The purpose of this study was to examine the role of family relational factors in treatment engagement of adult family members of low-income, HIV-positive African American mothers. We demonstrated that the family relational factors of support for the mother, the mother’s desire for involvement with her family, and the mother’s hassles with family members all predicted engagement. In addition, multivariate modeling showed that after the effect of the other relational factors and the mother’s level of engagement were taken into account, family support still added significantly to the prediction of family treatment engagement. The finding regarding family support suggests that such support generalized to participation in therapy that was aimed at helping a family member. Thus, the existence of supportive bonds was more powerful than relational barriers to family treatment engagement.
Given its key role in family treatment engagement, future studies should address factors associated with family support for HIV-positive mothers, and work toward the development of treatment strategies for enhancing support and reducing isolation. One important issue in this regard is stigma related to HIV/AIDS within the family. Some of the mothers described being forced to use separate eating utensils at family gatherings, and other forms of segregation.
Exploring the interaction between family support and the other relational factors shed additional light on their association with family treatment engagement. We found that in high-support families, the mother’s desire for involvement with family was highly predictive of family treatment engagement, whereas in lowsupport families, family engagement in treatment was low regardless of the mother’s desire for involvement with her family. This finding suggests that mothers with supportive families could choose whether or not to include their families in treatment, whereas mothers with less supportive families did not have this option. It seems that in supportive families it is particularly important to work through the mother’s own reluctance to include family members, perhaps by contracting to help her maintain or strengthen boundaries within the family.
The presence of family hassles was associated with increased family treatment engagement in low-support families, but not in high-support families. It is possible that in high-support families, the mother’s in-therapy disavowal of family problems was a protective effort to prevent family confrontations. The relationship between family support and conflict resolution styles should be addressed in future studies.
In low-support families, it seems that problematic relationships may have stimulated family participation in treatment, particularly by engendering the mother’s own commitment to treatment. Thus, in low-support families, which are the most challenging for family treatment engagement, a particularly effective engagement strategy for both the mother and her family may be to highlight the value of family therapy for addressing family problems.
The finding that the pressure of family hassles was related to engagement in low-support families is noteworthy given that African American s are believed to eschew revealing private family matters in psychotherapy. If, as it appears, these families were motivated to participate in therapy to work on their family hassles, then they showed a seemingly uncharacteristic willingness to air family business. It is possible that there is less reluctance to reveal family problems in low-support families because family members do not feel as protective of the family, or because they are motivated to work on family problems as a means of strengthening bonds.
There were two aspects of our intervention that may also have facilitated the willingness to address family hassles. The first is SET’s emphasis on building therapeutic alliances based on compatible relational goals, and joining techniques that respect the existing family structure. Secondly, all of the therapists were themselves African American women. It is possible that the combination of ethnic matching and careful attention to alliance building helped counteract concerns about intrusiveness and judgmental attitudes from therapists. Future studies might address the impact of these factors on treatment engagement.
Finally, substance dependence history, which we expected to be inversely related to family treatment engagement and family support, was not associated with either. This seems to speak to the resilience of the families in regard to wear and tear on relationships because of addiction. One possible scenario is that substance dependence led to circumstances that served to maintain family bonds, such as joint caregiving of children. It is also possible that family support toward the mother was related to HIV/AIDS, such that concern for the mother’s health and/or sympathy for her situation overrode past injuries. This is an important area for future study and can clarify the impact of substance dependence on family relationships, and suggest strategies for maintaining bonds.
A limitation of the current study is that it relied upon the mother’s self-report for relational variables. Thus, we have the view of one person regarding family functioning variables such as support and hassles. Future studies should use reports from multiple family members or more objective indicators of family relational factors, such as observational data.
Another limitation is the restriction on the definition of “family” to exclude members of the extended kinship network. As noted, this restriction was imposed to maximize comparability of this study to the existing literature on treatment engagement. Future studies might include a broader operationalization of family to examine whether these findings apply to the larger extended kinship network.
Finally, another limitation of the current findings is the constrained variability on history of substance dependence. Of the 31 mothers in the current sample for whom we have substance use history data, only 8 did not have a history of substance dependence. Of those eight, five had a history of substance abuse. We investigated whether the lack of correlation between history of substance dependence and family support would hold up when we looked at the data set from the entire clinical trial, and found support for the earlier finding (r = .002, p> .98). Of 196 mothers in the larger data set with substance use history data, 63 had no history of substance dependence, and only 10 of those 63 had a history of substance abuse. Although this test bolsters our confidence in the finding regarding a lack of relationship between substance dependence and family support, further study is warranted.
The impetus for this study was the observation that involving family members in family therapy is a difficult proposition. This study begins to disentangle relational mechanisms involved in family treatment engagement by testing hypotheses based upon clinical experience. The findings suggest studies that can further tease apart these complex processes, and clinical approaches for engendering treatment engagement. While some of our clinical hunches were supported, others were not, demonstrating both the value and danger of relying on clinical presumption. We believe that the iterative process demonstrated in this study is a valuable paradigm for advancing family interventions.