Synthesis, electrochemical, photophysical, and electroluminescent properties of organic dyes containing pyrazolo[3, 4-b]quinoline chromophore

Article abstract of DOI:10.1016/j.dyepig.2015.05.002

Abstract Organic dyes containing trifluoromethylated-pyrazolo[3, 4-b]quinoline were synthesized by using condensation reaction between substituted pyrazolo-4-formaldehyde and aryl amines in moderate yields. Quantum calculation, electrochemical, photophysi

Full text of DOI:10.1016/j.dyepig.2015.05.002

From Family Therapy to
Family Intervention
Allan M. Josephson, MD
KEYWORDS
ꢀ
ꢀ
Family therapy Family intervention Developmental psychopathology
ꢀ
KEY POINTS
ꢀ Clinical work with the family must always be part of the identity of the child and adolescent
psychiatrist.
ꢀ In every case, the child psychiatrist should evaluate for family vulnerabilities and coexist-
ing family strengths.
ꢀ The family regulates affect and behavior and shapes the formation of mind.
ꢀ The child psychiatrist should assess and intervene with the family enough to understand
the patient’s context, to communicate with nonmedical colleagues, and to avoid
diagnostic errors.
ꢀ Families are a core component of resilience: they confer genetic/experiential protection
against genetic/experiential risk.
The term, family therapy, has been part of psychiatric lexicon for several generations,
yet it may have outlived its usefulness. For many, the term conjures up the notion of all
family members being present for each session, but the field has been moving away
from this very specific meaning. The seminal idea of the “family as a system” is no
longer the sole theory guiding family work. The systemic perspective sees individuals
in a family system as interdependent, with no change occurring in a family without
everything else changing accordingly. Analogous to the overreach of interpretation
in the history of psychoanalysis, systems interpretations became overused.
Although the system remains a viable and important construct, there are now other
ways that clinicians work with families. Some of the terms used to encompass this
trend include family treatment, family-centered treatment, relational processes and
disorders, family psychiatry, family skills enhancement, family intervention science,
and parent management training.1
The term family therapy has become problematic in that, for some, it communicates
that it is the province of the nonmedical therapist, marginalizing its significance.
No disclosures.
Bingham Clinic, Division of Child and Adolescent Psychiatry, Department of Pediatrics,
University of Louisville School of Medicine, 200 East Chestnut Street, Louisville, KY 40202, USA
E-mail address: Allan.josephson@louisville.edu
Child Adolesc Psychiatric Clin N Am - (2015) -–-
http://dx.doi.org/10.1016/j.chc.2015.02.002
childpsych.theclinics.com
1056-4993/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.

Josephson
2
Ironically, the family’s systemic properties are congruent with numerous physiologic
mechanisms (eg, increase of heart rate with a drop in blood pressure). Equally prob-
lematic, for many clinicians, family therapy communicates a specialized set of skills,
even esoteric, that many practitioners feel ill equipped to implement. This article pro-
poses the use of the term, family intervention, to encompass the many ways contem-
porary clinicians work with families beyond the activities connoted by family therapy.
Family intervention is defined as a coordinated set of clinical practices designed to
alter family interaction, family environment, and parental executive function. This
collaborative intervention utilizes parents, child, and siblings to strengthen protective
factors and mitigate family risk factors associated with child and adolescent psychiat-
ric disorders. In addition to the amelioration of symptoms, family interventions typically
address any factor that impedes child and adolescent development.
Contemporary clinicians face a question not contemplated in previous generations:
what is a family? There are many changes in the contemporary family that are fully
reviewed by Sargent.2 For the purposes of this article, the term, family, refers to indi-
viduals who have regular contact with its children and assume the responsibility of
meeting their developmental and emotional needs. The term family implies biological,
affective, and legal bonds, occurring together or separately. The term, parent, refers to
the individuals who make decisions on behalf of children. In this article, the terms,
child and children, refer to any individual younger than 18 years of age; hence, the
use of child includes adolescents.
The family must be considered in each case. Avoiding family work, under the guise,
“I don’t do family therapy,” is not an option. In each clinical encounter, the clinician
must consider the ways in which the family ameliorates or exacerbates psychiatric
symptoms. What is the most appropriate family intervention? What are the target
points for a family intervention? Who implements it? What is the knowledge base
required of a clinician for a safe and effective intervention? This article responds to
these questions and prepares readers for this issue’s discussion of family work in
specific disorders by providing an overview of the next paradigm in family treatment.
CHALLENGES FOR THE CLINICIAN MAKING A FAMILY INTERVENTION
Many contemporary challenges take psychiatric clinicians away from a family focus.
These include but are not limited to
ꢀ The promise and peril of empiricism. “Not everything that counts can be counted,
and not everything that can be counted, counts” (Einstein).3
ꢀ Family-based treatments must follow the available evidence, yet there are helpful
family interventions that may not have been studied. Such interventions, ad-
dressing known risk factors, cannot be assumed to lack efficacy.
ꢀ The frequent use of medications, and the aggressive marketing of them,4 has
directed attention away from psychosocial interventions5,6
ꢀ Reductionism limits seeing the big picture.7–11 Scull has noted, “a simplistic bio-
logical reductionism has increasingly ruled the psychiatric roost. Patients and
their families learned to attribute mental illness to faulty biochemistry.It was bio-
babble as deeply misleading and unscientific as the psychobabble it replaced.”12
ꢀ Contemporary psychiatry provides less time for understanding patients, gath-
ering developmental histories, and carefully developing clinical case formulations
ꢀ The “med check” approach severely limits a gathering of data that allows a family
formulation.
ꢀ Psychiatric diagnoses often lack relational context and suffer from oversimplifi-
cation. Disorders are reified when a developmental explanation is more

From Family Therapy to Family Intervention
3
appropriate.13 If the symptoms of dysregulated children were seen as a regula-
tion failure instead of a major mental illness, the bipolar epidemic could have
been avoided.14,15
ꢀ The excitement of neuroscience discoveries is a legitimate factor decreasing
emphasis on all psychosocial factors, including the family.16
THE FAMILY AS AN INTEGRATING PRINCIPLE OF DEVELOPMENT
Family factors must be integrated into all treatment plans. Clarification between eclec-
ticism and integration is in order. Eclecticism is a pragmatic approach to a case in
which the ingredients of different approaches are used without concern for theory.
If it works, try it. On the other hand, integration assumes a more extensive blending
of approaches into a broader theory.17,18 This article describes a family approach
that integrates diverse aspects of development and developmental psychopathology
into a systems/developmental view of the family. It takes a broader view than a recent
article that delineated a specific integration between psychodynamic, developmental,
and family concepts.19
In child and adolescent clinical work, development must be central to any integra-
tion theory. Child psychiatry has moved from a focus on psychoanalysis in the first half
of the past century to a shift to the child in the system in the latter half of the cen-
tury.20,21 Both these approaches consider development as important. The field’s
contemporary challenge is to integrate the facts of the clinical history, including
assessment scales and rating scales, yet not lose the narrative/story of the child in
family context. Carlson and Meyer22 illustrated this challenge when they noted, “the
diagnosis of bipolar disorder is often made by mindlessly applying criteria without
understanding developmental history and context.”
So what is developmental psychopathology? There are numerous definitions but all
include the process of a child facing developmental tasks requiring mastery and a
range of risk factors that impede development and a range of protective factors that
foster it.23,24 The organism/child is in interaction with the environment. Treatment
efforts then are rationally directed toward decreasing environmental stress and
increasing organism resilience (eg, moving a child to a less demanding classroom,
increasing attentional processes through medication, and learning coping strategies).
The concept of resilience—“the capacity of a dynamic system to adapt successfully to
disturbances that threaten system function, viability, or development”25(p10)—merges
with the concept of developmental psychopathology.26
It is widely accepted that genetically programmed developmental tasks unfold
without interruption. As Masten has commented, “societies and families have
observed over generations that these developmental milestones signify that a child
is on track to do okay in the future. There is popular belief that competence begets
competence in these developmental tasks.”25(p19) Here is the family integrating princi-
ple again: children do not develop in vitro but in vivo. They develop in the context of the
family, and family processes can dramatically foster this development or significantly
impinge on it. In the former, the family operates as a protective factor and in the latter a
risk factor. These developmental tasks are sequential and cumulative. Success in one
area of development begets success in the next.
In behavioral studies of resilience, successful outcomes are defined as competence
in age-salient developmental tasks.25(p16) There is general acceptance of the following
common age-related, chronologic developmental tasks. Although acknowledgment
goes to Erik Erikson,27 numerous developmentalists have subsequently elaborated
on his ideas.28

Josephson
4
1. Infancy: establishing a social bond, a sense of basic trust, and security
2. Establishing a sense of autonomy, early independence, and self-control of
impulses
3. Developing socialization, enculturation, and early peer relationships
4. Establishing a sense of productivity and achievement through burgeoning physical
and intellectual skills
5. Adjusting to physical maturation; forming close, emerging romantic relationships;
and independence from family
In sum, a family intervention must facilitate task mastery by mobilizing family strengths
(protective factors) and by mitigating family weaknesses/problems (risk factors). Any
intervention that achieves this effect inevitably ameliorates clinical symptoms.
PREPARING FOR INTERVENTION
Family Assessment
The data on which a family formulation is based are derived from a comprehensive
assessment of family structure, family communication, family regulation of child devel-
opment, individual functioning of child and parent, marital functioning, and the stages
of the family life cycle. The data are best gathered by thorough history taking and
observation of family interaction.29,30
The simultaneous gathering of the facts of a clinical history and observing family
interaction is difficult for many clinicians. The number of individuals involved in a family
interview can seem overwhelming. Ironically, the assessment process can be simpli-
fied, and even efficient, by observing family interactions play out in a consulting room.
Apparent complexity can dissolve with such observations as the parent of an opposi-
tional child asking a child’s permission to comply, an overinvolved parent speaking
regarding an adolescent’s health concerns (eg, “Dr, we are having trouble with our pe-
riods.”), or an enraged, entitled adolescent cursing at a parent.
The Practice Parameter for the Assessment of the Family (American Academy of
Child and Adolescent Psychiatry) offers a helpful structured guide to eliciting a family
history.31 Other sources also describe family assessment in detail.32,33 For disorders
seen as primarily biological (eg, autism) in origin, families are seen as stressed and
responding to the disorder. In other disorders with strong psychosocial underpinnings
(eg, conduct disorder), the nature of family interactional sequences and parenting
practices seemd to give rise to disorder.34 In individual cases, there is often a key
sequence of interactional events that culminate in the need for clinical intervention.
When the assessments of individual parents, marital functioning, and the family as a
unit are conducted as part of an evaluation of a child’s disorder, the gathered data
are always directed toward understanding and treating the child’s problems.
Although some family assessments may be abbreviated (eg, straightforward atten-
tional disorder), it is imperative in certain situations to conduct a full exploration of
family functioning. These include instances in which assessment reveals
ꢀ History of significant parental risk factors (eg, parental substance abuse or
marital discord)
ꢀ History of specific family interactional problems (eg, intrafamilial aggression or
child oppositional behavior)
ꢀ Observations of problematic parent-child interactions (eg, harsh parental limit
setting or an overly close parent-child relationship)
ꢀ Minimal progress in an individual psychotherapeutic treatment or a pharmaco-
logic treatment. This indication for in-depth family assessment seems more

From Family Therapy to Family Intervention
5
prominent in contemporary psychiatry due to the challenges of contemporary
psychiatry discussed previously.
ꢀ Another family member with psychiatric symptoms
The Practice Parameter also provides a guide to observing basic elements of family
functioning.31(p932–34) Family structure refers to hierarchy and power relationships and
the invisible boundaries within families. Family communication refers to the clarity and
directness of communication and whether the content of communication is congruent
with accompanying affect. Family regulation connotes how the family regulates devel-
opment, specifically affect and behavior.29 This regulation, performed externally by
the family, ultimately becomes an internal regulatory process within the child and is
a crucial developmental achievement.35 Anders has provided a categorization of the
regulatory process that is particularly helpful when applied to each developmental
stage.36
Formulation
The clinical case formulation is essential for effective family intervention. It is a tool for
child and adolescent psychiatrists to determine how families protect and how they
pose risk for the emergence of a mental disorder. The effective formulation goes
beyond a mere listing of facts and maps out how an organism/child interacts with
the environment through consideration of specific factors in each category. The clin-
ical formulation is always consistent with available empirical evidence yet can go
beyond it. Effective formulations use clinical evidence understood through the lens
of developmental and systems theory. A formulation of parental overprotectiveness
can rationally be based on the clinical observation of a parent answering questions
for a teenage child in a family therapy session. Table 1 summarizes the factors to
be considered in developing a case formulation.
Key principles of the family-oriented case formulation:
1. There is an interactional basis (organism-environment) to child psychopathology. A
learning disordered child with problems in mathematics only becomes stressed
when academic challenge unmasks the disability. A dependent child in an en-
meshed family only develops a full-blown depression when leaving home to attend
university. Effective family interventions must consider decreasing environmental
stress and increasing organism resilience.
2. The behavioral and affective processes of psychological development are regu-
lated by families. A behaviorally disordered child is observed on an inpatient unit
during a parental visit. The mother rests on the child’s bed, reading a magazine,
making only a mild entreaty to stop her child’s disruptiveness and destructive play.
3. Family experience shapes mental function (ie, family interaction becomes part of
the child’s mind). As an example, a teenage girl scratches her wrist and offers
the cryptic comment, “I wanted to make a friend suffer.” Therapy revealed an enti-
tlement born of an adoring, almost worshipful mother, an attitude the girl came to
believe others shared.
4. A formulation suggests weighing clinical variables of importance, emphasizing those
with most impact on the clinical disorder. Family factors may be crucial in a serious
behavior disorder and less so in a straightforward case of attentional problems.
A family-based formulation must offer a template for understanding the family
factors that predispose to, precipitate, and perpetuate clinical problems. Family inter-
action can predispose to problems through life experience that is internalized and be-
comes part of the self (eg, physical abuse leading to paranoia). Family stressors, such

Josephson
6
Table 1
Toward developing a family-based case formulation
Current picture of individual characteristics of the child
Biological (capacities)
1. General health status
2. Medical disorder/genetic vulnerability
3. Temperament
4. Intelligence
5. Information processing/perceptual (eg, attentional
process, peripheral sensory, neuropsychological)
6. Uneven development (eg, precocious sexuality,
delayed speech)
Psychological
(motivations/cognitive set)
1. Mastery of age-related psychosocial tasks
a. Trust, quality of attachment
b. Autonomy, separation from others
c. Peers, differentiation of relationships, conscience
formation, empathy toward others
d. Achievement, sense of competence, self-esteem
formation
e. Identity, sexual competence
2. Has the family regulated these tasks in a balanced
manner?
3. What ongoing family interactional experiences have
predisposed the child to the mastery of develop
mental tasks or impeded such mastery?
4. What ongoing family interactional experiences have
predisposed the child to develop adaptive cognitive
sets or maladaptive cognitive sets?
5. How have these maladaptive cognitive sets affected
developmental task mastery?
6. Have family factors/parent-related dynamics
perpetuated problems or strengths?
7. Have family factors affected child coping strategies?
Environmental stressors
Social (environmental demand)
1. Family factors (acute): divorce, custody battle, family
geographic moves, unemployment, and poverty
2. Interpersonal: peer difficulties
3. Educational: demands outstripping ability
4. Developmental: new expectations, traumatic
experiences
5. Cultural disruption (acute): war, environmental
disaster
6. Cultural expectation (chronic): pressure to conform
behavior to societal norms
Adapted from Josephson AM. Family intervention as a developmental psychodynamic therapy.
Child Adolesc Psychiatr Clin N Am 2013;22:249; with permission.
as violence and family moves, can acutely precipitate disorder. Finally, chronic family
interactions inevitably perpetuate disorders, a long-held tenet of family systems ther-
apy. The resistance of such fixed family patterns to therapeutic change is often fueled
by the internalized world of the parents, often corresponding to relationship problems
of parents.37,38 On the other hand, family strengths can protect children from the onset
and evolution of these problems.
A thorough formulation helps determine whether families are primarily in need of
supportive education or encouragement of behavioral change. The disease model of

From Family Therapy to Family Intervention
7
contemporary psychiatry typically emphasizes psychoeducation. These principles
include assisting the family in recognizing onset of illness, understanding relapse,
describing the effects and side effects of medications, and supporting the family’s
strengths as it deals with significant mental illness. This, of course, is an approach
that should not be used in a family life experience model where family members must
change how they relate to another and parents must change parenting practices.39
The first approach educates and empathically supports a family dealing with an
illness. The second approach identifies problematic interactions, explores issues,
and empathically challenges a family to change its manner of relating. This polarity,
an either/or statement, is for heuristic purposes only. In reality, all families have
strengths and weaknesses, and clinical work often involves both support and chal-
lenge. There are specific areas of inquiry that can help clinicians decide when to explore
family problems and expect change and whento educate thefamily and offer support.31
INDICATIONS FOR FAMILY TREATMENT
Although families should be involved with all psychiatric treatments, there are specific
indications for a focused family intervention:
1. The clinical presentation is an interactional problem. Problems, such as physical
and sexual abuse, aggression directed toward a parent, a child running away
from home, an eating disorder, or separation anxiety all present as interactional
problems. Given that almost any childhood behavior problem is interactional and
disruptive behavior is the most common problem faced by child psychiatrists,
the indications for family interventions are frequent.
2. Parental psychopathology precludes effective parenting. Many times parenting
strategies are not effective due to the problems of parents, including disorders
such as substance abuse, aggressive behavior, and personality psychopathology.
A family focus is indicated when there is a mismatch between parental personality
style and child temperament.
3. Psychiatric disorders with identified family contributions. Research in develop-
mental psychopathology and family treatment outcome studies demonstrates
that there are family concomitants of many disorders that are becoming more
clearly defined.34
4. Psychiatric disorders requiring psychoeducation. It is recognized that disorders,
such as major depression, schizophrenia, and attention deficit disorder, have strong
biological loadings. Education about the disorders and guiding a family’s response
to their family member is an important intervention. Even though family processes
are not seen as directly etiologically important in some of these illnesses, relapses
have been documented to occur in the absence of family intervention.34
MAKING THE INTERVENTION: HOW FAMILY THERAPY WORKS1
The evidence of the effectiveness of family interventions is growing rapidly40,41 and is
discussed elsewhere in this issue in the article by Sharma and Sargent. In most in-
stances, the clinical issue is not should one intervene with families but how to do
so, when to do so, how to sequence the intervention with other interventions, and
how to intervene for specific disorders. Family interventions can range from brief his-
tory gathering episodes, to focused parent education, to extensive individual and
1 This section Adapted from Josephson.19

Josephson
8
family explorations. In making an intervention, the clinician should ask what is
impeding a child’s development. For example, the work of Weissman and colleagues
has demonstrated that treating maternal depression is associated with the remission
of child psychopathology.42 As a result, this intervention qualifies as a family
intervention.
The following section illustrates the sequencing and coordinating aspects of a family
intervention. Each of these stages does not occur in every treatment nor do they al-
ways occur in the sequence listed, but in more extensive treatments all may be
required.
Address Immediate Needs
Many families come to a clinic wanting to leave with something that can be done for
their child that day. The presenting problem can require urgent attention. Crises may
involve environmental interventions, such as removing a child from the home, most
commonly by hospitalization. Although not always indicated, pharmacotherapy is
increasingly offered as an immediate intervention by many clinicians, fueled by the
expectations of contemporary parents. In all nonemergent initial contacts, parents
need their anxieties addressed by a treatment plan: a clear description of the nature
of the child’s problem, what can be done about it, a time frame for change, and the
family’s role in the process.
This stage may include a focused behavioral intervention for conditions, such as
substance abuse disorders, conduct disorders, and oppositional disorders (these
topics are also discussed elsewhere in this issue by Spirito and colleagues, Zajac
and colleagues, and Dickstein). A well-timed behavioral intervention, consistently
applied with fidelity to a protocol, may be enough to stabilize a patient.
Parent Management Training
Parent management training, supported by a growing outcome literature,43–45 is not
traditionally seen as family therapy. Yet parents are the “executives” of the family
and change must start with them. Many parents, through lack of experience or their
own emotional issues, do not know fundamentals of child development. Furthermore,
they often need to be informed of factors related to the onset of disorder, the course of
disorder, and what the family needs to do to effectively manage it. This parent educa-
tion phase is important in disorders with significant biological aspects, such as disor-
ders of attention and learning.
Given the commonality of disruptive behavior problems, parents need a working
knowledge of behavior management principles. In milder problems, education and
parent management are often all that are necessary. In cases of more serious psycho-
pathology, parental vulnerabilities often preclude the effective implementation of
behavior management strategies. For example, a mother’s depression and depen-
dency often make limit setting difficult, or a father’s anger and aggression may
undo the effective limit setting efforts of the mother. When such events are observed,
it can lead to a broadening of therapy. The clinician formulates what needs to change
in the family, and empathically holds the family accountable to change, while appre-
ciating its difficulty. Often a next step is seeing the family together.
Intervention in Family Process
Intervening in family processes most closely resembles traditional family therapy. All
family members living in a household are invited to attend and the clinician guides the
family in altering problematic interactions between family members. Common inter-
ventions include shoring up parental support of each other when a child is

From Family Therapy to Family Intervention
9
disrespectful to one parent; encouraging parents’ authoritative, deliberate limit
setting in lieu of a friendly, deferential response; identifying how one parent may un-
dermine the other in limit setting efforts; and facilitating an engagement with a child
when there may be evidence of a parent being unempathic to a child’s distress.
Empathically intervening in various family processes can have a significant impact
on family and individual functioning.
For a generation, family systems therapy emphasized various techniques and
described these techniques in a voluminous literature.46,47 Interventions using tech-
niques, such as reframing problems and circular questioning, can be particularly
useful in elucidating interpersonal dynamics and the intrapsychic dynamics of spe-
cific family members. Often, however, these types of interventions are met with
resistance. Systems theory suggests that family homeostasis is the desired state,
yet careful study of the individuals in the family often reveals they have their own rea-
sons for resisting change.48 For example, in setting a limit on a child and experi-
encing the child’s natural resistance, a parent may experience fears of being
abandoned by the child. Understanding such fears may require an individual inter-
vention with a parent. When altering family interaction is successful (eg, parents
are more effective in setting limits or more engaged with their child), the internalized
world of the child shaped by previous dysfunctional interactions may require individ-
ual intervention.
Individual Intervention
Change in family interaction is often resisted due to the inner world of parents, which
have to be altered if family interactions are to change. By keeping parents’ internal
working models constant, family interactions perform a defensive, protective function
for the parents. The effect of enhancing parental self efficacy through an individual
intervention can be heightened when coupled with altering family relationships and
parent education. It is always important for a child clinician to remember when inter-
vening with a parent to relate the work to the needs of the identified child patient.
Successful family interaction work often unmasks a child whose inner world has
been shaped by family interactions. A child’s inner world stems from family interac-
tions but, as development unfolds, has a life independent from those interactions.
This inner world requires an individual psychotherapeutic intervention. For example,
a child who has been persistently indulged in a family context likely has a sense of enti-
tlement needing clinical attention.
Marital/Couple Interventions
Given that the parents’ decisions set the stage for many family interactions, a marital
and couple intervention flows from family interventions that are resisted or ineffective.
Driven by their internal working models, parents may unwittingly continue to facilitate
dysfunctional interactions between themselves, powerfully affecting their children.
One parent may have a helpful parenting perspective but may be undermined by
the other, only to have these roles shift in another context. Working on communication
styles and parenting can be the prelude for couples to be seen alone to explore their
individual perspectives on parenting and identify individual parental vulnerabilities.
Dealing with Siblings
It is not uncommon for family work, initially focused on an identified patient, to indicate
that there is another child needing intervention. This child is subjected to the same
family dynamics but may have responded differently due to individual variables (eg,
biologic differences in attention and learning, birth order, gender, or step-sibling

Josephson
10
status). In addition to gaining attention to their own needs, siblings can often provide a
unique perspective on the problems of their sibling, helping parents see things in a
different light. They may not be actively involved in regular sessions; however, an initial
assessment and other intermittent contacts can flesh out the clinician’s understanding
of the family.
In sum, the order of these interventions is flexible, and they may not all be needed in
each situation. In certain situations, one therapist can sequentially provide all thera-
pies; in others, multiple therapists need to be involved for pragmatic, if not theoretic,
reasons. The issue of the number of therapists and their relationship with each other
remains one of some contention but perhaps less so than in a previous generation.
Readers are referred elsewhere for a more complete discussion.49,50
CLINICAL VIGNETTE
Case Illustration of Intervention Sequencing
Blaine was a 10-year, 10-month–old fifth-grade student seen for a second psychiatric opinion of
moodiness, fears, and rages “when he doesn’t get his way.” At the time of psychiatric consul-
tation, the parents—Michael and Janet—saw Blaine as not being able to control his behavior;
his mother believed he was “suffering.” When angry, he would slam doors, curse, and yell for
periods of time, as long as 1 hour in duration. Managing his rages, related to homework expec-
tations, was difficult and emotionally draining for the parents, because it would often take 3
hours for Blaine to complete his homework. Blaine had been in treatment for more than
1 year with little progress, and his parents were frustrated, as well as fearful, about the effects
of his “bipolar disorder.” Treatment consisted solely of psychopharmacology, with little thera-
peutic effect, and 1 major side effect, a 25-pound weight gain.
Blaine was of average intelligence and had not failed any classes. He and his sister Laura, 2 years
younger, were biracial children adopted at the time of birth by white parents. The adoptive par-
ents had been married for 32 years; mother was 53 years old and father was 55 years old.
His parents had difficulty managing his rages when homework was required. Blaine could not
finish assignments unless his mother was there, and even then he would neglect her requests, at
times threatening violence. She then, in exasperation, would ask his father to help, who would
encourage, cajole, and then, in anger, challenge Blaine to complete his homework. When
pushed in this way, Blaine would often threaten to kill himself. During the homework sessions,
Blaine would frequently verbally assault his mother, calling her stupid, ugly, crazy, and a liar,
including vulgar epithets.
Therapy began with attempts to help parents stabilize Blaine’s current behavior. This meant
ensuring Blaine’s safety, and that of his parents, by doing careful interviews to assess the verac-
ity and credibility of his verbal threats to kill himself and his parents. The parents were given
instruction on how to find emergency care, although they never needed to use such care.
The first phase of therapy emphasized parent management techniques to facilitate homework
completion. The parents were encouraged in their firmness, and a positive reward system was
implemented to facilitate task completion.
The pleasant couple wanted Blaine to complete homework uneventfully and when his distress
mounted, it immobilized them. Behavioral management strategies were difficult to implement
because of family psychodynamic factors, which required a family intervention alongside a
couple intervention.
In couples work, it was revealed that mother had always wanted children, but father had not.
They had been married 22 years before they finally adopted. When the children were younger,
Michael adored the children. Yet as they grew older, he withdrew from active family life,
spending much of his time on the computer, leaving most of the parenting tasks to his wife.
Father wanted to be Blaine’s friend, making discipline next to impossible. He seemed influenced
by his own developmental history of “little discipline, lots of play, and no schedule.” The

From Family Therapy to Family Intervention
11
therapy emphasized the need for Michael to support his wife more and to expect his wife to be
less active as the primary limit setter.
One critical incident occurred in family work. Blaine physically confronted his parents after they
limited his activities with an electronic game. In that session, Blaine’s mother tearfully pleaded
for help from her husband. As if to take on her father’s role, Blaine’s younger sister crossed the
room and hugged her crying mother. Father verbalized that his son did not seem to understand
the concept of limits and wondered why Blaine expressed no concern toward his mother. As
therapy progressed and mother continued to insist that she needed support, her husband
Michael became mobilized and was more supportive of her. In the couples work, Janet stated,
“Mike doesn’t want to deal with confrontation and the stress that inevitably results from it.”
In couples work, the parents grappled with the issue of diagnosis and medication treatment.
Mother stated, “We took the view that we needed to help him control things by finding the
right medicine.” They acknowledged that a change in therapeutic approach to de-emphasize
medication was helpful. They told the therapist that “you listened to us more, and you gave
us hope. Particularly, you made us stop and look at the real parenting differences between
us, and how they were related to Blaine’s behavior problem. You got us moving in the right
direction.”
In couples work, mother was able to ventilate, stating, “I’m the more parenting person. Mike is
the fun parent. This made me angry, because it left me as the only person to get things done.”
The therapist pursued the goal of getting mother less involved, and father more involved, using
improved couple communication. Janet said, “Mike doesn’t like the imposition of a schedule,”
and the therapist was able to point out that children need schedules. Janet pointed out that
“Mike doesn’t deal with conflict,” while the therapist pointed out that active parenting natu-
rally involves conflict and demands solving it.
In individual work, Mike was able to see the influence of his own background. “My father
wasn’t around when I was growing up, and I vowed that I was going to be around more. I
wasn’t going to make the same mistake. I think his absence affected me. I now wish I’d been
closer to my father; I might have learned more.” The therapist pointed out that “you corrected
but you overcorrected.” Mike agreed, noting, “I have wanted to be a friend to my son, and not
a parent.”
The therapist challenged Michael with the question, “When children threaten to harm a kind,
caring mother, what does this mean?” He responded: “It means the child is too comfortable
with not enough limits.” Chagrinned, Michael came to see how he had enabled his son’s
tyrannical, verbally abusive behavior toward his mother. He came to understand that his
joking approach led Blaine to believe most of his behavioral indiscretions “weren’t that big a
deal.”
Finally, sibling work emphasized Blaine’s younger sister and her developing behavior disorder.
The parent’s identified Laura’s noncompliance and challenging of parents to be similar to
Blaine’s behavior but felt reassured that with their new self-knowledge of their family’s, and
their own, dynamics they would have solutions to her behavioral challenges (case report reprin-
ted from Josephson, 2013).19
CHALLENGES IN IMPLENTATION
For many clinicians, seeing a family raises ethical problems. The simplest of questions
focuses the main challenge: “Who is the patient?” Although therapy is initially planned
for the identified patient, as family interventions proceed, the concerns and problems
of other members may become a focus for treatment. When a clinician empathically
explores one family member’s perspective, she may be seen as alienating the patient
or another family member. Healthier families understand this apparent unfairness as
part of the process of therapy. Families who are influenced by psychopathology are
less likely to understand this type of intervention. In those cases, the clinician makes

Josephson
12
a deliberate attempt to relate to all family members and make the point that in time
each person’s perspective will be heard. With integrated treatment becoming more
common, these concerns may be less prominent than in the past.50
There are elements of clinical work that may not typically be seen as a family inter-
vention or family therapy but are crucial in developing family stability. These include
helping parents negotiate community support systems, such as in-home care for
developmentally disabled children, supporting parents’ efforts in procuring appro-
priate educational services, and communicating with the legal system.51 Coordinating
family interventions with other clinical interventions (eg, pharmacotherapy) is often
needed.52
Aspects of race, culture, gender, sexual orientation, and worldview are important in
all families.53,54 As the influence of the traditional family wanes, how patients develop
their idea of family is influenced by these various factors. Special problems, such as
divorce, custody, legal issues, and violence, are increasingly prominent in contempo-
rary society.55 These issues and others can complicate any family intervention.
SUMMARY
The power of family therapy—all members of a family meeting to understand and help
one of its child members—remains. Yet the flexible application of various aspects of
treatment comprises a paradigm shift to family intervention. The power is increasingly
focused on specific areas of family life. Because the family regulates affect and
behavior and shapes the child’s mind, the family continues to be a most formative in-
fluence on a child and adolescent’s life.
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