Furthermore, in unhealthy families, boundaries between parents and children are often overly rigid or excessively diffuse. Disengaged families are characterized by overly rigid boundaries, in which open communication between family members is stifled, and members feel disconnected from one another. In contrast, enmeshed families are characterized by diffuse boundaries where family members lack autonomy and constantly intrude into each other’s lives (Wendel & Gouze, 2015).
Adlerian family therapy is an alternative, contemporary approach to family systems therapy that helps parents manage their children’s behavior problems (Sherman & Dinkmeyer, 2014). An Adlerian family therapist believes that all family members, including children, seek lives based on meaning, effectiveness, and purpose. They view children’s behavior problems as a maladaptive attempt to achieve meaning or purpose in the family. Specifically, misbehavior can occur for four reasons: (1) to gain attention, (2) to assert autonomy from parents, (3) to extract revenge or “to get even,” and (4) to avoid responsibilities and be left alone. The therapist’s task is to identify the purpose of the child’s misbehavior and help parents find a more adaptive role in the family.
Family therapists would insist on seeing Anna and her parents together, for at least part of treatment. The therapist would likely pay attention to alliances and boundaries in Anna’s family and the way Anna’s eating disorder might help to maintain the family system in a maladaptive way. For example, the therapist might discover that Anna’s parents frequently argue with one another and are considering a divorce. The therapist might notice that the onset of Anna’s symptoms coincided with her parents’ marital problems. The therapist might hypothesize that Anna’s eating symptoms serve to maintain the family’s structure by distracting her parents from their marital disputes (Wendel & Gouze, 2015).
A family therapist might also notice that Anna’s parents are overprotective and excessively demanding. The therapist might interpret Anna’s desire to lose weight as a maladaptive attempt to gain the approval of her parents. The therapist might refer Anna’s parents to a marriage counselor to help them improve the quality of their relationship. At the same time, the therapist might work with Anna and her parents to improve communication at home. One goal of therapy might be to help Anna’s parents give her more autonomy over her day-to-day behavior (Bitter, 2013).
Psychodynamic Therapy
Psychodynamic therapy focuses chiefly on unconscious conflict within the self. Psychodynamic therapy is based on the theoretical and clinical work of Sigmund Freud (1923/1961), Anna Freud (1936), and a host of neo-Freudian theorists. Although there are a vast number of psychodynamic approaches to therapy, almost all believe that unconscious thoughts, feelings, dreams, images, or wishes influence our behavior (Barber & Solomonov, 2018).
Sigmund Freud believed the mind is analogous to a topographical map with different levels of awareness. According to Freud’s topographic theory on mind, two levels influence and direct our thoughts, feelings, and actions. The conscious mind consists of thoughts and feelings that are immediately accessible: the book that you are reading, noises in the background, or transient feelings of hunger. In contrast, the unconscious mind consists of mental processes that are not immediately accessible but can nevertheless affect our behavior: thoughts, feelings, wishes, and images that we cannot admit, even to ourselves. Unconscious mental activity can be influenced by experiences of loss, rejection, fear, or pain. From the psychodynamic perspective, psychological symptoms often reflect these unconscious mental processes (Terr, 2015).
The primary goal of psychodynamic therapy is to provide insight—that is, to make the person aware of unconscious mental conflict that contributes to his psychological symptoms. Insight is believed to result in symptom alleviation and more adaptive behavior (Barber & Solomonov, 2018).
One way therapists help clients gain insight is by paying attention to the client’s transference, the attitude and patterns of interaction that the client develops toward the therapist. Transference is believed to reflect the client’s history of interpersonal relationships and unconscious thoughts and feelings projected onto the therapist. For example, an adolescent who has been physically abused or neglected by her parents might express mistrust and hostility toward the therapist. The client might unconsciously expect the therapist to abandon, reject, or mistreat her in a way similar to her abusive parents. The therapist can use transference to help the client gain awareness of these unconscious thoughts and feelings. For example, the therapist might interpret the client’s transference by suggesting, “I notice that whenever we talk about ending treatment, you get very angry and resentful toward me. I wonder if you’re afraid that I’m going to abandon you?” Over the course of therapy, as clients gain greater insight into the causes of their distress, they may experience symptom reduction, develop better means of coping with anxiety, and achieve more satisfying relationships with others (Terr, 2015).
A psychodynamic therapist might focus on Anna’s transference. Over the course of multiple sessions, the therapist might notice that Anna often acts helpless and childlike during therapy sessions, as if she wants the therapist to tell her what to do. Furthermore, Anna might become frustrated and angry toward the therapist when the therapist remains nondirective and insists that Anna solve problems for herself. The therapist might interpret Anna’s transference as an unconscious desire to remain in a childlike state. The therapist might suggest that as long as Anna remains helpless and childlike, she does not have to assume adult responsibilities that cause her anxiety: getting a part-time job, going to college, or leaving home. The therapist might suggest that Anna’s eating disorder ensures that her parents will care for her and provide her with attention and sympathy, rather than insist that she develop more autonomous, age-appropriate behavior.
Review
Behavior therapists focus on children’s overt actions. They try to change problem behavior by modifying its environmental antecedents or consequences.
Cognitive therapists focus on children’s thoughts about self, others, and the future. They identify and challenge biased or distorted thoughts that lead to maladaptive actions or emotions.
Interpersonal therapists focus on the quality of children’s relationships with family and friends. They help children cope with disruptions in these relationships or improve their interpersonal skills.
Family therapists view the entire family system as their client. They believe that improvement in one family member will change all members of the family.
Psychodynamic therapists focus on unconscious thoughts and feelings that affect children’s functioning. Therapists attend to transference, that is, the client’s feelings and ways of responding toward the therapist based on his or her developmental history.
What Is Culturally Adapted Treatment?
Intersectionality
The American Psychological Association has developed guidelines for adapting therapy to meet the needs of children and families from multicultural backgrounds. In order to provide culturally adapted treatment, psychologists must develop an appreciation for, understanding of, and willingness to learn about clients’ social–cultural histories, identities, and values (APA, 2017b).
At the heart of the APA multicultural guidelines is the notion that a child’s identity is shaped by multiple ecological systems. Each child views herself as a member of a family, peer group, school, neighborhood, and community. The child’s identity is also formed by her educational background, ethnicity, gender, immigration status, income, religion, sexual identity, and social–cultural values. Identity is constantly changing, depending