Treating Parent-Adolescent Conflict 305

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Schultz, R. T., Carter, A. S., Scahill, L. & Leckman,J. E (1999). Neuro- (2001). Analyzing the influence of tic-related talk on vocal and
psychological findings. In J. E Leckman & D. J. Cohen (Eds.), motor tics in children with Tonrette's syndrome.Journal of Applied
Tourette'ssyndrome: Tics, obsessions,compulsions:Developmentalpsycho- Behavior Analysis, 34, 353-356.
patholo~ and clinical care (pp. 80-103). New York:John Wiley. Zohm; A. H., Apter, A., King, R. A., Panls, D. L., Leckman, J. E, &
Shimberg, E. (1995). Living with TouretteSyndrome. NewYork: Fireside. Cohen, D.J. (1999). Epidemiological studies. InJ. E Leckman &
Stokes, A., Bawden, H. N., Camfield, E R., Backman, J. E., & Dooley, D.J. Cohen (Eds.), Tourette'ssyndrome: Tics, obsessions, compulsions:
M. B. (1991). Peer problems in Tourette's Disorder. Pediatrics, 87, Developmental psychopathology and clinical care (pp. 23-41). New
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J. E, & Schultz, R. T. (1999). Phenomenology and natural history
of tic related ADHD and learning disabilities. InJ. E Leckman & Ellen J. Teng is now at Baylor College of Medicine in Houston, TX.
D.J. Cohen (Eds.), Tourette'ssyndrome: Tics, obsessions, compulsions: Michael E Twohig is now at the Department of Psychology, University
Developmental psychopatholog3 and clinical care (pp. 63-79). New of Nevada, Reno.
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Boston: Kluwer Academic. Received: March 26, 2003
Watson, T. S., & Sterling, H. E. (1998). Brief functional anlaysis and Accepted: September17, 2003

Treating Parent-Adolescent Conflict: is Acceptance the

Missing Link for an Integrative Family Therapy?
L a u r i e A. G r e c o , Vanderbilt University M e d i c a l Center
G e o r g H . E i f e r t , C h a p m a n University

Change-oriented strategies su& as problem-solving~communication training (PS/CT) and parental behavior management training
(BMT) have been used to treat parent-adolescent conflict. Although several studies have documented the efficacy of these approaches
relative to wait-list control conditions, clinically significant improvements have not been achieved for the majority of adolescents with
significant behavioral problems such as comorbid ADHD/ODD. A similar pattern of findings was observed in earlier studies exam-
ining couple relationships. Extending the focus and scope of traditional couple therapy to an acceptance-based integrative approach
has led to impressive treatment #nprovements in that area. In a similar vein, we propose an integrative family therapy and suggest
enhancing more traditional change-oriented approaches such as PS/CT and B M T by integrating acceptance strategies into a values-
centered family therapy. We discuss the role of experiential avoidance and values orientation within a family context and present ex-
amples of techniques adapted from traditionally adult- and couple-focused therapies. Finally, we discuss the balancing and sequenc-
ing of acceptance and change techniques and offer suggestions for future research and practice.

~ OLESCENCE is a d e v e l o p m e n t a l p e r i o d t h a t b e g i n s
t h e transition f r o m c h i l d h o o d to a d u l t h o o d a n d
i m p o r t a n t c o m p e t e n c i e s as t e e n a g e r s d e v e l o p values out-
side o f t h e i r p a r e n t s a n d b e g i n to r e d e f i n e a n d r e n e g o t i -
involves p r i m a r y c h a n g e s in p u b e r t a l / s e x u a l m a t u r a t i o n , ate roles across n u m e r o u s c o n t e x t s such as h o m e , school,
physical a p p e a r a n c e , a n d r e a s o n i n g ability (Berger, 2001). a n d w o r k (Grotevant, 1998). Moreover, i n c r e a s e d personal,
S e l f - e x p l o r a t i o n a n d a h e i g h t e n e d sense o f a u t o n o m y are social, a n d a c a d e m i c p r e s s u r e s o f t e n e m e r g e , p e r h a p s
c o n t r i b u t i n g to G. Stanley Hall's early n o t i o n o f adoles-
c e n c e as a p e r i o d o f " s t o r m a n d stress" (Hall, 1904). C o n -
t e m p o r a r y r e s e a r c h p r e s e n t s a m o r e positive a n d bal-
Cognitive and Behavioral Practice 1 1 , 3 0 5 - 3 1 4 , 2004
1077-7229/04/305-31451.00/0 a n c e d view o f a d o l e s c e n c e (e.g., F e l d m a n & Elliot, 1990;
Copyright © 2004 by Association for Advancement of Behavior L a u r e n s & Collins, 1994; P e t e r s o n , 1993). Yet, t h e r e a r e
Therapy. All rights of reproduction in any form reserved. u n d e n i a b l e physical, social, a n d i n t e r p e r s o n a l c h a n g e s
306 Greco & Eifert

during this period that challenge the structure and integ- et al. (1992), for example, c o m p a r e d three family ther-
rity of important relationships, perhaps most notably the apy programs in their ability to treat conflict a m o n g fam-
parent-adolescent relationship (Robin & Foster, 1989; ilies with ADHD teens. Sixty-one parent-teen dyads were
Steinberg, 1981, 1988). randomly assigned to participate in 8 to 10 sessions o f
Although disagreements and discord may be inevitable either: (a) PS/CT, (b) parent-training in behavioral man-
(Montemayor, 1983), some families experience extreme agement techniques (BMT), (c) family structural therapy,
levels of conflict and distress warranting intensive family- or (d) a wait-list control condition. W h e n comparing
based treatment. Adolescents with attention-deficit/ group mean differences, families in the three treatment
hyperactivity disorder (ADHD) alone or with comorbid groups demonstrated reductions in communication diffi-
oppositional-defiant disorder (ODD) are at heightened culties, conflict, and internalizing/externalizing symptoms.
risk for experiencing severe family conflict (e.g., Barkley, Despite statistically significant improvements at the group
Guevremont, Anastopoulos, & Fletcher, 1992). This is level, however, only 5% to 30% of these families demon-
not surprising given that parents worry frequently about strated significant within-family change or improved on
their A D H D / O D D teen's rebellious behavior and opposi- an index of clinical significance (i.e., m o v e m e n t to a sub-
tion to authority (Fletcher, Fischer, Barkley, & Smallish, clinical range of impaired functioning). The authors con-
1996). Moreover, both adolescents with A D H D / O D D and cluded that, "Such sobering statistics indicate that most
their parents have been f o u n d to exhibit high levels of ADHD adolescents (70% to 95%) . . . show no clinically
conflict-related behavior such as defensiveness, insults, and significant change in their n u m b e r of family conflicts or
commands when discussing neutral topics and disagree- the anger frequency/intensity of these conflicts, with
ments (Barkley, Anastopoulos, Guevremont, & Fletcher, 80% to 95% remaining deviant after treatment" (Barkley
1991; Fletcher et al., 1996). et al., 1992, p. 460).
According to Robin (1981 ), parent-adolescent conflict Barkley et al. (2001) conducted a follow-up study fo-
often results from a combination of deficits in interper- cusing on teens with comorbid A D H D / O D D and their
sonal and problem-solving skills, as well as distorted or families. To replicate their earlier work, Barkley and col-
irrational beliefs about their own or a family member's leagues c o m p a r e d the effects of parental BMT to PS/CT.
behavior. This combination may result in aversive interac- Following 9 sessions of either BMT or PS/CT, all families
tional patterns a m o n g family members and consequently participated in an additional 9 sessions of P S / C T to allow
interfere with a more harmonious and mutually satis- for comparison of P S / C T alone and in combination with
factory family life. Problem-Solving and Communication BMT. The authors sought to improve earlier findings by
Training (PS/CT) is a widely investigated cognitive- doubling the n u m b e r of treatment sessions to 18 sessions
behavioral intervention used to treat parent-adolescent and requiring families to attend clinic twice per week. Re-
conflict (e.g., Anastopoulos, Barkley, & Shelton, 1997; suits of this more intensive protocol were similar to those
BarNey et al., 1992; Robin, O'Leary, Kent, Foster, & reported earlier (Barkley et al., 1992), showing signifi-
Prinz, 1977). Although variants of P S / C T exist, most pro- cant change on most d e p e n d e n t measures at the group
grams include a multi-step problem-solving approach in level of analysis. O f note, results of behavioral observa-
which family members are taught to define the problem tions indicated no change in positive or negative commu-
areas, generate and evaluate alternative solutions, and nication patterns at mid-treatment, and were observed
implement an agreed-upon solution. Communication only in mothers' behavior by the end of treatment. More-
training and cognitive restructuring are additional com- over, Barkley and colleagues (2001) reported minimal
ponents of P S / C T in which families learn communica- change at the individual level of analysis, concluding that
tion skills (e.g., speak in an even tone, avoid interrupting, " . . . neither form of these therapies is especially effective
maintain eye contact) and are taught to identify and re- in reliably changing the majority of families having
structure irrational or rigid beliefs about their own a n d / A D H D / O D D teens and significant parent-teen conflict"
or a family member's behavior (see Robin & Foster, 1989, (p. 19).
for a comprehensive description of PS/CT). The important work of Barkley and colleagues (1992,
The efficacy of P S / C T has been d o c u m e n t e d in nu- 2001) suggests that mainstream cognitive-behavioral ap-
merous studies, with results demonstrating its superiority proaches such as P S / C T and BMT may be inadequate for
to wait-list control conditions (e.g., Barkley et al., 1992; treating severe family conflict, particularly for teens diag-
Foster, Prinz, & O'Leary, 1983; Guerney, Coufal, & Vogel- nosed with ADHD or c o m o r b i d A D H D / O D D . Moreover,
song, 1981). There is little evidence, however, to support their findings suggest that we may need to implement
the clinical meaningfulness of the measured outcomes, more idiographic approaches to p r o m o t e change at the
particularly for adolescent.s with ADHD (Barkley et al., individual-family level. Similarly, it is unclear whether all
1992) and A D H D / O D D teens and their families (Bark- families lack problem-solving and communication skills
ley, Edwards, Laneri, Fletcher, & Metevia, 2001). Barkley and whether the prescribed strategies are universally
 Treating Parent-Adolescent Conflict 307

beneficial. Further, mastery of P S / C T skills in the clinic parent-adolescent conflict. We p r o p o s e that chronic and
n e i t h e r guarantees their effective use across multiple set- excessive levels o f EA c o n t r i b u t e to individual a n d inter-
tings such as at h o m e o r a public venue n o r does it ensure personal suffering a m o n g family m e m b e r s . F o r e x a m p l e ,
an a p p r o p r i a t e response from others (Foster et al., 1983). parents who e x p e r i e n c e h e i g h t e n e d anger and distress in
Finally, some researchers believe that i m p l e m e n t i n g P S / response to a b r o k e n curfew may e n g a g e in u n p r o d u c t i v e
CT skills d u r i n g emotionally c h a r g e d discussions is un- behavior such as yelling a n d lecturing to r e d u c e t h e i r
realistic a n d unnatural, n o t i n g that it is simply too diffi- own distress. This behavior may in turn increase conflict
cult for a n y o n e to act in this c o n t r i v e d m a n n e r d u r i n g and decrease closeness within the p a r e n t - t e e n relation-
highly contentious circumstances (Jacobson & Christen- ship. Parents may subsequently feel guilty a b o u t over-
sen, 1996). reacting a n d a t t e m p t to eliminate these feelings o f guilt
Given the a p p a r e n t limitations o f P S / C T a n d BMT, we by giving their teen positive attention o r tangibles a n d / o r
p r o p o s e the integration of acceptance strategies into a by lessening the severity o f the initial consequence. Thus,
values-centered family therapy. T h e p u r p o s e is to in- attempts to avoid u n c o m f o r t a b l e private experiences such
crease an e m p a t h i c u n d e r s t a n d i n g o f the m u t u a l frustra- as a n g e r a n d distress that arise d u r i n g conflict may actu-
tion that teens a n d parents e x p e r i e n c e as a result of their ally exacerbate difficulties b o t h in the teen's behavior
ineffective a n d often self-defeating strategies o f trying to and the p a r e n t - a d o l e s c e n t relationship.
c h a n g e each other. Acceptance strategies also serve to in- Adolescents also engage in behavior to eliminate un-
crease p a r e n t a n d teen willingness to e x p e r i e n c e natu- wanted thoughts a n d emotions, even if this behavior leads
rally o c c u r r i n g private events such as thoughts a n d emo- to conflict with parents. For example, teenagers might
tions. We discuss n e x t the potential role o f experiential stay o u t past curfew to avoid feeling left o u t by their
avoidance o r unwillingness in m a i n t a i n i n g personal and peers. W h e n c o n f r o n t e d by their parents, adolescents
family conflict. may feel angry because their f r e e d o m has b e e n violated
and subsequently engage in u n p r o d u c t i v e behavior such
as arguing a n d withdrawal. In PS/CT, parents a n d teens
Experiential A v o i d a n c e a n d Family Conflict
m i g h t be instructed to challenge a n d restructure the con-
Experiential avoidance (EA) refers to attempts to avoid, tent or form of e x t r e m e thoughts a n d e m o t i o n s (e.g.,
suppress, o r otherwise alter the form o f negatively evalu- "My child is deviant for b r e a k i n g curfew;" "I hate my fa-
ated private events such as thoughts, emotions, m e m o - t h e r for trying to run my life") and, in BMT, p a r e n t s
ries, a n d / o r somatic-bodily sensations (Hayes & Wilson, m i g h t receive instruction in the consistent use o f limit-
1994; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). setting a n d p u n i s h m e n t (e.g., g r o u n d i n g ) to m a n a g e un-
EA can be c o n c e p t u a l i z e d as falling o n the same contin- desirable t e e n behavior.
u u m as psychological acceptance, with inflexible or high As an alternative to change- a n d c o n t r o l - o r i e n t e d strat-
levels of EA reflecting low a c c e p t a n c e a n d a g e n e r a l un- egies, an acceptance-based a p p r o a c h to t r e a t m e n t targets
willingness to e x p e r i e n c e fully (e.g., without j u d g m e n t or EA by p r o m o t i n g a f u n d a m e n t a l o p e n n e s s to experience
defense) one's internal-subjective experience. Notably, r a t h e r than control o r change negatively evaluated pri-
EA may n o t always reflect a p a t h o g e n i c process and in vate events s u r r o u n d i n g family conflict. Thus, u n w a n t e d
fact may e n g e n d e r behavioral effectiveness in some con- thoughts a n d emotions are n o t viewed as i n h e r e n t l y
texts, such as when distraction is used d u r i n g child im- problematic. Instead, attempts to suppress or otherwise
munizations to facilitate c o p i n g d u r i n g a circumscribed, control these private experiences are c o n c e p t u a l i z e d as
time-limited p r o c e d u r e with acute e m o t i o n a l salience EA, which is a potentially harmful process c o n t r i b u t i n g to
(e.g., Cohen, Bernard, Greco, & McClellan, 2003). In the d e v e l o p m e n t a n d course o f family conflict. Exposure
contrast, chronic o r excessive attempts to avoid one's sub- and mindfulness training (described below) can be im-
jective e x p e r i e n c e a p p e a r to p r e d i c t adverse outcomes p l e m e n t e d to u n d e r m i n e EA, a n d values work can be
and may be a core m e c h a n i s m c o n t r i b u t i n g to the exacer- used to motivate families a n d guide treatment.
bation of h u m a n suffering (see Hayes, Strosahl, & Wilson,
1999). Clinical a n d laboratory research on acceptance has
A c c e p t a n c e , M i n d f u l n e s s , a n d CBT
increased dramatically in r e c e n t years, with evidence indi-
cating an inverse relation between EA a n d healthy adapta- Within a t h e r a p e u t i c context, a c c e p t a n c e involves a
tion across a b r o a d range o f potentially stress-inducing sit- counterintuitive a p p r o a c h toward constructive living in
uations (Bond & Bunce, 2000; Feldner, Zvolensky, Eifert, which clients are e n c o u r a g e d to give u p their struggle o f
& Spira, 2003; Forsyth, Parker, & Finlay, 2003; Greco et c h a n g i n g what c a n n o t be c h a n g e d for the sake o f pro-
al., in press; Hayes et al., in press; Marx & Sloan, 2002). m o t i n g change in d o m a i n s o f their life where c h a n g e is
To date, little has b e e n d o n e to u n d e r s t a n d the role o f possible (see Hayes, 2002; Hayes et al., 1999). T h e basic
EAwithin the c o n t e x t o f stressful family situations such as i d e a is to let go o f ineffective a n d u n w o r k a b l e a g e n d a s
308 Greco & Eifert

to open the door for genuine, fundamental change to change, have the courage to change what you can change, and
occur. Mindfulness is a core acceptance-oriented method develop the wisdom to know the difference between the two.
derived largely from Buddhist philosophy and practice
such as Zen Buddhism (Robins, 2002). In its simplest
Integrative Couple Therapy
form, mindfulness refers to paying attention on pur-
pose, in a way that fosters a nonjudgmental moment-to- Many interventions for children and adolescents are
m o m e n t awareness of one's surroundings, activities, age-downward extensions of therapies developed for
thoughts, and emotions (Kabat-Zinn, 1990, 1994). Mind- adults. For example, PS/CT was derived from skills-training
fulness involves being fully present, embracing and let- approaches implemented in couple therapy (e.g., Mar-
ting go of each moment as it inevitably unfolds (e.g., golin & Weiss, 1978; Weiss, Hops, & Patterson, 1973). Simi-
Ch6dron, 2000; Suzuki, 1999). Mindfulness training can lar to the adolescent literature, PS/CT in couple therapy
be integrated into therapy by practicing in session the act has yielded short-term, clinically significant improve-
of sitting with and observing ongoing private events with- ments for less than 50% of treated partners (Jacobson &
out attempting to change or respond to them (Barn; Addis, 1993). Leading couple researchers responded to
2003; Hayes & Wilson, 2003; Roemer & Orsillo, 2002). these findings by identifying shortcomings of traditional
Rather than attempting to "restructure" or otherwise con- behavior couple therapy and incorporating strategies for
trol thoughts and emotions, clients practice sitting with promoting emotional acceptance (Jacobson & Christen-
and noticing them as they are in the present moment. sen, 1996). Acceptance strategies have since become an
Dialectical behavior therapy (Linehan, 1993a, 1993b) integral component of what has been termed Integrative
was perhaps the first behavior therapy program that oper- Couple Therapy (ICT) and represent both an extension
ationalized mindfulness training into two sets of trainable of and departure from traditional PS/CT.
skills: "what" skills and "how" skills (Robins, 2002). The Conceptual and empirical work within couple therapy
three what skills are (a) observing one's private experiences research may be relevant to parent-adolescent conflict
without describing them or doing anything about them; because both deal with interpersonal conflicts in close re-
(b) describingwhat one observes without judging or evalu- lationships. In addition, traditional couple therapy's em-
ating it; and (c) participating or acting in the world with phasis on behavior change also characterizes traditional
full engagement or awareness. The three how skills are PS/CT for parents and teens. Based on a history of dis-
(a) focusing on doing one thing at a time with full aware- appointing findings,Jacobson (1992) articulated the need
ness without thinking about something else at the same to balance the traditional behavioral emphasis on change
time; (b) being nonjudgmental in regard to one's experi- with a new dimension developed to promote mutual ac-
ences; and (c) being"skillfully effective, focusing on the most ceptance of the partners. An integrative approach to
important goals in one's life and engaging in behavior couple therapy, Jacobson and Christensen's ICT (1996) has
that makes their attainment more likely (see Baer, 2003; improved overall treatment outcome and perhaps para-
Hayes & Wilson, 2003; Linehan, 1993a, 1993b). doxically has produced as much or more change in some
Therapeutic strategies to promote emotional accep- areas of the relationship (Christensen, Prince, Cordova,
tance and mindful living have been incorporated into & Eldridge, 2000). Incorporating this type of acceptance
cognitive-behavioral therapies targeting diverse patient model into parent-adolescent therapy intuitively makes
populations, including adults diagnosed with borderline sense given the tendency for adolescents to develop values
personality disorder (Linehan et al., 1999), substance and ideas that are different (perhaps directly opposed) to
abuse (Marlatt, 2002; Wilson, Hayes, & Byrd, 2000), anxi- what their parents hold as truth. We will provide some
ety disorders (e.g., Becker & Zayfert, 2001; Roemer & suggestions for incorporating acceptance strategies into
Orsillo, 2002), chronic pain (Hayes, Bissett, et al., 1999), treatments for parent-adolescent conflict and refer to this
eating disorders (Heffner, Sperry, Eifert, & Detweiler, approach as an Integrative Family Therapy (IFT).
2002; Heffner & Eifert, 2004), and H1V/AIDS (Logsdon-
Conradsen, 2002). Within a CBT framework, acceptance
IF[
strategies commonly are used in conjunction with more
traditional change-oriented techniques such as skills Emotional acceptance within the context of parent-
training and exposure, counterbalancing the emphasis adolescent relationships does not imply passive resigna-
on change typically associated with behavior therapy tion or diminished personal responsibility. It does not
(Robins, 2002). In this sense, integrative treatments help refer to the removal of parental controls or the condon-
clients put into action the famous acceptance creed (Nie- ing of dangerous and delinquent acts, nor does it require
buhr, 1986) that many clients already know coming into adolescents to abandon their quest for autonomy and
therapy but typically find very difficult to apply to their identity. Rather, acceptance strategies are implemented
own life situation: Accept zvith soenity what you cannot to create a space for family members to think and feel
 Treating Parent-Adolescent Conflict 309

their thoughts and emotions without attempting to alter how they are both frustrated by their differences, they ac-
their own or the other person's subjective experience. tually begin to get a glimpse into each other's experience.
W h e n beginning acceptance work, we often help family Acceptance strategies have helped couples to view differ-
members to experience how they are mutually stuck in ences and incompatibilities as vehicles for increased inti-
the rut of trying to control potentially uncontrollable cir- macy, greater marital satisfaction, and to move beyond
cumstances (e.g., personal discomfort, the other person's the impasse by perhaps trying out a new behavior. The
behavior and discomfort). By experiencing the hopeless- precise mechanisms of change are unclear at this point;
ness of the current situation, it becomes possible to move however, data from a controlled clinical trial byJacobson
beyond the often self-motivating agendas that each person et al. (2000) showed that these changes did o c c u r Em-
initially brings into therapy. pathic joining and unified d e t a c h m e n t are two strategies
used in ICT to illustrate stuckness or mutual e n t r a p m e n t
Stuckness Within Family Contexts resulting from rigid inflexible repertoires. Both tech-
W h e n families enter into therapy, they typically do so niques have been useful in our work with families.
for a reason: at least one family m e m b e r is "stuck." Within
a family context, stuckness refers to rigid and often in- Empathic Joining
flexible behavioral repertoires at individual and family Empathic joining is a strategy used in ICT to p r o m o t e
levels. A lack of response variation and the clinging to interpersonal- and self-acceptance by talking about in-
old, ineffective change strategies have failed to produce compatibilities in a different way, such as by reframing
behavioral effectiveness within the family system. Instead, the conflict as a mutual struggle that one cannot possibly
such inflexible repertoires may contribute to a sense of win (Jacobson & Christensen, 1996). W h e n families enter
hopelessness and interpersonal distance, perhaps lead- therapy, there often is an identified patient (typically the
ing to an impasse between parents and teenagers. In "out-of-control" teenager). Family members who present
these circumstances, acceptance strategies can be used with blaming monologues tend to focus exclusively on
constructively to broaden behavioral repertories and to the offensive or problematic behavior of the other per-
increase flexibility in responding (Hayes et al., 1999; son, with little or no consideration of the interactive, multi-
Hayes & Wilson, 2003; Wilson & Murrell, in press). faceted contextual influences which together shape and
U p o n entering therapy, family members often have define functionally the behavior. T h r o u g h empathic join-
made numerous unsuccessful attempts to alleviate their ing exercises, accusatory behavior and other forms of
relationship problems a n d personal distress. Parents conflict can be u n d e r m i n e d by: (a) emphasizing the role
and adolescents have tried everything, but nothing has of context as opposed to flaws in the individual, and (b)
worked or changed, and n o b o d y is budging. This stuck- refraining the conflict as a mutual trap that is painful for
hess or unworkability is illustrated in the example of the everyone involved.
following family situation: Seemingly irreconcilable con- Exploring the role of context with families is a way of
flict arises when Carrie feels justified in her attempts to normalizing behavior that otherwise might be labeled de-
develop into a unique, i n d e p e n d e n t individual. Given viant, incompetent, or pathological. It may be helpful to
her values of independence and privacy in personal rela- draw a diagram in session using interlocking/overlap-
tionships, Carrie becomes more secretive and demands ping circles to represent the multiple interacting systems
increased levels o f freedom. Meanwhile, her parents within and across which a family participates, perhaps
value family closeness and wholeheartedly believe in ful- focusing most specifically on the bidirectional influence
filling their parental responsibilities and supervisory roles. of each person's behavior within the family system (e.g.,
They begin implementing restrictions, such as earlier cur- Bronfenbrenner, 1979; Bronfenbrenner & Morris, 1998;
fews and less time with friends. Carrie responds with an- Henggler & Bourduin, 1990; Henggeler, Bourduin, &
ger, withdrawal, and begins sneaking behind her parents' Mann, 1995). To disrupt unproductive and often one-
backs. Carrie's parents b e c o m e furious u p o n discovering sided discourse in session, family conflict can be reformu-
that she has been sneaking out of the house and lying to lated as a series of acts situated and understood function-
them. They attempt quite unsuccessfully to implement ally as events that participate in and with their historical
additional consequences and house rules. and situational contexts (see Biglan & Hayes, 1996; Gif-
Carrie and her parents have reached an impasse. They ford & Hayes, 1999; Hayes, Hayes, & Reese, 1988). An in-
are stuck, yet both are so consumed with their own nega- session analysis of the social contexts which shape and
tive emotions that they do not recognize each other's maintain parent and adolescent behavior serves to un-
frustration, pain, and mutual entrapment. As a result, dermine unproductive blaming in session while promot-
family members feel emotionally distant from each other. ing interpersonal understanding and acceptance.
In ICT, when partners recognize some differences as Using language and examples tailored to each family,
complementary rather than opposing and experience therapists might suggest that even the most extreme forms
BlO Greco & Eifert

o f behavior can be u n d e r s t o o d only when c o n s i d e r e d in tions in b o t h e x p e r i m e n t a l settings with y o u n g c h i l d r e n

relation to o t h e r events in the environment. W h e n family (Heffner, Greco, & Eifert, 2003) a n d adults (Eifert & Heft-
m e m b e r s label acts as right o r wrong in an absolute net, 2003).
sense, therapists can offer an act-in-context r e f o r m u l a t i o n Unified detachment. Unified detachment is another strat-
in which behavior a n d e n v i r o n m e n t are viewed as a cohe- egy i m p l e m e n t e d in ICT that can be used with families to
sive i n t e g r a t e d p h e n o m e n o n . Self- a n d i n t e r p e r s o n a l ac- p r o m o t e the d e v e l o p m e n t o f a different type o f relation-
ceptance may be p r o m o t e d by r e f r a m i n g an individual's ship with the i n t e r p e r s o n a l conflict a n d associated dis-
behavior as the p r o d u c t o f his o r h e r l e a r n i n g history (as comfort. Using this a p p r o a c h , therapists guide families to
o p p o s e d to a p e r s o n a l defect or weakness) a n d by viewing engage in a m o r e intellectual (as o p p o s e d to emotional)
the m e a n i n g o f events as inseparable from context. For analysis o f their conflicts. A m o r e distant a n d objective
example, a m o r e useful r e f o r m u l a t i o n m i g h t be pre- stance is assumed by e x p e r i e n c i n g the p r o b l e m ( s ) a n d
sented when Nick's father describes his son's "bad atti- t h o u g h t s / e m o t i o n s as an it instead of a you or a me. Dis-
tude" as a causal variable (e.g., "Nick's b a d attitude gets a g r e e m e n t s a n d conflicts are c o n c e p t u a l i z e d as a com-
him into trouble at h o m e a n d school, which creates dis- m o n e x p e r i e n c e that must be dealt with together.
tance between us"). A m o r e useful analysis m i g h t be to In family therapy, exercises d u r i n g this phase m i g h t
c o n s i d e r Nick's behavior in relation to the o t h e r contex- involve having family m e m b e r s describe, draw, a n d / o r
tual features in the environment, e x p l o r i n g the func- "act out" the physical a n d behavioral characteristics o f
tion(s) a n d i n t e r c o n n e c t e d n e s s o f each person's behav- the conflict. W h e n talking a b o u t the conflict as an it, fam-
ior within a n d across i m p o r t a n t social domains. ilies might be asked to describe its color, shape, texture,
Therapists can also use m e t a p h o r s a n d experiential a n d behavioral characteristics. This t e c h n i q u e has b e e n
exercises to r e f r a m e conflict as a m u t u a l bidirectional t e r m e d physicalizi~g (e.g., Hayes et al., 1999) a n d can be
struggle. Eifert a n d Heffner (2003) a d a p t e d the Chinese used in c o n j u n c t i o n with e x p o s u r e a n d mindfulness exer-
finger trap m e t a p h o r from Hayes et al. (1999) a n d con- cises. D u r i n g these exercises, aversive thoughts a n d emo-
verted it into an experiential exercise for persons with tions are b r o k e n down into their c o m p o n e n t parts a n d
high anxiety sensitivity. This exercise c o u l d also be in- analyzed in an objective, n o n j u d g m e n t a l manner. W h e n
c o r p o r a t e d into an e m p a t h i c j o i n i n g exercise to illus- working with teenagers, a scientist m e t a p h o r can be used
trate family conflict. T h e finger trap is a woven straw tube by asking clients to imagine themselves as an e x p e r t sci-
which is 15 cm l o n g a n d 1 cm in diameter. First, the teen entist specializing in self-observation. T h o u g h t s a n d emo-
a n d his o r h e r parent(s) must slide their i n d e x finger into tions are to be inspected u n d e r a high-powered micro-
either side o f the straw tube. Initially, b o t h teen a n d par- scope, in the same way that a scientist would inspect an
e n t have the c o m m o n goal o f wanting to get out of their a m o e b a - - n o t i c i n g a n d describing t h e m without j u d g -
trap. T h e intuitive action o f pulling away causes the tube m e n t o r defense.
to catch a n d tighten. T h e only way to get o u t of the trap is Families also can be instructed to sit t o g e t h e r o n o n e
for b o t h parties to push their i n d e x fingers in first a n d side o f the therapy room. O n the opposite side o f the
then slide t h e m out. Even if they do n o t slide them out, r o o m facing t h e m is an e m p t y c h a i r to be o c c u p i e d by
p u s h i n g the finger in will allow m o r e space to m a n e u v e r the it. Family m e m b e r s share their personal e x p e r i e n c e
(literally some "personal wiggle room"). T h e goal of this of the conflict by describing the physical a n d behavioral
exercise is to let p a r e n t a n d Child discover that attempt- characteristics of the it, which is then p l a c e d in the chair
ing to get o u t o f the trap by d o i n g the seemingly logical facing them. As in ICT, family m e m b e r s can take turns
a n d obvious thing (pulling h a r d to free the finger) only carrying on a n o n b l a m i n g , intellectual discussion with
creates m o r e tension a n d p e r p e t u a t e s the struggle: the the it that has t h e m so w o u n d u p emotionally. Parents
h a r d e r you pull, the m o r e the trap tightens, resulting in a n d adolescents may r e p o r t thoughts a n d / o r e m o t i o n s
m o r e discomfort a n d pain. In contrast, d o i n g s o m e t h i n g (e.g., "I feel stupid d o i n g this"; "This does n o t make
counterintuitive, p u s h i n g the fingers in r a t h e r than out, sense") that interfere with their participation in this exer-
will give everyone m o r e space to move. cise. Thus, it may be necessary to e n g a g e in additional
Increasingly, researchers a n d clinicians have a r g u e d mindfulness exercises in which these interfering thoughts
that figurative language a n d m e t a p h o r i c a l instructions a n d e m o t i o n s are b r o u g h t up, observed u n d e r a micro-
may be emotionally m o r e m e a n i n g f u l a n d h e n c e m o r e scope, a n d subsequently p l a c e d in the chair alongside the
likely to i m p a c t a p e r s o n ' s overt behavior than straight- it. This is d o n e for the p u r p o s e o f this exercise; after
forward rational-logical talk (Hayes & Wilson, 1994; Otto, which, clients are free to "put back on" or reclaim their
2000). Similarly, Barker (1996) suggested that figurative thoughts a n d emotions. W h e n working toward unified
talk m i g h t e n h a n c e client u n d e r s t a n d i n g , facilitate rap- d e t a c h m e n t , it m i g h t be helpful at this p o i n t to use m o r e
p o r t building, a n d decrease resistance to therapist direc- traditional P S / C T to g e n e r a t e alternate ways o f r e s p o n d -
tives. We have f o u n d empirical s u p p o r t for these asser- ing to the it in the future.
 Treating Parent-Adolescent Conflict 311

Other Methods to Promote Acceptance egies m i g h t evoke increased defiance. A n u m b e r of clini-

Mindfulness training. Mindfulness exercises can be im- cal a n d e x p e r i m e n t a l studies illustrate the p a r a d o x i c a l
p l e m e n t e d t h r o u g h o u t t r e a t m e n t to p r o m o t e e m o t i o n a l effects o f striving to establish a n d m a i n t a i n control in es-
acceptance. For example, prior to empathic j o i n i n g (thera- sentially u n c o n t r o l l a b l e contexts (Ascher, 1989; B o n d &
peutic reframing), mindfulness m e d i t a t i o n can be used Bunce, 2000; Forsyth et al., 2003; Marx & Sloan, 2002;
to h e l p clients b e c o m e m o r e c e n t e r e d in the p r e s e n t mo- Spira, Zvolensky, Eifert, & Felder, 2002; Wegner, 1994).
ment. In a comfortable, eyes-closed position, family mem- Rather t h a n a t t e m p t i n g to m a n a g e conflict or fine tune
bers are instructed to focus on the flow o f their breath. existing control agendas, acceptance-based therapies such
W h e n thoughts drift a n d emotions arise (e.g., m e m o r i e s as Acceptance a n d C o m m i t m e n t T h e r a p y (ACT; Hayes et
o f a r e c e n t family dispute, thoughts a b o u t dinner, frustra- a., 1999) focus o n e x p l o r i n g each family m e m b e r ' s values
tion a b o u t n o t getting to b o r r o w the car, e x c i t e m e n t by identifying what really matters a n d how one's own be-
a b o u t an u p c o m i n g date), family m e m b e r s are instructed havior has i n t e r f e r e d with personal values across mean-
to acknowledge t h e m a n d r e d i r e c t their attention back to ingful life d o m a i n s (e.g., family, school, work, friends).
their breath. We m i g h t use this particular exercise at the Rather than working to eliminate conflict o r to decrease
b e g i n n i n g o f sessions to h e l p families b e c o m e psycholog- negatively evaluated thoughts a n d emotions, the goal of
ically p r e s e n t a n d / o r to disrupt the collective m o m e n - acceptance work is to increase flexibility in r e s p o n d i n g so
tum o f unworkable, self-motivated c h a n g e agendas. that family m e m b e r s can engage in values-guided action
Mindfulness can also be used to e x p a n d client willing- w h e t h e r o r n o t conflict o r related e m o t i o n a l distress has
ness to e x p e r i e n c e u n w a n t e d thoughts a n d emotions o c c u r r e d (Hayes et al., 1999).
r a t h e r t h a n acting u p o n o r struggling to control them. We begin this work by distinguishing between values
Family m e m b e r s m i g h t be instructed to sit with a n d a n d goals, p r e s e n t i n g values as g u i d i n g principles a n d
simply observe their subjective experiences following a chosen life directions that can be p u r s u e d t h o u g h never
salient conflict o r disagreement. We have f o u n d these ex- fully obtained. Values refer to what really matters in life
ercises to be particularly useful w h e n m u t u a l frustration a n d reflect what the client wants to s t a n d for across differ-
a n d conflict occur d u r i n g session. In this way, families e n t domains. In contrast, goals are o b t a i n a b l e tasks that
m a k e direct contact with u n c o m f o r t a b l e a n d often dis- can be "checked off" on a to-do list. Goals have a clear
tressing events. Instead o f working to solve the p r o b l e m , e n d point, whereas values do not. A n adolescent, for ex-
family m e m b e r s simply sit a n d observe what shows up un- ample, m i g h t identify "being a caring a n d h o n e s t friend"
d e r their skin. This exercise involves creating a space for as an i m p o r t a n t value within the d o m a i n of friendship.
family m e m b e r s to e x p e r i e n c e fully their own t h o u g h t s Being a caring a n d h o n e s t friend c a n n o t be achieved in
a n d emotions while allowing the o t h e r p e r s o n to d o the an absolute sense, b u t a series o f goals such as r e m e m b e r -
same. An i m p o r t a n t goal o f mindfulness in this context is ing a friend's b i r t h d a y a n d k e e p i n g a secret can b e ac-
for clients to e x p e r i e n c e the dynamic a n d transient na- c o m p l i s h e d in the service o f this broader, g u i d i n g value
ture o f private events such as thoughts, emotions, a n d (Wilson & Murrell, in press).
bodily sensations. In this way, clients practice mindful- O n c e family m e m b e r s u n d e r s t a n d the difference be-
ness to make r o o m for painful thoughts a n d emotions, al- tween values a n d goals, we begin intensive values work by
lowing t h e m to show u p for b o t h themselves a n d the h e l p i n g each p e r s o n to identify i m p o r t a n t life d o m a i n s
o t h e r person. a n d to e x p l o r e barriers that interfere with moving toward
W h e n working with teenagers, m e t a p h o r s can be used chosen values in these domains. T h e Valued Living Ques-
to facilitate mindfulness training. F o r example, the ther- tionnaire (VLQ; Wilson, 2002; Wilson & G r o o m , 2002) is
apist m i g h t instruct clients to e x p e r i e n c e thoughts a n d a very useful clinical tool that helps to identify inconsis-
emotions as a continuous flow by i m a g i n i n g a stream o f tencies between a client's personal values a n d actual be-
bubbles floating in front of their faces. W h e n thoughts havior in domains such as family, friendship, c o m m u n i t y /
a n d e m o t i o n s c o m e up, they should be p l a c e d in a bub- p e e r group, a n d e d u c a t i o n / s c h o o l i n g . W h e n working
ble a n d observed as the b u b b l e floats past. Parents a n d with families, the V L Q also can be used to e x p l o r e consis-
teens can be instructed to notice what is in the b u b b l e tencies a m o n g family m e m b e r s ' values a n d behavior. In
without p o p p i n g it. Attempts to grab, hold, o r push away this way, similarities a n d differences can be illustrated
a b u b b l e will result in p o p p i n g . The goal h e r e is simply to d u r i n g session a n d used as material for acceptance work
sit with a n d observe the c o n t e n t in the bubbles without over the course of therapy (Greco, 2002).
j u d g m e n t o r defense. With teenagers, it may be helpful to begin values work
Values work. Despite the normality o f i n d e p e n d e n c e in the first session. Then, t h e r a p e u t i c strategies such as
seeking in adolescence, it is n o t u n c o m m o n for parents mindfulness a n d p r o b l e m solving can be used to under-
to r e s p o n d with a u t h o r i t a r i a n efforts to m a i n t a i n control. m i n e barriers standing between clients a n d their c h o s e n
Counterintuitive to parental intentions, such control strat- values (Wilson & Murrell, in press). Values work with
312 Greco & Eifert

teens may be particularly effective given the developmen- b e i n g viewed as pathological (e.g., feeling like an unfit
tal i m p o r t a n c e of identity formation a n d values clarifica- p a r e n t or a deviant teen). Ultimately, we must e x a m i n e
tion d u r i n g this period (Peterson, 1993). In our experi- the effects of different methods of sequencing these treat-
ence, even the most oppositional teens enjoy talking m e n t components. Similarly, we n e e d to examine empir-
a b o u t what matters to them a n d have b e e n very receptive ically the i n c r e m e n t a l utility of integrating acceptance
to values work. D u r i n g the first session, therefore, we in- strategies into existing change-oriented approaches a n d
form families that t r e a t m e n t will be guided by what really use the resulting data to shape the d e v e l o p m e n t of a co-
matters to each person. In this sense, therapy is a client- herent, effective IFT. As in the case of couple therapy, it is
centered process that is guided by personal values. It is likely that some c o m b i n a t i o n of change a n d acceptance
n o t a b o u t c h a n g i n g beliefs or controlling deviant behav- techniques will be the most successful approach to pro-
ior. Rather, the goal of acceptance work is to help individ- d u c i n g clinically m e a n i n g f u l results.
ual family m e m b e r s make room for difficult thoughts a n d In summary, despite a recent t r e n d toward integrating
emotions such as anger a n d frustration as each person acceptance strategies into adult therapies (e.g., Hayes,
moves in his or h e r valued directions. Thus, willingness to 2002; Logsdon-Conradsen, 2002; Marlatt, 2002; Robins,
experience private events (i.e., emotional acceptance) 2002), there has n o t yet b e e n a similar m o v e m e n t in
a n d values-guided action b e c o m e the primary markers of treatments for children a n d adolescents. This is unfortu-
therapeutic success, whereas attempts to eliminate or con- nate in view of recent evidence that children appear to be
trol conflict a n d negative emotions are ancillary a n d may responsive to experiential exercises a n d prefer metaphors
or may n o t be achieved. to literal instructions (Greco, 2002; Heffner et al., 2003;
Murrell & Greco, 2003). Given that clinically significant
Balancing Acceptance and Change improvements have n o t b e e n f o u n d for the majority of
We do not r e c o m m e n d completely a b a n d o n i n g change- treated families with A D H D / O D D teens, it may be timely
o r i e n t e d techniques such as P S / C T or BMT. Rather, we for researchers a n d clinicians to embark o n an extension
propose the integration of acceptance a n d change to of what typically has b e e n used to alleviate conflict a m o n g
p r o m o t e valued living across i m p o r t a n t life domains. Re- these challenging families. To this end, we have provided
search suggests that such an integrative approach may a proposal for integrating acceptance-based strategies
lead to m e a n i n g f u l change, with acceptance strategies such as mindfulness a n d values orientation into behav-
perhaps paving the way for g e n u i n e change to occur ioral interventions for parent-adolescent conflict.
(Jones et al., 2000; Roemer & Orsillo, 2002). Becker a n d
Zayfert (2001), for instance, f o u n d that acceptance tech-
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