Peggy Papp, M.S.W., bases her approach to adolescent therapy upon helping the family identify belief systems that control their lives and relationships, on the premise that these activate or maintain the adolescent's symptomatic behavior.
All families have such belief systems, says Papp, director of the Depression Project at the Ackerman Institute for Family Therapy in New York.
"[They are the] expectations, values, attitudes-the basic assumptions-that govern family interactions," said Papp. Because they determine the structure and organization of a family, the traditions they follow, the rules they abide by, and the values they hold, these beliefs shape the kinds of problems a family has and how they go about trying to solve them.
"Generally, the adolescent is either acting upon, rebelling against or challenging these values and beliefs," says Papp. Because the beliefs are on the implicit rather than the explicit level, people usually aren't aware of them. The goal of therapy is to help the adolescent and family become aware of the beliefs and behavior that perpetuate the problem so they can consciously choose how to change them.
How does the therapist determine what these belief systems are? "Mainly through the process of deduction and elimination," Papp says. "Listen to the stories the families tell, how they tell them, the descriptions they give of themselves and of each other. Look for attitudinal statements that characterize the family's overall patterns."
She begins with questions she considers a crucial part of the intervention.
- What are the beliefs or attitudes surrounding the presenting problem? Since a family has many different kinds of beliefs, it's important to zero in on those triggering the adolescent's presenting symptoms.
- Are there interactional patterns that take place around these values and beliefs? Because families tend to speak in generalities, she tries to get a picture of the family dynamic by asking for a blow-by-blow description of how these beliefs are played out in the family. She asks members to describe a scenario in great detail, "almost like a slow-motion picture": What do you do when he does that? How do other members react? Then what happens?
- How are these beliefs acted on in other contexts-in the extended family, at work, at school, socially? "The therapist should get a whole picture of the family's social relationships," Papp says, "because sometimes the place to intervene may be in the school or within peer relationships or someplace else."
- What is the source of these beliefs in the extended family and the families of origin, and how are they are being replayed in the present? She goes back at least one generation to see how these beliefs were played out then.
- What needs to happen in order to change the problematic belief? She often gives family members exercises, the specifics of which grow out of the case material.
In a family in which a 15-year-old boy was lying and stealing, Papp unearthed the mother's belief that the boy had inherited a bad gene from his grandfather, who was a kleptomaniac. Her intense reaction to every small incident of normal childhood misbehavior actually began fostering sneaky behavior in the child, who felt he had to cover up everything since he never knew what would set his mother off.
"It was important to uncover the belief that lying and stealing were genetic," says Papp, "and to debunk that myth and talk about it with the son so that he wasn't mystified by his mother's extreme reactions." Papp also asked the mother to write down all the ways the boy differed from his grandfather so she would stop seeing her son metamorphosing into her father.
While questioning a 14-year-old girl who was rebellious, skipping school, exhibiting uncontrollable behavior and taking drugs, Papp quickly picked up on a frequently uttered attitudinal statement: "I have to stand up and fight for my rights." Who else feels this way? Papp asked everyone else in the family. Who doesn't? What happens when you do or don't? Do you ever stand up for anyone else's rights?
"In this family," says Papp, "rebellion went back three generations; it colored all of their personal transactions." The parents had been flower children as teens but had never progressed from that state, and were anti-establishment in every aspect of their lives. The father had lost two jobs rebelling against authority and both parents still were working out issues of autonomy with their own parents. At one point the father actually said, "If I have taught my children anything, it's never to have any respect for authority."
Papp also learned that the parents never stood up for their rights with each other, so that the daughter was standing up for the mother's rights against the father, and the son was standing up for the father's rights against the mother.
"The central questions then became how, when, where and with whom is it productive in life to fight for your rights?" says Papp. "And under what circumstances is it counterproductive?"
Once the erroneous beliefs were brought to the surface, that whole theme took on a different meaning. The parents learned to stand up for their rights against each other so their conflicts weren't diverted to their children. The rebellious daughter decided to fight for her right to go to college and law school, where she could realize her new goal of becoming a defense attorney-to help other people stand up for their rights.
At the U.S. Psychiatric & Mental Health Congress last November, Papp brought her technique to life using video footage of a family in therapy. Jimmy, a defiant 13-year-old, was depressed, his behavior was uncontrollable and he'd threatened to jump out a window. Several chronic physical illnesses had plagued him since birth. The previous year he'd spent seven months in a residential treatment center, where he'd been on nine medications, none of which had much effect.
According to Jimmy's parents, Sherry and Steve, Jimmy had only two modes: total passivity, where he lay around the house in pajamas, unresponsive, refusing to go to school and sick with some ailment or other; or explosive anger with violent tantrums. He was empty inside, they said. He manipulated his parents and was trying to ruin their marriage. If they didn't prompt Jimmy he'd do nothing, but in spite of their pushing and prodding he still found ways of failing.
"Let me tell you the phrases that rang a bell with me," said Papp after showing the initial video clip. "'We give him pep talks.' 'I'm dancing for him.' 'We try to motivate him.' 'His failure becomes our hurt.' 'Maybe we're killing his motivation.' 'He gets people to do everything for him.' 'We don't let him fail.' "
The first belief she uncovered was that Steve and Sherry thought a good parent never lets a child fail. Sherry's belief came directly from her family of origin, where her mother had done everything for her, short of going to school and taking tests for her.
Papp challenged this belief by giving Sherry and Steve an assignment: to make Jimmy responsible for his own homework and to allow him to fail.
In the next video clip the family described how, given responsibility for a social studies test, Jimmy had scored 91. Sherry and Steve were flabbergasted. Jimmy was less sullen and more willing to participate in the session. He even looked different.
Another problem in the family was how to deal with Jimmy when he misbehaved. Because Steve felt that Sherry was inconsistent, he stepped in to establish some kind of discipline. But he reacted harshly, triggering another belief of Sherry's: that Jimmywould be psychologically damaged if she didn't intervene. Equating Steve with her iron-handed father, who had terrified everyone, she took Jimmy's side against Steve, giving Jimmy the message that he could get away with anything because his mother would always protect him.
Papp suggested ways to break this pattern, and the next time Steve lost control, Sherry sympathized with him instead of comforting Jimmy. Because she broke the destructive pattern, the incident quickly blew over.
An exercise Papp often gives patients is to one day act upon the old set of beliefs and the following day upon a new set, and to notice the difference. She asked Sherry to act first as she always had, as if Jimmy were sick and all his problems internal. The next day Sherry was to believe he was normal and that his behavior simply needed to be dealt with. The difference was so profound that this was the turning point of therapy.
With several successful interventions behind them, Sherry and Steve's confidence grew and Jimmy slowly began to improve. He went back to school, rode his bike, made friends and became less defiant.
Next Papp began exploring the source of Steve's anger toward Jimmy. She learned that Steve came from a family so chaotic that he, as the oldest child, had assumed all responsibility; Sherry described him as "the choir boy, the Boy Scout, always doing good for others." Steve believed he wasn't entitled to needs of his own, but anger and frustration inevitably built up.
Sherry was a woman of many talents but felt guilty about pursuing them. Instead she focused her energy on Steve and Jimmy, believing she could control them, "fix" everything that was wrong with them and inspire them to reach the aspirations she had for them. Her dreams for Steve, however, weren't the same as his were for himself. Believing that confrontation led to abandonment-as it had when his father walked out on the family-he withdrew from Sherry and directed his frustration toward Jimmy.
Papp's unraveling of these family myths allowed Steve to begin learning how to express his feelings to Sherry, and this lessened his anger toward Jimmy. Sherry learned to stay out of Steve and Jimmy's interactions so that Steve didn't have to be the bad guy, and this allowed Jimmy and Steve to have their own relationship. And Sherry learned to focus on developing her own potential rather than everyone else's.
Jimmy continued improving. With the big issues under control, his physical ailments disappeared and he made many friends. By the time therapy ended, he was running for student council.