The gradual transition to independence during late adolescence and young adulthood can be a treacherous course for youth and parents to navigate.1 Young adults who remain at home, highly reliant on parents and avoiding higher education and employment, present the clinician with a baffling challenge and many questions. Moreover, few data exist to guide case conceptualization or intervention strategy. These individuals suffer stigma for their “failure to launch” (FTL) and are often perceived as overly pampered and lazy, and their parents are commonly ridiculed for being too indulgent. In fact, young people struggling to function independently and overwhelmed by the demands of adulthood frequently suffer shame and alienation, as same-aged peers accumulate accomplishments while they accrue increasing disability. Better conceptualization is needed if mental health providers are to be useful agents of change in the lives of these young adults and their families. Rather than focusing on “failure,” which denotes the end of a process and acceptance of defeat, clinicians equipped with a theoretical formulation of the problem, and practical tools to address it, can be the starting point for a process of growth, change, and development. For the remainder of this article, I use “FTL” for the sake of brevity in place of “adult children living at home and highly dependent on parents,” but I use it without judgment and in a non-pejorative, descriptive way.
For the clinician, work with cases of FTL can seem more like treatment with child patients than adult patients. Parents often initiate the clinical contact and, in many cases, the dependent adult is not open or willing to engage in treatment. Clinicians might struggle to form a working alliance with, or even to determine with confidence, who their patient might be. These difficulties are compounded by issues of confidentiality owing to the adult status of the patient with FLT and by the fact that most parent-based interventions are designed with much younger children in mind.
The work my colleagues and I have done with the parents of youth with clinical anxiety has suggested a theoretical conceptualization and a means of intervention in cases of FTL. Children with anxiety display a similar pattern of reliance on parents for help in avoiding the situations they find distressing, a process known as family accommodation.2, 3 Working with parents on decreasing family accommodation has shown promise as a means of gradually increasing the child’s capacity for independent coping. In this Clinical Perspectives article, I describe a composite patient vignette (appropriately modified to protect patient anonymity) illustrating the challenging nature of FTL. Then, I discuss the theoretical conceptualization and a parent-based treatment approach for tackling these challenges.
Ivan was a 23-year-old man living at home with his parents since attending a single semester of college at 18 years of age. Ivan had a history of social and separation anxiety and was currently taking fluoxetine 20 mg daily. He had twice begun therapy, only to stop after 2 to 3 sessions. Ivan had severed most social ties and spent most of his time in his room, often sleeping during the day. Ivan’s parents provided lodging and services, including laundry, utilities, and Internet access, gave him money for expenses, and dealt with any necessary interactions with the outside world. They refrained from inviting guests to the home because this invariably distressed Ivan. His parents felt sorry for Ivan and expressed the belief that he was unable to cope with life’s many challenges. They also felt increasingly frustrated with his presence and struggled to hide their disappointment from him. Attempts to deny Ivan services or accommodations had backfired when he became angry and distraught. On one occasion he had even become physically aggressive, out-of-character behavior for which he later apologized. Ivan’s parents felt trapped and believed that all their actions only made things worse. Ivan also expressed his disappointment with life and occasionally made suicidal statements.
This vignette highlights the importance of conceptualizing FTL in interpersonal terms, as a system that involves the young adult and the parents. The vignette also illustrates the “dependency trap:” how behaviors of the young adult and the parents are mutually reinforcing and efforts by either side to alleviate the condition can actually aggravate it. The adult with FTL relies on parents for help in avoiding challenges that feel insurmountable, and the parental accommodations reinforce the avoidance and lack of self-efficacy. As the dependence continues and becomes further entrenched, parents often become fearful that the accommodation will lead only to greater impairment or resentful of the impositions on their own lives. Driven by fear or resentment, parents make sporadic attempts to modify the situation or decrease the accommodation, but these are met with expressions of anger, betrayal, and aggression on the part of the adult with FTL. These high-emotion reactions, or extinction bursts, triggered by parents’ attempts not to provide accommodation, can put the parents into full retreat. The parents feel helpless and paralyzed, and their despair makes them less likely to make additional attempts in the future. Isolation from sources of support, as in the case of Ivan’s parents, who no longer invite guests to the home, is common and makes it even harder for the family system to access new ideas, tools, or strategies that might alleviate the situation.
Clinical experience suggests that anxiety and its disorders are frequent, although not exclusive, factors that trigger and maintain the dynamic of interpersonal dependence and accommodation (as in the vignette). Avoidance is the natural response to anxiety, and children are predisposed to look to their parents for help in coping with danger or distress. However, it is likely that any factor increasing the difficulty of independent coping could equally underlie this dynamic. The difficulty in coping drives the youth to more reliance on parents, who provide negative reinforcement for the avoidance through their accommodating behaviors, and a self-sustaining cycle of avoidance and accommodation is created. The cycle intensifies as time passes, making a return to normal functioning appear ever more daunting in the eyes of the youth and ever less likely in the eyes of the parents.
Parent-based treatments have the potential to turn the systemic nature of FTL from a liability into a strength, because modifying one part of a system influences the other parts. Just as youths’ vulnerability draws parents into increasing accommodation, decreasing that accommodation provides a means of boosting the youth’s faltering “launch” and helping the youth to achieve independence. This approach suggests a parent-based treatment strategy for FTL. In one study, my colleagues and I worked with the parents of 27 adults with FTL who were living at home and were very reliant on their parents for everything from basic needs to financial support.4 Parents were trained in decreasing the accommodation they provided and empathically acknowledging the genuine difficulty and distress of the dependent adult. Rather than attempting to directly change the FTL behavior through threats or lecturing, parents focused on modifying their own behavior by gradually decreasing the accommodations and trusting in their child’s capacity to grow. The focus on self-change in the parents rather than other-change (in the child) is grounded in a powerful philosophy. By accepting that they could not directly change their adult child’s behavior, including forcing him or her to participate in treatment, parents were free to ask what they could be doing differently. The systemic nature of the problem also meant that changes they did make had meaningful effects on their dependent children. After treatment, the adults with FTL had made significant gains in employment, living arrangements, social behavior, and other forms of engagement with the adult world.
Decreasing accommodation can be as nerve-wracking for the clinician as for the parents, especially when the dependent adult is not an active participant in treatment. In our work, we have developed a set of tools aimed at minimizing the potential for parent–child conflict and for coping effectively with acute responses to the parental steps. In particular, parents are encouraged to enlist the support of others from outside the home so that they do not act alone. The mere presence of others in the house during the initial stages of treatment can have an inhibitory effect, making severe escalation less likely.
Despite inherent challenges, conceptualizing dependent adult children as more than mere “failures to launch,” acknowledging the distress and underlying issues that might maintain their retreat from independent life, and embracing the systemic nature of the dependency trap they have become embroiled in allow for a paradigm shift in these difficult cases. Parents can extricate themselves from the quagmire of accommodation and resentment and move from a position of helpless frustration to one of actively helping themselves and their child. Clinicians can offer feasible treatment options that respect the dependent adult and the parents who have often been subjected to blame and stigmatization in the past.
Acknowledgments
Dr. Lebowitz gratefully acknowledges support from the National Institutes of Health (K23MH103555) and the Brain and Behavior Research Foundation (21470).
Footnotes
Disclosure: Dr. Lebowitz has received royalties from John Wiley and Sons.
References
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