The Referral Behavior—Why Naming It Clearly Matters (and Why It’s Not the Problem)
Every course of treatment begins with a referral behavior. A youth is aggressive. A child is refusing school. A caregiver is overwhelmed. A system is worried about safety. These behaviors are the reason therapy begins—but in systemic family therapy, they are not the reason therapy works.
Referral behaviors function as signals, not diagnoses of the system. They tell us where distress is concentrated, not where responsibility lives. When therapists mistake the referral behavior for the problem itself, treatment becomes narrow, reactive, and often ineffective. The family may comply temporarily, but the underlying interactional pattern remains unchanged.
Best practice requires that the referral behavior be named clearly and collaboratively. Families deserve transparency about what brought them into care and how the therapist understands that concern. At the same time, systemic therapists must explicitly distinguish between the presenting behavior and the relational context that gives it meaning.
For example, a child’s aggression may appear to be the primary issue. But aggression rarely exists in isolation. It often emerges within systems struggling with inconsistent caregiver leadership, unresolved trauma, or chronic stressors embedded in the family’s social ecology. Without clarifying this distinction early, families may assume therapy is about “fixing the child,” reinforcing blame and undermining engagement.
Agreements for treatment begin here. Therapists must clearly state:
What the referral behavior is
Who noticed the behaviors
How did we get here
This clarity creates safety. It helps caregivers feel less blamed and more capable. It invites collaboration rather than compliance. It also sets realistic expectations: therapy is not about eliminating a behavior in isolation but about restructuring the relationships that sustain it.
When referral behaviors are framed systemically, families can begin to see the problem as shared rather than owned by one individual. This reframing lays the groundwork for all future agreements about participation, dosage, and responsibility for change.
In short, you cannot form an ethical or effective agreement for treatment unless everyone understands what brought them together—and what that behavior truly represents.
Andrew Benesh, PhD, LMFT-Behavioral Health Education and Community Development Professional comments on drafted rule changes.
I know there’s a lot of anxiety floating around regarding upcoming changes to student loan rules, and their anticipated effects on students.
The Department of Education (ED) is moving forward with draft rules that will fundamentally change how graduate students finance their education. Under the rule ED will propose, many healthcare professions are not classified as professional programs, but instead as graduate programs. “Graduate programs” will have a $20,500 annual limit, with a $100,000 total cap, while programs defined as “professional programs” will have a $50,000 annual limit, and $200,000 total cap. This means that many students, including MFT students, would be subject to significantly lower loan limits. This change will take effect on July 1, 2026, and will apply to new borrowers. The ED is expected to open this proposed rule up for public comment early next year, most likely in January.
AAMFT has been actively advocating for the inclusion of MFTs in the professional degree definition throughout the rulemaking process, including joining coalitions of health professionals advocating for a more expansive definition of professional degree. AAMFT and many other healthcare associations will be submitting public comments to ED on this proposed rule. AAMFT will alert members once the public comment period begins.
What can be done before the public comment period begins?
It is important for Members of Congress to hear from their constituents on this important issue, and to ask Members of Congress to make sure that ED includes MFTs and other healthcare professions under the professional degree definition in the final rule. Use this link to contact your Member: https://lnkd.in/eZ6qQmaj
In addition, AAMFT wants to hear how federal graduate student loan program has supported your path to licensure and how these proposed limits would impact future students. Your stories will help show Congress the real-world impacts of these changes on current and future MFT students, as well as how these changes will exacerbate the shortage of behavioral health providers. Share your story here: https://lnkd.in/eBFKMdZh
The above is based Original Message: Sent: 11-24-2025 04:04 PM From: Neal Sombke
Hello Family TEAM members,
Thank you for your comments on this important issue. AAMFT has been actively advocating for the inclusion of MFTs in the professional degree definition throughout the rulemaking process, including joining coalitions of health professionals advocating for a more expansive definition of professional degree.
We have linked here two coalition statements AAMFT has signed on to within the last month that urge the Department of Education to classify MFT degrees and other healthcare degrees under a more inclusive professional degree definition.
The Department of Education (ED) is moving forward with draft rules that will fundamentally change how graduate students finance their education. Under the rule ED will propose, many healthcare professions are not classified as professional programs, but instead as graduate programs. “Graduate programs” will have a $20,500 annual limit, with a $100,000 total cap, while programs defined as “professional programs” will have a $50,000 annual limit, and $200,000 total cap. This means that many students, including MFT students, would be subject to significantly lower loan limits. This change will take effect on July 1, 2026, and will apply to new borrowers.
The ED is expected to open this proposed rule up for public comment early next year, most likely in January. AAMFT and many other healthcare associations will be submitting public comments to ED on this proposed rule. AAMFT will alert members once the public comment period begins.
What can be done before the public comment period begins? The federal bureaucracy does listen to Congress. Therefore, it is important for Members of Congress to hear from their constituents on this important issue, and to ask Members of Congress to make sure that ED includes MFTs and other healthcare professions under the professional degree definition in the final rule. AAMFT has developed a grassroots message that you can send to your Members of Congress.
In addition, AAMFT wants to hear how federal graduate student loan program has supported your path to licensure and how these proposed limits would impact future students. Your stories will help us show Congress the real-world impacts of these changes on current and future MFT students, as well as how these changes will exacerbate the shortage of behavioral health providers. Please click here to share your story.
AAMFT continues to monitor the situation and how these changes will affect MFTs. If you would like to read about how these changes will affect MFTs, you can click this article. Please contact AAMFT at FamilyTEAM@aamft.org if you have any questions.
Recording therapy sessions is a powerful tool for promoting professional growth and improving therapeutic outcomes. Without this practice, therapists miss out on valuable opportunities for feedback, self-reflection, and skill enhancement, which are essential for ongoing development.
The Importance of Feedback in Therapy
Feedback is a cornerstone of professional growth in any field, and therapy is no exception. For therapists, receiving feedback on their work is crucial to understanding how their interventions are perceived, identifying areas for improvement, and refining their techniques. Without recording sessions, it becomes challenging to obtain accurate and detailed feedback. Relying solely on memory or subjective impressions can lead to a skewed understanding of the session, missing out on subtle but important nuances in the therapeutic process.
Enhancing Self-Reflection
Recording sessions allows therapists to revisit their work with a critical eye, enabling them to analyze their interventions, communication style, and the overall flow of the session. This practice fosters self-reflection, helping therapists recognize patterns in their behavior that may be hindering or facilitating the therapeutic process. For example, a therapist might notice that they frequently interrupt clients or that they struggle to maintain a non-judgmental stance in certain situations. Identifying these patterns is the first step toward making intentional changes that can enhance the effectiveness of therapy.
Facilitating Supervision and Peer Review
Recorded sessions are invaluable in supervision and peer review processes. Supervisors and colleagues can provide more precise and constructive feedback when they can observe the session directly rather than relying on second-hand accounts. This external feedback is critical for identifying blind spots, challenging assumptions, and exploring alternative approaches. Without recorded sessions, therapists may miss out on these rich learning opportunities, limiting their professional growth.
Improving Client Outcomes
Ultimately, recording sessions and using the feedback to improve therapeutic skills leads to better outcomes for clients. When therapists are more aware of their strengths and weaknesses, they can tailor their approach to meet clients’ needs more effectively. This continuous process of learning and improvement ensures that therapists are providing the highest quality care possible.
Conclusion
If you aren’t recording your therapy sessions, you are likely missing out on key opportunities for growth. By incorporating session recordings into your practice, you can enhance self-reflection, receive valuable feedback from supervisors and peers, and ultimately improve your therapeutic effectiveness.
Dr. Kenneth Hardy’s work offers a profound framework for understanding power, privilege, and oppression within therapeutic relationships and broader social systems. His concepts of the tasks of the privileged and the tasks of the subjugated challenge therapists to examine not only the dynamics within the families they serve, but also the relational forces that exist between therapist and client.
Hardy (2016) explains that privilege and subjugation are relational positions, not fixed identities—both shaped by historical, social, and cultural contexts. Those in positions of privilege have the task of acknowledging, naming, and owning their privilege. This includes developing an awareness of how their position influences interactions, interpretations, and access to resources. Privileged individuals must resist the temptation to minimize or universalize experiences of marginalization and instead cultivate curiosity and humility.
Conversely, the tasks of the subjugated involve reclaiming voice, validating lived experience, and challenging the internalized messages that come from systemic oppression. These tasks are not the responsibility of the oppressed alone, but require environments where it is safe to speak truth and be believed.
In Ecosystemic Structural Family Therapy (ESFT), joining—the process of authentically entering a family’s world—is at the heart of systemic change. Hardy’s framework deepens our understanding of joining by reminding us that power differentials always exist in the therapy room. Therapists, whether aware or not, bring their own privilege into the system—through education, race, class, professional role, or authority. When privilege goes unacknowledged, it can replicate the very hierarchies that perpetuate distress within families.
To join effectively, therapists must intentionally decenter themselves and cultivate empathy through curiosity and transparency. They must ask: “What might it be like for this family to be joined by someone in my position?” and “How might my privilege or my own subjugated experiences be shaping how I join?”
By integrating Hardy’s lens, joining becomes not just a clinical technique, but an act of social justice—a way of restoring balance in relationships fractured by inequity. True joining honors both voices: the courage of the subjugated to speak and the humility of the privileged to listen.
Reference: Hardy, K. V. (2016). The View from Black America: Reflections on My Work and Journey. In D. Combs et al. (Eds.), Family Therapy Review: Contrasting Contemporary Models. Routledge.
An important distinctions we make in Ecosystemic Structural Family Therapy (ESFT) is the difference between first-order change and second-order change. Understanding this difference is crucial for therapists committed to creating meaningful, sustainable outcomes for families.
First-Order Change: Behavior Changes in Interactions (Linear, External, and Compliance-Driven)
First-order change focuses on surface-level behavioral shifts. It’s linear, cause-and-effect in nature, and often driven by external factors like rewards, consequences, or direct instructions. The goal is to stop or start a behavior, and the motivation is frequently tied to the fear of punishment or the promise of a short-term incentive.
While first-order change can offer temporary relief, it rarely addresses the deeper relational dynamics that sustain the behavior over time. In many cases, the family’s underlying patterns remain intact because the structure is still the same. The change is often fragile—likely to regress the moment the external motivator is removed.
For example, a child might stop yelling because they’ve been threatened with the loss of screen time. But without addressing the relational patterns driving the behavior—like poor emotion regulation or lack of parental leadership—the change won’t last.
Or the professional may step in and redirect the child. This makes the therapist part of the structure. So of course the behavior changes. When the therapist leaves the unwanted behaviors signaling distress come racing back!
Second-Order Change: Relational Changes in Interactions (Internal and Transformative)
Second-order change, in contrast, happens at the level of structure, meaning, and relationship. It’s not just about doing something different—it’s about thinking, feeling, and relating differently. The structure (hierarchy, boundaries, and family culture) requires a collaborative change and active in deliberating practicing shift in roles, and new patterns/ emotional responses.
Second-order change is: ✅ Internal – driven by insight, motivation, and relational shifts ✅ Dynamic – involving multiple members of the family system ✅ Sustainable – changes are maintained because they’re meaningful and integrated into daily life ✅ Collaborative – both caregivers and children participate in creating and maintaining new patterns
In ESFT, we guide families toward second-order change by focusing on co-regulation, attachment, co parenting, alliance building, and caregiver leadership. We help families see their patterns, understand their emotional processes, and take ownership of creating new interactional cycles that are healing, not harmful.
For instance, instead of a caregiver demanding a child “just calm down,” the family works together on building emotional safety and regulation strategies that change how stress is handled systemically.
Why the Difference Matters
First-order change may help in the short term—but second-order change transforms the family system. It’s the difference between managing symptoms and reshaping the emotional environment that sustains wellness over time. At PCFTTC, our focus is always on helping therapists and families work toward deep, relational, and lasting change—the kind of change that doesn’t rely on external control but grows from within.
Example of First-Order Change (External, Linear, Compliance-Based)
Scenario: A teenager is refusing to complete homework and is spending excessive time on video games.
Therapist Intervention (First-Order): The therapist coaches the caregiver to implement a behavioral consequence plan:
The caregiver tells the teen, “If you don’t complete your homework by 7 PM, you lose access to video games for the rest of the night.”
The teen complies with the homework expectation—but only because of the fear of losing privileges.
What makes this First-Order Change?
It’s linear: If you don’t do X, Y will happen.
It’s externally motivated: The change happens due to fear of consequence, not internal motivation.
It’s compliance-focused and likely temporary: If the caregiver stops enforcing consequences, the old pattern will likely return.
Example of Second-Order Change (Internal, Relational, Sustainable)
Scenario: Same teenager, same homework avoidance.
Therapist Intervention (Second-Order): The therapist works with the entire family system to explore the relational and emotional dynamics driving the avoidance through the family assessment tools. Therapist discovers:
The teen feels disconnected and overwhelmed but doesn’t know how to express this.
The caregiver tends to escalate quickly into frustration and yelling, which increases the teen’s avoidance and emotional shutdown.
The therapist guides the family to deliberately practice in session:
Improve caregiver leadership and co-regulation:
The caregiver practices giving clear, emotionally regulated instructions and checks in with the teen about emotional needs before setting expectations.
Build emotional safety:
The teen is helped to voice feelings of anxiety around schoolwork.
Develop a new relational pattern and anchor it:
Together, the family creates a homework plan that includes built-in support, positive connection time afterward, and space for emotional check-ins.
What makes this Second-Order Change?
This change is caregiver lead and therapist facilitated.
The family shifts relational dynamics and emotional responses—not just behaviors.
Motivation becomes internal and relational, not driven by fear or reward.
Caregiver leadership is strengthened, and the teen feels emotionally safer and more engaged, making the change sustainable over time.
Hall, G. C. N., Berkman E. T., Zane N. W., Leong F. T. L., Hwang W. C., Nezu A. M., Nezu, C. M., Hong J. J., Chu J. P., & Huang, E R. (2021). Reducing mental health disparities by increasing the personal relevance of interventions. American Psychologist, 76(1),91–103. https://doi.org/10.1037/amp0000616
La Roche, M. (2013). Cultural psychotherapy: Theory, methods, and practice. Sage.
La Roche, M. (2020). Towards a global and cultural psychology: Theoretical foundations and clinical implications. Cognella.
La Roche, M. J. (2024). Changing multicultural guidelines: Implications for multicultural psychotherapies. Practice Innovations, 9, 320–335. https://doi.org/10.1037/pri0000255
Sánchez, A. L., Jent, J., Aggarwal, N. K., Chavira, D., Coxe, S., Garcia, D., La Roche, M., & Comer, J. S. (2022). Person-centered cultural assessment can improve child mental health service engagement and outcomes. Journal of Clinical Child and Adolescent Psychology, 51(1), 1–22. https://doi.org/10.1080/15374416.2021.1981340
Smith, T., & Trimble, J. (2016). Foundations of multicultural psychology: Research to inform effective practice. American Psychological Association. https://doi.org/10.1037/14733-000
Soto, A., Smith, T. B., Griner, D., Domenech Rodriguez, M., & Bernal, G. (2018). Cultural adaptations and therapists’ multicultural competence: Two meta-analytic reviews. Journal of Clinical Psychology, 74(11), 1907–1923. https://doi.org/10.1002/jclp.22679
Substance Abuse and Mental Health Services Administration. (2015). Racial/ethnic differences in mental health service use among adults (HHS Publication No. SMA-15-4906).
Recently, I watched a short video of a foster mother cat gently caring for a kitten who had clearly endured trauma. The kitten flinched at every movement, tucked itself into corners, and froze at any attempt at touch. But the mother cat didn’t retreat. She moved slowly, calmly—relentlessly. With every lick, every soft purr, every patient pause, she sent the same message: You are safe now. I won’t hurt you. I’m not going anywhere.
As I watched, I realized: this is exactly what it looks like to build attachment with a child who has experienced complex developmental trauma.
In Ecosystemic Structural Family Therapy (ESFT), we talk about the importance of reestablishing safety and connection as the foundation of all therapeutic work. For children who have learned through experience that adults are unpredictable, unavailable, or unsafe, attachment isn’t automatic—it must be earned through consistency, patience, and deep emotional attunement.
The caregiver’s role is to embody safety. Not to demand closeness, but to offer connection without pressure, and to remain emotionally available even in the face of rejection or withdrawal. Just like the foster mother cat, the caregiver must be willing to show up again and again, saying with their actions: 💬 I see you. 💬 Your fear makes sense. I would be afraid too. 💬 I’ll stay until you trust.
Attachment doesn’t come from grand gestures—it comes from the quiet, repeated moments of co-regulation: sharing calm, honoring the child’s emotional state, and staying present without needing immediate results.
In a trauma-informed, strength-based model like ESFT, we understand that healing happens through relationship, not in spite of it. And while the journey is slow, the impact is profound.
That tiny kitten eventually crept toward the mother cat and tucked itself under her warmth. It didn’t happen all at once—but it happened. The same is possible for the children we serve.
Traumatized children don’t need perfect caregivers. They need relentless ones. Ones who stay. Ones who wait. Ones who whisper safety through every calm breath and patient act of love.
Because healing begins where fear once lived—and trust is the bridge we build one steady step at a time.
If you’ve ever heard the iconic spoken-word song “Everybody’s Free (To Wear Sunscreen),” you know it’s packed with practical, poetic, and unexpectedly emotional advice. Originally a column by Mary Schmich and popularized by Baz Luhrmann, the song reads like a love letter to life’s complexity—with one recurring reminder: wear sunscreen.
But if you listen closely, the heart of the song is about more than sun protection—it’s about perspective. It’s about embracing uncertainty, holding paradoxes, and trusting that life is rarely linear. And if there’s any therapeutic model that echoes that spirit, it’s Ecosystemic Structural Family Therapy (ESFT) – making the complex simple by seeing the challenge as relational not behavioral.
“Don’t waste your time on jealousy. Sometimes you’re ahead, sometimes you’re behind. The race is long—and in the end, it’s only with yourself.”
In ESFT, we often help families move away from competitive, comparison-based narratives and toward shared emotional connection. Healing happens when we shift from proving or winning to joining and reframing. Families don’t need perfect answers—they need safe spaces to be seen, to struggle, and to grow.
“Do one thing every day that scares you.”
In the family therapy room, vulnerability is that one thing. Asking a caregiver to hold limits with love, encouraging a teen to share hurt instead of anger, or guiding a therapist-in-training to sit in discomfort—these are ESFT moments. Progress isn’t comfortable; it’s courageous action inside safe structure.
“Be kind to your knees. You’ll miss them when they’re gone.”
We help families appreciate the everyday, not just the crisis. ESFT is a model rooted in social ecology, reminding us that growth doesn’t happen in isolation—it happens in schools, homes, neighborhoods, and quiet moments. The small, unseen strengths families already possess often become their greatest tools for change.
The Therapist’s Sunscreen? Structure.
Just as sunscreen protects us from invisible harm, structure protects families from the chaos of unchecked patterns. The ESFT therapist holds that structure so families can safely explore their agency. We aren’t rescuers—we’re guides walking families toward their own power.
In a way, wear sunscreen is exactly what we ask families to do: protect what matters, risk connection, trust the process—and be gentle with yourselves.
