How Do We Start Family Therapy?: On Getting Adult Siblings, Parents, and Spouses in the Door

My Family–Adult Siblings, Parents, Spouses–Needs Family Therapy: How Do We Get Everyone On Board? 

As family therapists, we frequently receive questions from one or a few family members who are looking for family therapy with adult siblings, as well as perhaps their parents and their spouses, and need some help with getting everyone in the door. 

The critical question in starting family therapy is that everyone needs to have buy-in, which is to say, all members need to agree they want to do therapy together. This means work to listen to one another, ask hard questions, receive criticisms, and be open to a therapist’s input. This can be scary for everyone–both those hearing the criticism and those who need to give it. Obviously, everyone also needs to feel like the therapist is the right choice. 

In family therapy, there's often an organizer or organizers–one or a few members of a family that initiates enlisting a family therapist for help. If there’s conflict, longstanding disagreements, entrenched allegiances, or a history of difficulty in coming to terms with disagreements (and if you’re looking for the help of a family therapist, there likely is), just getting everyone to agree to show up can be a challenge. There may be a few steps to this process and certain family members may want to meet individually with the family therapist. Because we recognize the difficulty, we want to offer some guidance on how to start family therapy:

It’s okay to engage a family therapist before you have everyone on board (You might need help in how to even think about this) 

As the person reaching out for family therapy, you might consider having a session yourself to get some therapeutic guidance on getting everyone on board and helping everyone feel good about the process and choice of therapist. In these early conversations, you and the family therapist can speak about how to build allegiances that increase the chances of getting the family in the room, how to raise this with family members, and how to deal with individuals’ concerns.

Often there’s worry on the part of the organizer or organizers of the family therapy that if they speak with the therapist individually, they’ll bias them toward a particular point of view. Family therapy is too messy to worry about that. This is a situation we, as family therapists, deal with all the time. From the moment you reach out, our “patient” is the family as a whole and we orient ourselves to take in what families need, listening to any member with this in mind. It’s not precisely correct to say we’re unbiased–we’re biased toward healthy families and toward supporting families to be together in ways that support the family to grow and thrive.

It’s okay to have a few reluctant family members on the fence leading up to the session

We often say, “Let’s just get everyone in the door!” Our job, as family therapists, is to take it from there and engage everyone.

How do we do this? Family therapy is something that’s tough to picture in the abstract. Individual therapy is portrayed in the media and is more common so most people have some idea of how it works. Family therapy is portrayed terribly in the media–either as woo-woo, new age-y nonsense or as a screaming match (often the latter aligns with what’s actually been happening in the family).

Part of how we, as family therapists, can win over reluctant family members is to create a process that is credible in the sense of helping family members feel like this can actually work by making sense and engaging in real conversation. We maintain a sense of structure and safety so that a new kind of hard conversation can be had, one in which difficult issues are discussed but without screaming and enmity. We also work to identify and engage resistance, making a particular effort to notice and attend to the hesitations or fears of those who have them the most.

It's okay to show up in a fight or with angry family members

Family therapists must be able to tolerate a decent amount of chaos. Especially when working with adult siblings and perhaps their parents and spouses, the odds are high that just getting everyone in the room may be a challenge. We understand how to approach families that are coming in the door in conflict. 

And this approach can be as varied as the families with whom we engage. At times, there needs to be a tight structure, though it’s best when the least amount of necessary externally imposed structure is used. Skilled family therapists find that balance. We also understand the difference between useful conflict and conflict that’s merely hurtful or otherwise unconstructive. Family members who are angry may need space to give voice to that, though limits may need to be negotiated.

It’s okay if not everyone shows up 

Family members understandably don’t want to leave anyone out, but there are instances in which one or more members of a family simply aren’t able to be there. This can be due to logistical constraints or due to hurt feelings or longstanding disagreements. While it’s desirable to want everyone present, that isn’t always best for that person or the family as a whole (or both).

This doesn’t mean that person won’t benefit or grow from the work even if they’re not there. They might. We think about families as a system of interconnected relationships or better still, as a whole. If we help the family as a unit, everyone can benefit.

Should children be involved? How young is too young? 

The answer depends a great deal and should be discussed in an initial call. In some instances, the scope of what a family needs to take in is too sensitive for children and the answer is straightforward.

In other instances, there may be competing interests between protecting children from stressors or painful aspects of a family’s history versus making space for children to discuss what they’re already aware of (though the adults may not know it–usually children know a lot more than adults think they do). It’s not uncommon to have different family members present for different conversations. When there’s concern about children being overexposed, this may be one of the issues the adults discuss in an earlier session.

We’ve worked with families where as many as ten or more family members have engaged in treatment. That’s a lot of buy-in to build. In this context, the therapist in the initial session can allow everyone to ask questions about the process and discuss what they might need in order to feel good about it. While the family is our patient, some members may benefit from a chance to speak directly to the therapist in order to build trust, talk about issues that are difficult to discuss with the family at large, or perhaps to gauge the appropriateness of raising that issue in a given climate within the family or a given stage of the work.

A Few Notes On Logistics: 

Technology is our friend

As family therapists, we’ve learned two things about using video conferencing for family therapy: First, video conferencing isn’t nearly as good as in-person therapy, and second, video conferencing is definitely good enough!

Video chat has proved a blessing to adult families that don’t live close by (and let’s face it, it’s rare for extended families not to have members living apart). Technology has caused families to consider family therapy who may never have thought about it just because of the question of distance.

It’s useful to talk about who will pay for the session and how

Given that both families and money can be complicated (and emotional), we recommend being especially clear with everyone involved about how this will work. Insurance coverage can apply here, but it’s best to investigate that in advance. Typical questions are: 

-Who will pay? One individual versus some sort of split?

Remember that offering to pay for everything, while potentially done in a generous spirit, can raise as many issues as reluctance to pay. Also consider younger or less well-off family members getting a break or splitting the cost in proportion to their ability to pay. 

-Who will be the one to “put the card down” so to speak?

At Tribeca Therapy, we use an online billing software and require there to be one individual who leaves a credit card on file. If the therapy is “split,” it’s best to discuss how that person will be reimbursed.

How long is a typical family therapy session?

A typical individual therapy session is 45 minutes. That’s not enough time for a family. Depending on the size of the family, we recommend 60 or 90 minutes. If follow-up sessions involve smaller subgroupings of family members, then a shorter time may work. At Tribeca Therapy, we have a standard hourly rate and prorate it based on the length of the session, which is always clarified in advance.