find it necessary to provide case management that includes communicating with providers or systems. Because this is a legal and ethical issue, the reader is advised to get legal counsel regarding specific situations. This training cannot provide legal advice.

Referrals for other family members: Depending upon whom the therapist is going to treat, other parties are likely to need referrals. This can entail cautious education of family members so that there is a positive regard for the referral recommendations. Ideally, the therapist should have sufficient knowledge of the adult child's impairments to ensure that he or she can adequately educate the parents, and understand possible outcomes of interventions under consideration. This may require the therapist to consult on an ongoing basis for a period of time. If the situation is emotionally volatile, the therapist must have enough experience with such situations to ensure competent handling of such situations. If the negotiation is going to primarily function in the same way as an intervention, the therapist must have adequate experience or consultation. The therapist should be able to address the question of whether an interventionist should be considered.

Treatment and Services for the Adult Child

Including the adult child: In conducting family therapy, the therapist must initially determine the unit of treatment. The therapist may find that it is appropriate to include the adult child in at least some sessions of family therapy with the parents (or some combination of family members).

Other treatment: The therapist should support the appropriate use of treatment, community services, and benefits for the adult child. It is important that the parents have an adequate understanding of the resources that may be involved. The therapist may play a role in referral to and coordination with services such as psychotherapy for the adult child.

Parent-funded or mandated treatment: Often, the adult child will only be able to afford treatment because the parents are funding it. The adult child may only consent to treatment because the parents require it as a condition of receiving support of some kind. Serious problems can develop in this situation, because many therapists are not experienced in dealing with issues of mandated treatment. The problems have to do with the practical, legal, and ethical issues involved.

This matter is covered in some detail in the sister Revolving Door Families course, with specific guidelines drawn from the experience of mandated treatement in situations such as employee assistance programs, and court-mandated referrals, as well as familial referrals.

General Issues Affecting Behavior of Parents: "Inner Pressures to Act" and Related Factors

Below is a list of normal "inner pressures" that can push parents into perpetuating dysfunctional patterns. It is important to be aware of them because of their powerful, unconscious effects on our behavior. They reflect normal drives, and can be addressed in treatment as strengths as well as vulnerabilities. They can be important topics in the psychosocial education of parents. Such education can normalize the parents' behavior and give them some distance from which to reflect and reconsider their actions from a more empowered perspective. This list of pressures is derived from evolutionary and cultural psychology, as well as well accepted psychodynamic considerations. These pressures or dynamics function mostly unconsciously. The decision to incorporate them into psychosocial education depends upon the parents' ability to grasp such material. Unconscious and motivational change approaches may be important in addressing these dynamics. Two additional, related factor types follow that list.

Normal "internal pressures to act":



These factors may have greater conscious access, allowing for direct discussion and change:

This factor may be the primary consideration of the initial treatment plan. A parent may have little grasp of the significance, or be fully prepared to discuss and respond to these factors with treatment and accommodation as needed:

Roles that may Arouse Concern and Related Clinical Responsibilities

Some of the negotiation guidelines in this system may be criticized where they support heroic efforts by parents, and where the parents demand the ability to supervise their adult child in some ways. For example, the parents may demand that their adult child have random drug screens as a condition of living at home. There are five points that may help to resolve such concerns and that exemplify roles that therapists can play in revolving door families.

1) Many parents will want to take these measures regardless of whether the therapist or anyone else feels that they are excessive. According to AAMFT ethical guidelines, therapists must refrain from insisting that clients follow their advice, unless there is a significant safety issue. They state, "1.8 Marriage and family therapists respect the rights of clients to make decisions and help them to understand the consequences of these decisions. Therapists clearly advise the clients that they have the responsibility to make decisions regarding relationships such as cohabitation, marriage, divorce, separation, reconciliation, custody, and visitation." (AAMFT, 2001) Parents may wish to exhaust every option, even when the odds are long that they will save their child from the serious consequences that concern them.

2) Parents who are inclined to take extraordinary measures often do so in harmful or clumsy ways. It is a legitimate clinical objective to assist such parents in improving their odds of success, and enhancing their well being and safety as much as possible.

3) Maintaining stability in the adult child's life, even though it involves means that are not considered age appropriate, can be a legitimate clinical goal. This is so when the adult child has impairments that call for assistance and structure that falls outside of age norms. For example, the state provides support to persons with developmental disabilities that are far from age appropriate. This is because of their disability. The adult child with other forms of mental disorder or other impairments may not be able to achieve age-normed expectations, either. Every year that goes by without an incident with the law, drugs, or other harm, is a year that allows the adult child to gain some additional wisdom and to settle down. It is a year that may provide greater odds that the child will become independent or less likely to experience or do harm of some kind.

4) Conversely, parents may abruptly or otherwise decide to withdraw support, sometimes to an extreme. Again, the therapist cannot ethically decide for the parents what support they should provide. The therapist must continue to focus on the clinical needs of the parents. These efforts might include helping a parent continue their recovery from trauma, grieve their disillusionment regarding their child, or restore harmony with a spouse alienated through prior conflict over how much support to give.

5) The family may be in conflict over where to draw the line on support. The therapist may help the parents become unified, and improve their negotiation abilities.

Plans on Hold The therapist may help the parents come to terms with a "plans on hold" situation. This occurs when the child is not dependent upon the parents and will not negotiate, but may become dependent in the future. Should their child become dependent on them, they can use this as an opportunity to negotiate concessions from the child. For example, the parents might allow the child to return home after participating in a residential drug program. The child will be able to stay if there is consistent work in a career training program.

Judgment Calls Parents must be helped to come to terms with the fact that they cannot predict the results of their actions. They can only make an informed choice based on odds, their own intuition, and the potential costs involved. A parent who fears that their child is at too much risk on the street may be willing to have that child stay at home despite the child's unwillingness to comply with demands such as drug screens. The parents may come up with other reciprocation elements for negotiations. For example, if the adult child follows a timeline in getting additional support, then the child will be afforded additional considerations such as being driven places or supplied with preferred foods.

Orchestrating negotiation The therapist can help parents ensure that the support they provide will have the most constructive possible effect, and that their involvement will not harm them emotionally, financially, or any other way. This often calls for a structured form of negotiation that is cognizant of the parents' boundaries and needs. Part two of this training provides detailed coverage of this process, taking the learner through stages of assessment, preparation, negotiation, follow up, and termination. It also covers conditions necessary for such negotiation and alternative strategies where it is contraindicated.



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