Session 8: Family Roles, Communication, and Support

Session 8 is again focused primarily on family communication and dynamics for the purposes of identifying and addressing parenting behaviors and parent–teen dynamics that may unwittingly undermining teen confidence in becoming more independent in managing their illness and lifestyle. The clinician engages the family in a discussion of parental and teen roles within the family system and an examination of the impact of the teen’s illness on family members’ roles. Behavioral family systems concepts of “misguided support” and “strong beliefs” that family members hold, but that inadvertently may be serving to maintain a dependent or even overprotective/enmeshed family dynamic, are introduced and applied to the family situation, along with strategies for moving these dynamics in a more independence-engendering direction.

Session 6: Increasing Teen Independence

Session 6 is intended to be a family-focused session, with the teen and parent(s) seen conjointly for all or at least a major portion of the session. This format allows the clinician to observe the ways in which the teen and parent(s) approach such issues as problem solving and decision making and to coach and provide feedback and guidance in developing family dynamics that increase teen confidence and skills in becoming more confident and independent. The mechanism for stimulating these discussions is generated from the Workbook exercises and Worksheets addressing the activity schedule of a healthy teen versus the teen with a chronic illness and together generating strategies for increasing teen independence that they will approach between sessions.

Session 1: Stress Identification and Management

Session 1 of the Children’s Health and Illness Recovery Program (CHIRP) addresses the impact of illness- and non–illness-related stressors on teens with chronic illness and coping strategies needed to reduce stress. This chapter provides the clinician with techniques for guiding the teen in developing methods for identifying stressors and assessing the impact they may have on their symptoms and functioning. The importance of sleep and developing healthy sleep hygiene practices are introduced, along with instructions for the teen in completing a Sleep Log to assess their own sleep patterns and practices. Graduated physical activity is also assessed and encouraged. These data will be collected over the course of several sessions in order to facilitate more effective coping, stress management, and sleep hygiene practices.

Session 9: Keys to Maintaining Progress

Session 9 provides a review of the individual skills the teen has acquired in the Children’s Health and Illness Recovery Program (CHIRP) with a focus on relapse prevention strategies and anticipatory guidance. Key components of CHIRP are emphasized as they apply to teen and parent strategy for “Working Towards a Normal Daily Schedule.” At this point in the program most teens should have recognized the benefits of improved sleep and activity levels, increased social contacts with peers, and increased comfort in assertively communicating with others. Parents should demonstrate an increased willingness to support and trust their teen in becoming more independent in managing various aspects of their chronic illness, as well as in decision making in setting their personal schedule and making lifestyle choices. A key component to success in sustaining these gains is the willingness of family members to continue to follow established family rules for communicating about symptoms and resolving conflicts.

Session 7: Assertiveness and Relationships

In Session 7 the teen is introduced to the concept of avoidant coping and the pernicious impact this has on creating increased functional disability in multiple areas of one’s life physically, academically, and socially. Behavioral strategies to disrupt this cycle inevitably involve improving engagement behaviors such as increasing social contacts and improving school attendance, all of which call for improved interpersonal communication skills and assertive behaviors; that is, the behavioral antithesis of avoidance. The clinician will employ several worksheets in the Workbook in the process of increasing teen skills and comfort at communicating and asserting their wants and needs with others.

Sessions 10–12: Skill Reinforcement and Relapse Prevention

During the remaining Sessions 10–12 of the Children’s Health and Illness Recovery Program (CHIRP) no new skills or strategies are introduced. Rather these sessions focus on continuing to practice and consolidate the skills introduced in Sessions 1–9 and problem solve those areas where the teen and parent(s) continue to struggle.

Session 4: Thought-Challenging and Thought-Changing Skills

Employing information from their Thought Record homework, in Session 4 the teen is instructed in applying cognitive behavioral therapy (CBT) thought-challenging skills employing the “Challenging Your Thoughts” worksheet in the Children’s Health and Illness Recovery Program (CHIRP) Workbook. Common cognitive errors (e.g., hopelessness, catastrophizing, mind reading) are introduced and applied to the teen’s own identified automatic thoughts. For youth with chronic illness, the impact of their symptoms on their functioning can adversely impact on their expectations and willingness to set challenging yet appropriate goals for themselves. CBT skills in challenging and changing unsubstantiated and disabling beliefs and schema are crucial to overcoming these barriers.

Session 3: Relaxation Skills

When, for various reasons, the teen cannot alter the stressfulness of a challenging situation via active problem solving (“Solving the Problem”), such circumstances call for employing strategies to “Manage the Impact” of the stressor on their physical and emotional functioning. In Session 3 of the Children’s Health and Illness Recovery Program (CHIRP), the clinician instructs the teen in effective relaxation skills including diaphragmatic breathing and progressive muscle relaxation. These are introduced and practiced in the session, with homework practice assigned for skill development. Cognitive behavioral therapy skills are introduced to help the teen understand the bidirectional relationships between thoughts, emotional responses, and behavioral responses. Finally, thought-changing skills and activities are introduced from the CHIRP Workbook with the assignment of recoding stressful situations and their associated thoughts and feelings on a Thought Record sheet.

Session 2: Problem-Solving Skills

Session 2 of the Children’s Health and Illness Recovery Program (CHIRP) builds on the topic of stress and stress management by introducing the concept of reducing the impact of stressors via developing more effective coping strategies. In CHIRP, two specific forms of coping are emphasized: “Solving the Problem” coping and “Managing the Impact” coping. This session focuses on teaching the teen about these two forms of coping and learning the when and how of applying each, with the main emphasis being on developing active problem-solving skills in order to reduce stress by addressing and altering the situation.

Session 5: Time Management and Prioritization

For teens with a chronic illness, setting reasonable and reachable personal expectations while titrating their activities in response to their disease/symptoms is often a major stressor. In Session 5 the teen is taught specific strategies to distinguish between desired (want to) and required (have to) activities and to create (and revise) personal schedules that address problems they may have with over- and/or underscheduling physical and social activities in their daily life. These issues are particularly important in working with teens who are on home-hospital/home-bound schooling or who are home-schooled and thus more likely to have less structure and peer social contact.