All in the family

When Russian author Leo Tolstoy wrote in his novel Anna Karenina, “Each unhappy family is unhappy in its own way,” he was definitely on to something. A dysfunctional family environment has myriad effects on its members — effects that are intricately woven by factors such as personalities, communication abilities, attachment issues and sometimes even family violence.

But Tolstoy’s narrator got it wrong upon saying, in contrast, “Happy families are all alike.” On the face of it, the inaccuracy of that declaration seems obvious: Of course no two families (or people) are alike. But the more substantive implication — that people from happy families emerge without problems, untouched by the environment in which they grew up — is also false.

For good or ill, our families — of origin or the ones we choose — shape us all in some way. A family’s influence on its members is lifelong, and counselors must keep that effect in mind as they seek to understand and treat individual clients. Some counselors choose to place even greater focus on family as a primary factor in overall mental health and wellness, adding family counseling to their practices, calling clients’ family members in to discuss specific issues or simply learning the concepts behind family systems theory as another way to inform treatment.

We are family

It starts at birth, as we enter the world, confused and a little bit cranky. How much of who we are is already inside us? Nurture versus nature has long been the subject of debate, but the authors of a 2013 article in The Family Journal: Counseling and Therapy for Couples and Families make their argument clear in the article’s title: “Nurture Is Nature: Integrating Brain Development, Systems Theory and Attachment Theory.” Their position is that parents and caregivers introduce significant environmental stimuli when the brain is still forming, and these influences shape how the brain develops.

As children grow, they continue to seek information about the world and themselves. Along the way, parents and caregivers teach or help them learn many fundamental skills: how to talk, walk, tie their shoes, use utensils and, most critically, interact with other people.

“Parents are the ultimate teachers. They teach their children what to think about the world, what is important or unimportant and about their own self-worth,” say researchers Shea M. Dunham and Shannon B. Dermer in the first chapter of the 2011 book they co-edited with Jon Carlson, Poisonous Parenting: Toxic Relationships Between Parents and Their Adult Children. Dunham and Dermer go on to assert that directly or indirectly, parents teach children how to feel and how to love both other people and themselves.

In fact, a research review, “The Role of the Family Context in the Development of Emotion Regulation,” published in the journal Social Development in 2007, found that children learn emotional regulation through observation, modeling and social context, particularly in the family environment. Emotional regulation is the ability to identify and control emotions — to know when and how it is appropriate to express certain feelings. According to the article, family factors that influence emotional regulation include parenting style, the strength of the emotional attachment between parents and children, family expressiveness and the relationship between the parents. The authors state that the lessons of emotional regulation learned within the family set the stage for additional emotional and social learning from other sources, such as peers.

But some families don’t model healthy emotional regulation for their children. This may be because of abuse, neglect or simply that the parents or caregivers never learned to regulate their own emotions. Children who do not learn emotional and social cues at home often have difficulty interacting with peers and teachers. These children are at greater risk of falling behind in school, developing learning difficulties and acting out.

Sadly, some families aren’t just behind on the social learning curve; they are instead actively abusive or neglectful. In the past 20 years, large studies by the federal Centers for Disease Control and Prevention and partner institutions have found that children who are exposed to high levels of violence or who are victims of trauma such as physical or sexual abuse and neglect suffer significant emotional, developmental and physical problems. These children are more likely than their peers to struggle to keep pace in school, smoke, abuse drugs and alcohol, and commit acts of violence. These effects, along with significant health problems, continue into adulthood. (For more on the effect trauma has on children, see “The toll of childhood trauma” in the July 2014 issue of Counseling Today.)

In other instances, families can’t control the traumas their children are exposed to. For instance, many families that are economically disadvantaged have little choice but to live in neighborhoods that are violent and dangerous. However, research suggests families that feature healthy attachments and strong parenting styles can help mitigate the trauma. A 2004 study, “Exposure to Community Violence and Violence Perpetration: The Protective Effects of Family Functioning,” published in the Journal of Clinical Child & Adolescent Psychiatry, found that children from supportive family backgrounds who were exposed to excessive neighborhood violence were less likely to be violent than children from dysfunctional family environments.

Other research has found that family support can make a significant difference in both the prevention and successful treatment of substance abuse, mental health, school and peer problems.

A surprising discovery

Many family counselors would say that these effects are examples of systems theory at work. Systems theory holds that all of the parts of any system, such as a family, are interdependent and affect each other in ways that may not be obvious.

“Seemingly unrelated parts of systems are more related than we think,” notes David Kaplan, the American Counseling Association’s chief professional officer and a past president of the International Association of Marriage and Family Counselors (IAMFC), a division of ACA.

As an example, he cites the experiences of a group of pediatricians working with children with Type 1 diabetes, an autoimmune disease that causes the body to destroy all insulin-producing cells, at the Children’s Hospital of Philadelphia during the 1960s. Type 1 diabetes can be difficult to control, but these physicians developed a plan that combined diet modifications and a strict schedule of insulin injections. Because individuals with Type 1 diabetes are entirely dependent on insulin (not having the ability to make their own) and because people with any form of diabetes must watch what they eat to help keep their glucose levels under control, it was critical that the children and their parents followed the physicians’ plan.

When a child was first diagnosed, the doctors would sit down with the parents and explain the details of the plan and how to follow it, Kaplan says. Most of the children they treated did pretty well after being put on the plan, but a small number of the same patients kept appearing in the emergency room with diabetic comas caused by hyperglycemia, an excess of sugar in their blood. After each emergency, the doctors would meet with the child’s parents and review the plan again. Still, some of the same children continued to show up in crisis over and over again.

Finally, the pediatricians began searching for similarities between these children — not just with their physical health but in all areas of life — and eventually identified one big common denominator: All of them came from homes with significant parental conflict. The children would see their parents fighting, get scared and stop taking their insulin because when they did, the resulting illness would unite their mothers and fathers. Once the child was better, however, the fighting would resume, and the cycle would start all over again.

Clearly, something had to change. So the doctors sat the parents down once again and told them that the best thing they could do to improve their child’s health was to work on their own relationship with each other. These parents weren’t neglectful, Kaplan points out. They had done their best to follow the treatment plan, but they were thinking only about the mechanics of the disease and not the other influences surrounding their child, he explains. This idea that the family environment could significantly influence treatment was new to health care. In fact, although the idea has gradually gained acceptance, it is still not an active influence in many health systems today.

Counselors, however, had already been exploring the influence of the family environment. Family counseling was unofficially “born” in 1942 with the founding of the American Association for Marriage Counselors. And today, family counselors continue to preach that physical and mental health issues are intimately connected to the family environment.

‘Live’ dynamics

From the perspective of systems theory, people represent just one piece of various systems that are always “running.” A family runs by simply going about its daily routines, interacting with and influencing each other. Sometimes the system runs smoothly, while other times its “pieces” encounter a monkey wrench, says Esther Benoit, a licensed professional counselor (LPC) and ACA member from the Hampton Roads region of Virginia.

Systems theory is related to the idea that a body in motion tends to stay in motion and that systems are generally self-perpetuating, Benoit says. The system — in this case, the family — will continue to try and function as it is, even if it is malfunctioning and the resultant effects are harming or breaking down the system.

Benoit offers an example of how this might play out in a family. A couple has a child who is having disciplinary problems at school that are caused or exacerbated by marital tension at home. Focusing solely on maintaining discipline will not correct the behavior, she says, because the tension, unless addressed, will still be there.

Family counselors believe that even issues that seem specific to an individual client can be connected back to the family. “Both individual and family therapy offer an approach to treatment and a way of understanding human behavior,” says Brandé Flamez, IAMFC’s representative to the ACA Governing Council, “but a major premise of family therapy is the belief that most problems originate and can be solved within families.”

Not all family counselors use family systems theory, but the idea of connection still underlies their work. Karena Heyward, a family counselor and LPC from Lynchburg, Virginia, admits she’s biased, but she believes all branches of counseling can benefit from the principles of family counseling.

“As human beings, we do not live in isolation. Our stressors do not typically occur in isolation. So, why would we tackle these stressors in counseling in isolation?” she asks.

“Show, don’t tell” is a classic piece of guidance that is often handed out to aspiring writers and journalists. Family counselors contend that “showing” is also an important factor in their work with clients.

“Family counselors look for family dynamics to be re-created in the counseling room so we can continue the healthy patterns and make changes to things that are not working for the family,” explains Heyward, who is also an ACA member and assistant professor at Lynchburg College.

“Instead of individuals talking about their experiences with someone, you get to see it live [in family counseling],” says Greg Czyszczon, an LPC and ACA member in Harrisonburg, Virginia. “That has so much potential for healing if we have a good ‘road map’ and a good sense of where they are stuck.”

As Czyszczon watches these live scenarios, he looks for clues concerning why a family is struggling to resolve its problem and how he might help the family move forward. “We guide them to have a different experience of enactment,” he says.

For example, if parents are having difficulty getting their child to go to bed, Czyszczon will ask them to reenact their bedtime ritual. The details — spoken and unspoken — of the interaction unfolding before him allow him to come up with alternative scenarios the family can try. Changing the interaction could involve helping the parents understand what the child is trying to communicate by acting out and resisting going to bed. Or it might involve helping the parents explore different ways of approaching bedtime.

Individual vs. family counseling

Family counselors eagerly extoll the benefits of family therapy and even encourage counselors who work with individual clients to consider the family environment. For instance, bringing in family members to help an individual client work on an issue can be very beneficial.

David Lawson, an LPC and professor at Sam Houston State University in Huntsville, Texas, had a client for whom the validation of others was very important. The client’s husband was a taciturn, cerebral man, and she really wanted him to talk to her more. She also wanted him to listen to her concerns and participate more in her counseling.

“So we tried to break it [the problem] down into pieces,” Lawson recounts. “She said she would love to have him sit down and talk to her about something for an hour. We started with trying to get him to talk for a few minutes on something that he was really interested in, and then we would add to it gradually.”

Once the woman got her husband talking — and listening — to her, she was able to open up about her concerns. He eventually agreed to come into some of her counseling sessions so that he could better understand what she needed, Lawson says.

However, family counselors emphasize that individual counseling is very different from family counseling. In individual counseling, the individual is the client; in family counseling, the family is the client.

“I think there are several difficulties that novice family therapists often encounter,” says Flamez, an LPC and national certified counselor (NCC) who counsels at-risk youth at a community center in Corpus Christi, Texas. “[These include] overemphasizing content over process, focusing too much on one member of a family, trying to make everyone happy and overemphasizing verbal statements as a way to change families.”

“Other difficulties include failure to engage each and every family member in the session, failing to establish the structure of the therapeutic session or failing to focus on the family and what they want,” she continues.

Family counseling is not for those who have difficulty multitasking, adds Benoit. “There’s so much going on [in family therapy]. You have multiple people giving you so much information, both verbal and nonverbal,” she explains. “And then [you have] the points of connection between them, with all these interactions and subtle patterns. A lot of family work is about the space between people.”

“Initially, family counseling looks very similar to individual [counseling],” Benoit explains. “You are still doing active listening, but one of the key differences is that you are checking in with multiple people. You’re not just listening to one person and watching what they are not saying, you’re also looking at how other family members are reacting.”

For instance, a female client may be in tears while telling her story. As Benoit listens, she might also notice that the woman’s husband has shifted his posture, turning away from his wife. Benoit files this away so that she can return to it and ask about it once the wife has finished talking.

But even counselors who prefer to work primarily with individual clients shouldn’t disregard the influence of family when treating these clients. ACA President Robert Smith believes it is important for all counselors to learn as much as possible about a new client’s social systems and family in the initial sessions.

“A systems assessment during beginning sessions may help determine whether the family is playing a role in helping the client maintain a problem or a set of problems,” explains Smith, who helped to found IAMFC in the late 1980s and later served as its executive director.

Adds Lawson, “Looking at family cycles and stages can be helpful even if a counselor doesn’t see [himself or herself] as a family counselor.” For instance, if a client is being particularly resistant, the reason might connect back to the person’s family background, and the client might not even be aware of it, he says.

“Any counselor needs to understand that the past is present,” Lawson says. “Our families are always there — even when they’re not. They’re ghosts in a sense.”

And those ghosts might be more active than a client realizes, Lawson notes. When a client mentions unresolved past issues and grievances with family members, those same complaints often pop up in the present, he says. As an example, he mentions a client who comes to counseling and spends a significant amount of time complaining about his or her current relationship with a spouse or partner. “When a client gets upset with a partner, I will stop and ask them about the people in the past,” Lawson says.

He asks them to consider what percentage of their distress might actually be tied to a family member, such as a father or mother, rather than the spouse. Together, they will look at the source of distress and talk about loved ones in the client’s past who also displayed these behaviors. Upon doing so, Lawson says, clients often realize that although they have been attributing all of their anger or sadness to a spouse’s behavior, much of it relates back to unresolved issues with a parent or other caregiver.

Lawson urges counselors to proceed cautiously when helping clients resolve past issues. “You have to be careful to not paint parents, even horribly abusive ones, as monsters, even if they were,” Lawson cautions. “Even if a client is criticizing a parent or partner, don’t join in. Those emotions can change, and the client may then turn on you.”

“There is often a part of the traumatized client that loves that parent, is still emotionally connected and remembers only good,” he continues. But the client also harbors memories of the hurt and abuse, so Lawson finds a way to help the individual integrate those conflicting emotions.

“In various cases, I have helped people totally cut themselves off psychologically and physically [from their abusers],” Lawson says. “They may not speak to them, or only do so once a week, but they still need to find a place for them [cognitively and emotionally].”

He helps these clients make a place emotionally to remember some good things about the person but also teaches them not to look beyond those small moments for more.

Of course not all clients have unresolved traumas or current interpersonal problems, but counselors may still look back to the family to uncover clues to an individual’s persistent emotional issues.

“Even in the absence of participating family members, bringing in that sense of family as an extended system can be helpful,” says Benoit, who is also a professor in Walden University’s marriage, couple and family counseling program. She will often ask clients to complete a genogram, in which they list three generations of their family members and note any elements of physical, mental and relationship health of which they are aware. This might include causes of death (including suicide), history of mental illness, chronic physical illnesses, divorce, and emotional or physical trauma. When clients look at their family history plotted out in the genogram, it can be easier for them to identify patterns, Benoit says.

Culture clash

When many people think about the concept of family, they still picture a white father, a white mother and 2.5 kids. Although counselors are aware that there are many colors, definitions and configurations of family, without the experience of growing up in a minority culture, it is difficult to understand the extra challenges facing these diverse families.

One example is the many immigrant families who come to the United States looking for a better life. Many of these immigrants are met with outright hostility and a dearth of opportunity. The pressure of adapting to a new life and culture creates problems that go beyond the stress and strain of everyday life, notes Kathryn Norsworthy, an ACA member who works with local aid organizations to provide counseling services around the Orlando, Florida, area to migrant workers from Mexico, Central American and Haiti.

“Oppression can seep into family dynamics,” explains Norsworthy, a counseling professor at Rollins College in Winter Park. “For example, in a migrant family, one of the things that happens is that quite often, the children and teenagers become the public face of the family because the adults don’t speak English or don’t speak it well. So, kids and teens become translators and the navigators of public systems — the family advocate.”

In playing this role, children and adolescents have to deal with adult-level institutional barriers, assuming responsibilities that are beyond their years, Norsworthy continues. The parents often feel humiliated because they can’t take care of their own interests, and the family hierarchy is upended. The younger members of the family are elevated to a place of power that is inappropriate. Counselors working with these clients need to be aware of these skewed dynamics to help the families cope with the tension it creates, Norsworthy adds.

In addition to the role reversals and upended power dynamics, immigrants also face a culture clash — not just with their new home country, but within their families as well, Norsworthy says.

“In this country, quite often, people of color will tell you they are reluctant to identify themselves as American because it seems like [to do that] you have to give up who you are, be like other white people,” she says. “They feel like they lose big parts of who they are.”

“Parents have very strong ties to their original culture that they want children to know about, and they often parent through the framework of their culture,” she continues. Meanwhile, their children — like kids everywhere — are just trying to navigate their environment and find a place to fit in. “The kids are being pulled toward assimilation and internalizing the values of this culture, and the parents are upset because they don’t want them to forget where they came from,” Norsworthy says.

These parents and their children may also clash over educational and career choices. That’s true for many families, of course, but for immigrant families, there is often an extra layer of anxiety. The parents fear their children won’t be able to overcome the barriers that the parents themselves faced or still face.

The parents of one family with which Norsworthy worked were from West Africa, but the children had been born and raised in the United States. After the daughter started college, she decided she wasn’t really ready and didn’t want to keep attending. She voiced her desire to stop for a bit and find a job doing something that interested her to see how that worked out. The father was adamant that leaving school was unacceptable. The only option was for her to finish college. He was so resistant to discussing other alternatives that Norsworthy probed further to see what was behind his anger.

“It was because of the struggle he had when he first got here,” she explains. “He could see that the only way for people with West African background to succeed was to have all the resources that were possible, and for him that [meant] education. He was afraid she would face more racism and discrimination by walking away from her education.”

Once the reason was out in the open, Norsworthy was able to successfully work with the family, helping the daughter to understand her father’s concerns and helping the father to accept that the daughter needed to find her own path to success and belonging.

The Haitian migrants with whom Norsworthy works face fear and superstition surrounding their Voodoo religion. Most Americans don’t understand the religion, associating it instead with the occult or black magic. This can be a problem especially for Haitian children and adolescents, Norsworthy says, because when they go to school, they hear negative comments about their parents’ spiritual practices, and the children absorb that. Because of such reactions, the Haitian migrants feel they have to be very discreet about their religious beliefs and sometimes give up their practices altogether, she says.

That scenario offers a valuable lesson to all counselors working with individual clients or families from a different culture. Because these clients’ religious practices or other customs can be so different from the “norm” in the United States, and thus so easily misunderstood, it is important for counselors to educate themselves about these practices. This is particularly important, Norsworthy says, because immigrants often find solace and a kind of sanctuary in their culture and religion. These things often connect them to the places where they grew up and still consider “home.” Counselors need to draw those cultural connections and strengths out and not just focus on the problems that immigrant families might be confronting, she says.

“A lot of times, they have strong faith traditions that ground them as they face barriers and challenges in life,” Norsworthy says. “These communities will have different traditions that connect them to their cultural roots.”

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Children caught in the middle

One of the most difficult challenges a family counselor can confront is a family facing divorce, particularly when child custody issues are involved, says Ruth Outz Moore, a licensed professional counselor and national certified counselor in Savannah, Georgia.

Matters can become further complicated when the breakup involves a same-sex couple who have children. Although a growing number of states now allow same-sex couples to marry, many states still do not, and this can be a particularly knotty problem when it comes to custody issues, says Moore, a member of the American Counseling Association. Even in states where these couples are legally married, a parent can find himself or herself shut out depending on how the law is written and interpreted.

“Sometimes the idea is who is the biological parent?” Moore explains. “For instance, in a lesbian couple who become parents through one partner being inseminated, even though they are equally parents, if they split, the biological parent can say that she doesn’t want the other parent to have contact with the child.”

“I have worked with many parents who have lost relationships with children because of this kind of inequality,” she continues. “I worked with a heterosexual male-female couple in which the mother ended up in a same-sex relationship. The father got so mad that he attempted to use that to deny her custody of the child.”

Moore also worked with a child whose parents were splitting up because the father was transitioning to a woman. The child was naturally upset about the divorce but was also confused because his father was becoming a woman, she says.

Children are very resilient and can adjust to a wide range of circumstances, including a parent’s transition, says Moore. But too often, she says, one parent is trying to deny the other parent custody, and the child is left wondering, “What do you mean my other mom isn’t my mom anymore?”

— Laurie Meyers

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Further reading

• Youth at Risk: A Prevention Resource for Counselors, Teachers and Parents, Sixth Edition, David Capuzzi & Douglas R. Gross, 2014
• Family Violence: Explanations and Evidence-Based Clinical Practice, David M. Lawson, 2013
• Multicultural Issues in Counseling: New Approaches to Diversity, Fourth Edition, Courtland C. Lee, 2013
• Casebook for Counseling Lesbian, Gay, Bisexual and Transgender Persons and Their Families, Sari H. Dworkin & Mark Pope, Editors, 2012
• Family Matters: The Intertwining of the Family With Career Decision Making, Second Edition, Robert C. Chope, 2012
• Understanding People in Context: The Ecological Perspective in Counseling, Ellen P. Cook, Editor, 2012
• Counseling Multiple Heritage Individuals, Couples and Families, Richard C. Henriksen Jr. & Derrick A. Paladino, 2009
• Family Counseling for All Counselors, David M. Kaplan & Associates, 2003
• Techniques in Marriage and Family Counseling, Volume One, Richard E. Watts, Editor, 2000
• Techniques in Marriage and Family Counseling, Volume Two, Richard E. Watts, Editor, 2002