Jose is an 11-year-old boy who has, for years, been threatening his family to run away and never return when he is upset with them. His family has tried to cope with these behaviors the best they could, but things reached the point that they felt they needed further assistance. His grandmother made a decision to bring Jose to the clinic to obtain assistance, and the Multiple Family Therapy Group was suggested as an approach that might be helpful.
Each fall for the past two years at the Institute for Community Living’s Guidance Center of Brooklyn Heights, we have conducted a group in conjunction with Mount Sinai School of Medicine’s Department of Psychiatry Research Center called the Multiple Family Therapy Group. The group runs for a 16-week cycle, including time for research data collection. The clients are children ages 7-11 diagnosed with Oppositional Defiant Disorder, and they are accompanied by their parents and other family members. The group curriculum focuses on teaching the participants the “Four R’s:” Rules, Responsibilities, Relationships and Respectful Communication. The goal is for both parents and children to learn how to incorporate the four R’s into their lives with resulting improvement in the child’s behavior.
The first year, the group was conducted by a clinical supervisor from the outpatient clinic and a parent advocate from the Brooklyn Parent Resource Center. The second year, it was run by New York University interns supervised by the clinical supervisor. The participants are families of children in the designated age range who are diagnosed with oppositional defiant disorder. The group can consist of up to six families at the same time. A “family” is defined as those individuals who participate in raising the child and who can commit to a 16-week group treatment process. Once started, the group is closed to new members after the third meeting.
Initial group activities are focused on helping the families understand the purpose and goals of the group and to identify the concerns of each individual in the family. Every effort is made to elicit verbal participation and engagement so that all members of the group are invested in the process. After all, each member of the family contributes something unique to the culture and dynamics of the household. The process of setting rules is initiated by the group facilitators, but the children are asked to contribute rules as well. All the rules are written on a large sheet and posted on the wall for everyone to see. Then the families sign the rules to emphasize the importance of following them. Together, we also identify goals for each family. The goals are revisited frequently throughout the course of the group and provide a focus for families; something to work towards.
An integral part of this group experience is sharing a meal. Time is allocated during the group for staff and families to enjoy a meal with one another. Most of the children request pizza, so that is what we order. In an attempt to promote healthy eating and to supplement the children’s food of choice—pizza, we also order salads. The experience of sharing ideas and issues while eating together creates a bond with participants that feels like a family experience as well as a group process. Ours is a hands-on group. Many of the activities involve games and/or encourage writing and working together toward a common goal.
The first few sessions include ice breakers though which the families become acquainted and begin to understand that there are others with similar issues. With this newfound knowledge, the group becomes a safe place to share problems. As the group proceeds, the members take on specific roles, often replicating the roles they assume within their own homes. For example, one parent is the “biggest talker,” often taking over the group and sharing the most frequently. One of the children may act as a “protector” for other children in the group Still another is the “jester” who makes jokes and does not listen well. As these roles surface, they are acknowledged by the staff and the other families and associated behaviors and patterns are identified and discussed.
Communication is both verbal and non-verbal. Children learn how to communicate from their parents and their peers. What they learn is not always respectful communication. One of the goals in the program is to increase communication between parents and children and to teach listening skills as well. To warm up the group, we play a game of telephone where a statement is whispered around the room. This illustrates that if the communication is not clear and attention not focused, the idea does not get across accurately. Children and parents are asked separately how they know if someone is listening: eye contact, verbal acknowledgement, body language and ultimately the response are the answers we tend to get. Families know how to listen and how to talk to each other, but they do not always exercise these skills effectively.
There are challenges that we face during the group; some are physical, some are emotional. The room in which we run the group is very small, which makes it difficult to walk around and check in personally with all of the families. Staff makes an effort to move about and touch base with each family and their progress. There is also a good amount of coordination required to ensure that the group runs smoothly. Ordering food, writing notes, distributing Metro Cards and preparing material are a few of the concrete tasks involved.
The first year that we ran the group we had a particularly challenging group of participants. Children with oppositional disorder presented unique behavioral issues beyond actions and symptoms associated with the majority of children in treatment. Children do not always feel like talking about their issues from school or home and they tend to act out their anger instead of verbally expressing it. Video games, phones and Mp3 players are not permitted in the group since they tend to distract everyone. Asking a child to put aside a video game to talk about stress at school may provide the group with a clear and immediate example of defiant behavior.
One added benefit of having multiple parents in the room is that they act as parents to all the kids. If a parent is not managing her own child, rest assured another parent will let the child know they are acting out. For instance, one child in the first group consistently talked back to his grandmother and the grandmother was unable to redirect her grandson. One of the other mothers became exhausted with this routine and firmly told the child that he was disrespecting his grandmother and that if he lived in her household, that behavior would not be tolerated. The behavior stopped and the grandmother shared that she felt more empowered.
Relationships are our key to interacting with the world. The relationships we have with our parents and the relationships our parents have with each other teach us how to behave with those outside the family. To help families understand the importance of relationships, we focus on positive activities the families can do together. Individual families choose their activities, and then as a larger group we discuss rules around family time, obstacles to spending time together and how to prioritize family fun time.
We learn new lessons every time we run the group. During the first year, we found that a reward system is an extremely effective tool to encourage the kids to participate. Even a small, inexpensive toy is an incentive to get children back on track. We used the star system. Children start out with 5 stars in the beginning of the group. If they participate in an activity, they receive an additional star. If they act out, a star is taken away. By the end of the group, if the children have 10 stars, they are rewarded with a toy. Our goal was to create a system in which every child is rewarded with a prize by the end of group, and it worked.
Both groups of families expressed verbally how much they gained from attending the multi-family group. Approximately one-half of the participants completed their treatment following the group and acknowledged that their goals had been achieved. The remaining families stayed on and were assigned an individual therapist. We plan to run the group again this fall in a different setting: the ICL Emerson-Davis Family Development Center. While this will add a new set of challenges concerning different age groups and confidentiality among residents of the same congregate facility, a positive aspect is that residents will not need to travel to get to the group. Since families live where the group takes place, there should be fewer instances of absenteeism. We look forward to extending our experiences within a clinic setting to a residence and to continue learning from the challenges that will present.