Dr. Combrinck-Graham, tell us about your emphasis on families in treating children.Dr. Combrinck-Graham: Every child has a family. Sometimes families are difficult and sometimes they are nontraditional. But children live in families and most often their families are their greatest resources and the medium by which children can improve.
So you advocate for having the family be a big part of a child’s therapy.Dr. Combrinck-Graham: Yes. One problem with individual child therapy is that there are loyalty conflicts that are never addressed. I, as a perfect stranger, say to the child, “Anything you say to me will be between us.” What does that say to a child? Who am I? Why should we be having these private conversations and secrets that don’t involve his parents?
Is this true for adolescents as well?Dr. Combrinck-Graham: Yes, although some argue that since adolescents are working on their individuation they shouldn’t have therapy with their families. There may be some things they want to discuss alone with me, but the fact is that their families should be their most significant resources.
Do you think overlooking the power of family is a common mistake psychiatrists make?Dr. Combrinck-Graham: In my view, not seeing the family at all is a mistake. Some people assume that the family is not effective or is not positive or is undermining or hurting the child before ever actually seeing them. But the actual presence of the family can really transform your view of the child.
How so?Dr. Combrinck-Graham: Because you get the see the child responding to family members. And I’m talking about siblings and grandparents and pets. They’re all part of the family.
Basically anyone the child has a relationship with is part of the family.Dr. Combrinck-Graham: Right. And those therapists who have been trained to see only the child might not give the family adequate consideration for their efforts, but it’s important to see where each member of the family comes from. There is a principle invented by Ivan Boszormenyi-Nagy called “multilateral partiality,” that says that ultimately the outcome of good family therapy is for all family members to understand the sides of all other family members while firmly standing on their own sides.
How do you deal with family members who don’t want to participate?Dr. Combrinck-Graham: First, you should insist that the “family” is not just the mother, and that the father and siblings should be there. It’s important not to just accept it when people say they’re not coming. I recommend working really hard to find a time that works for dads, for example. And call them. Say, “I really need you here because I’m missing your perspective and your input.”
Do you find that sometimes with parents, fathers in particular, they resent the idea that you are this person who knows more about parenting than they do? Not that that is the case, but that may be their perspective.Dr. Combrinck-Graham: That is actually a good thing, because, in fact, we don’t know more about parenting their children than they do, and that’s why we need them there. I offer advice about things—families should try to eat dinner together; kids shouldn’t have TVs in their rooms—but not because I’m a better parent than they are. I say it because these things promote family communication. You have to start out family therapy with the humble feeling that you really don’t know anything about what they have to live with.
What advice would you offer to a child psychiatrist about how to engage the family at the initial meeting?Dr. Combrinck-Graham: There is a difference in opinion among family oriented child psychiatrists about whether to see the parents alone first or see the family first. I think you should see the whole family first. This is an opportunity for the child to hear why his parents thought he needed to come and for the child to respond. Probably 99 percent of the time, in my practice, the child doesn’t know why he’s there, according to him.
How does this initial meeting usually go?Dr. Combrinck-Graham: They come in as a family. You meet each individual person equally. You ask each what their difficulties in the family are and what they have tried to do about it. You observe interactions between them By the end they are usually engaged because they are curious about what to do next.
As psychiatrists, we don’t always have time for multiple sessions with a family, though.Dr. Combrinck-Graham: True. I don’t get to do a lot of family therapy, but I do all my evaluations with the family present and I sometimes do follow-ups with everyone, too. At the end of that first session, there should be some statement back to the family about what you observed, and what are some things you think they might want to work on. I never want them to leave with the idea that I have some knowledge that I’m keeping to myself.
What is a situation where you might want to see the family again?Dr. Combrinck-Graham: Sometimes I want to see the parents without the child in a situation where the child is so involved in the parents’ business that I think a little mystery needs to be created. This can give parents a sense of more control.
Can you give us an example?Dr. Combrinck-Graham: I had this family where a child kicked the father out of the parental bed so she could sleep with her mother. She slept in the bed, but she mostly kept the mother up all night talking about important things, but in a totally tyrannical fashion. And the parents were just completely at her whims. So we started meeting without her. And at first she would come in and we’d have to leave to go to a different room. And she hated me for this, but her parents learned to contain themselves and not be tyrannized by her, and she started sleeping in her own room and focusing on her own life instead of theirs.
So one of your techniques is to create mystery or curiosity in your situations.Dr. Combrinck-Graham: Yes, creating curiosity or raising questions make people think about how they could be different. In my book Giant Steps, I talk about how there are different ways of thinking about things—there is no one true version of a story. In a family, you need to hear everyone’s version of the story and figure out how they all fit together.
Are there any other techniques you like to use?Dr. Combrinck-Graham: Play therapy works really well for some families. From puppets, to role playing, to family drawings. In some families we might even play a ball game. In chaotic families, I’ll pass the hat so only the person with the hat can talk. It’s amazing how it gets everyone to want to talk and they all have arguments over who gets the hat!
How do you deal with particularly hard families?Dr. Combrinck-Graham: One thing that makes working with families hard is abuse or exploitation of the child, or abuse of the child through domestic violence between parents. Another type of hard family is one where the parents are so preoccupied with their own lives that they neglect the child. Often I feel like the best I can do is say, “This is really hard. What can we do to make it different?” I’m just trying to get the parents involved in solving the problem. Getting in consultants is helpful too, but you’ve got to do it with humility. For example, saying, “I’m really stuck, but I think Dr. so-and-so has some ideas. Would that be all right with you?”
Are there special considerations for children who are not part of traditional families?Dr. Combrinck-Graham: For kids in foster care, I really try to get the foster parents involved. So many of these children have attachment problems, so it’s important for the foster parents to be in the session to understand how a child’s behavior might be a stance he has to take to protect himself.