Potencial de crecimiento de mercado

Determining whose goals and issues should be prioritized is often an ongoing and complex negotiation in CBT with children and their families. The authors believe it is important at the outset of therapy to elicit and acknowledge any differences in the view of the problem before working towards finding a way

of agreeing common understanding and goals. In exploring differences of view, Stallard (2002b) has suggested that the therapist needs to maintain a ‘detached, objective and impartial position’. Others have argued that a position of objective impartiality may be unobtainable, but that therapists need to be as aware as possible of their own biases and views and try to manage different perspectives by allowing them space to be heard, and by offering their own views and thoughts as appropriate (Wilkinson, 1998).

Drawing on systemic interview techniques and understandings may be of help in initial meetings with families as a way of opening up and exploring differences in perception between family members as to what they see as the problem and what they want done about it (Watzlawick et al., 1974; Hoffman, 1981;

McGoldrick,1998). The work of Pearce and Cronen (1980), in particular, can be seen as applying a cognitive approach to family communication by exploring and elucidating how underlying beliefs (both individual and shared) may influence the behaviour and relationships of individual members.

‘Reflexive questioning’, a form of questioning used in family therapy (Tomm 1987a,b), can be employed to help family members challenge their own beliefs and cognitions. Reflexive questions are defined as: ‘questions asked with the intent to . . . (activate) . . . the reflexivity among meaning within pre-existing belief systems that enable family members to generate or generalize constructive patterns of cognition or behaviour on their own’ (Tomm,1987a). While the language is different from that of CBT, the underlying principles could be seen as similar in that, by challenging false beliefs and cognitions, the individual members in the family are encouraged to come up with more constructive alternative understanding.

The technique of ‘reframing’ that arises out of the systemic literature may also be powerfully employed with families in helping them come to a shared view of the difficulties. ‘Reframing’ involves the therapist in encouraging family members to apply new meanings, which facilitate the development of a more positive slant on particular behaviours or events. For example, a child labelled as aggressive by his parents may be referred to, in another context, as passionate.

If the therapist refers to the ‘aggressive outbursts’ as ‘passionate outbursts’, alternative meanings may be given to the same behaviour (Wilkinson,1998).

Where possible, the aim is for the therapist and all family members to come to a view of the difficulties that does not involve blaming the referred child or other family members, but that positions all family members as collaborating to overcome the difficulties. Michael White’s use of externalizing conversations, which use interview techniques to emphasize a shared way forward and do not dwell on issues of causation, seems to the authors to be concordant with general

CBT theory and practice (see Table7.1) and provides a useful way forward in this regard (White and Epston,1990). March (see Chapter17) draws on the work of Michael White in helping parents understand their child’s obsessive compulsive disorder as something outside the child’s or parent’s control that they can all work on together (March and Mulle,1998).

7.2.2 Addressing family issues

We recommend that, wherever possible, clinicians should undertake a thorough assessment of the child, their family and the school context before any decision is made about whether individual CBT may be appropriate.

The aim of this family assessment is to assess the nature of the problem, clarify different people’s views and help arrive at a shared formulation of the problem and action plan. It is not within the scope of this chapter to suggest how best to undertake a full family assessment – readers are referred to Wilkinson (1998) and Carr (1999) for useful overviews of this topic. However, it is perhaps worth reiterating that such an assessment does not just serve to provide information for the clinician, it can also be used in attempts to develop a shared formulation of the difficulties that all family members can agree on.

In terms of the distinctive CBT aspects of this assessment in relation to working with parents, two related but separate questions need to be addressed: to what extent can the presenting difficulties be understood as linked to family issues, and to what extent is direct intervention with the parent(s) indicated?

In terms of assessing how far the presenting difficulties can be understood as linked to family issues, it is widely accepted that for many difficulties parental views and behaviours influence the development of difficulties in the child (Carr, 1999). For example, anxious children are more likely to have parents with a range of anxiety problems, and family processes have been shown to contribute to avoidant responses in anxious children (Barrett et al.,1996). Similarly, in relation to disruptive and conduct-disordered children, there is much evidence to show the powerful effects of parental behaviours and cognitions in the development and course of such difficulties (Kazdin,1995).

In some cases, family assessment may indicate that family issues are so sig-nificant as to preclude CBT as an approach in the first instance. If there are significant child protection concerns, these may need addressing prior to any therapeutic intervention being offered. Similarly, family assessment may reveal major parental mental health issues or marital stresses that need addressing as a primary focus. However, it is our view that, even if family factors are implicated as contributing to the presenting difficulties, this does not necessarily mean that the parents should be the primary focus of the intervention. Individual CBT

with the child may still be appropriate, although the clinician may need to deter-mine how best to address parental and/or family issues alongside work with an individual child.

There is little available research in this area to guide the clinician as to how to determine when it is best to work directly with parents alone, when with the child alone and when with a combination of child and parents. Negotiating family involvement is a complex and sensitive task. Demanding intensive family involvement when this runs counter to the wishes and views of key family mem-bers can lead to resentment and non-compliance with treatment. Conversely, when the clinical situation requires it, the failure to address family issues may seriously limit the potential benefits of CBT with an individual child.

There is a range of possible configurations of parental involvement in ther-apy including: the child being seen alone with minimal parental involvement, the child being seen along with their parents, the whole family being seen or the parents being offered separate/parallel interventions. The role of par-ents in any of these scenarios can vary from facilitator, to co-therapist to client/patient in their own right. Clearly, there are many possible variations and parents can be involved in their child’s CBT in different ways during the course of a single intervention. In the light of what limited evidence there is avail-able, the authors have started to construct a very crude tentative hierarchy of parental involvement, described below, to help guide decision making in clinical practice.

7.2.2.1 Parent as facilitator – child offered individual CBT with parent