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Book Reviews   |    
Family First: Your Step-by-Step Plan for Creating a Phenomenal Family
Reviewed by Pedro Ruiz, M.D.
Psychiatric Services 2005; doi: 10.1176/appi.ps.56.4.493
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by Phil McGraw; New York, Free Press, 2004, 304 pages, $26

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Family First: Your Step-by-Step Plan for Creating a Phenomenal Family is a masterpiece in terms of the initiatives it proposes for achieving healthy and successful families in American society today. Phil McGraw—or "Dr. Phil" as he is known to his television audience—conveys quite well his understanding of the challenges faced by American families in their quest for growth, success, and maturity. He describes his own experiences, first as a growing child and later as a parent, adding a personal touch as well as much-needed sensitivity to the understanding, diagnosis, and counseling of families in need of help and support.

Despite a family's best intentions and desires, many families in this country lack the expertise and knowledge required to address the serious problems that make them dysfunctional. Issues such as alcoholism, drug use, poverty, violence, and behavioral problems are threatening, disrupting, and even destroying many American families. In Family First, McGraw presents clear and practical recommendations on how to satisfactorily resolve these serious problems.

The text is divided into two parts. The first addresses the ingredients needed to create a phenomenal family. These six chapters address family dynamics and the relevance of the family as a single unit in life; key issues pertaining to divorced parents and how divorce affects children; the five most important factors needed to create a phenomenal and healthy family; "family legacy" and what to do to achieve healthy changes in this regard; an examination of different parenting styles and how to intervene to achieve harmony and functionality; and ways of achieving healthy status among family members, particularly the ingredients needed for children's success. The practical exercises offered in this section are useful for the development of insight. They represent excellent resources to be used in clinical settings.

The second section examines the key tools McGraw considers essential to the achievement of successful parenting: a definition of parental success; how to appropriately listen, communicate, and learn when relating to your children; how to negotiate successfully with your children; how to understand the role of stress and depression among children; ways to identify and appropriately address behavioral problems; how to change the family structure to achieve harmony among family members; and how to help children grow and mature by providing ideal role modeling.

I strongly recommend this book to mental health professionals and trainees as well as to the lay public. Actually, I wish I had read this book 40 years ago, when I was myself struggling with how to be an "ideal" parent.

Phil McGraw's book offers a "step-by-step plan for creating a phenomenal family." Designed primarily for laypersonsand entry-level mental health professionals, the book contains a personalized reflection on the author's troubled family of origin, descriptions of five important factors for a "phenomenal family," seven detailed tools for "purposeful parenting,"and a plan for evaluating the reader's family background and parenting style.

The seven parenting tools have names designed to cue recall of parenting goals, such as parenting with purpose, parenting with clarity, parenting by negotiation, parenting with currency, parenting through change, parenting in harmony, and parenting by example. These parenting tools are discussed in detail and constitute more than half the book. McGraw uses examples from his own family relationships as well as those of persons who have sought his consultation. Unlike a detached textbook of family therapy, this book has a McGraw-personalized feel to it that is more suited to a lay audience and includes McGraw's own views on family dynamics and parenting.

Absent from the bookis a substantive discussion ofa biologically basedcontribution to behavioral problems among children. McGraw does not adequately address how children with mental illness may present with behavioral dyscontrol despite adequate parenting skills. One crucial flaw in this book isits neglecting to make a detailed recommendation of the warning signs of childhood mental illness andto give information about whenparents may want to seek a psychiatric evaluation for psychotherapeutic or pharmacologic treatment for their child withbehavioral problems.

One additional comment relates to thetenor of the book: it tends tobe fairly critical of many typicalparental responses to behavioral problems yet directs parents to stop blaming themselves for their children'soutbursts. The book's value is ingiving laypersons step-by-step guidelines for managingbehavioral problems and providing consistent parenting. However, most seasoned mental health care professionals will find it overly simplistic.

In his latest book, Phil McGraw offers clear advice that many parents will find useful. The advice is often preceded by questionnaires that guide the reader toward increased self-awareness, followed by recommendations that are sometimes founded on empirical studies. The empirical reach extends to topics such as healthy nutrition.

For broader issues, such as styles of parenting, McGraw turns to the management literature of the business world; has parents answer 30 questions that result in classifying their parental styles as authoritarian, equalitarian, or permissive; goes on to state the consequences of each approach compared with the style of the child; and makes recommendations whereby he hypothesizes that there will be problems. For the combination of permissive parent and passive child, for example, he hypothesizes, "You're vegetating," and he recommends a more authoritarian parental style.

A major difficulty with this and similar books is the implication that the author is able to predict what will happen in a given situation. In the suggestion that following Dr. Phil's recommendations will result in a "phenomenal family," those who do not have phenomenal families may conclude that they did something wrong. On the other side of the coin, can one predict that dreadful parenting leads to troubled adults? Not necessarily. For example, the book describes a severely alcoholic father who was unavailable to his son and clashed with his son whenever he was drinking—"searing these experiences in the boy's mind." The alcoholism led to many job changes, uprooted the family, disrupted the boy's life, and left the family in poverty. The mother was unable to counterbalance her husband's behavior and the children's flight from the father's drinking. The result: The boy became a highly successful, loved national figure: Dr. Phil.

Phil McGraw's advice is worth pursuing, but he should not suggest that achieving a "phenomenal family" is a certainty.

Four-year-old Susan won't speak to her mother. Dr. Phil plays the "Cheerio game" with her, and she is soon speaking to him like a normal four-year-old child. He lets the mother watch through a one-way mirror, but still the child does not speak to her mother at home. He asks the mother if she has tried the Cheerio game. The mother replies that she does not have time for games. Thus we have Dr. Phil's take-home message: If you want change at home, you must put time and effort into it.

Phil McGraw provides questionnaires, checklists, directives, timetables, contracts, guidelines, and unbridled enthusiasm. He subtly incorporates the principles of systems theory, the importance of family structure, and the role of a family legacy and emphasizes that the person who shows up in the emergency room may not be the person who is most in need of treatment. He teaches parents how to negotiate with adolescents, how to set limits, how to present a united front, and how to modify behavior according to good behavioral therapy techniques. These are all sound family therapy concepts that are familiar to family therapists. McGraw's strategies for families will work especially well for fathers who lack a good parenting role model.

The book is based on a survey of 17,000 parents. Results from this survey are peppered throughout the text, and an upcoming peer-reviewed journal article will present the results of McGraw's survey. For example, 53 percent of parents indicated significant resentment in making sacrifices as a parent. The Texas saying "All hat and no cattle" refers to families that are all show and no substance, which is an ailment of modern living, according to Dr. Phil. Parents give too much and expect too little, are too afraid of put their foot down for fear of upsetting the child. "Enough!" says Dr. Phil. Forget about what the neighbors will say. Reduce the show and put back the substance into the family. Take all material possessions out of the badly behaved child's room and let the child earn these things back, one by one, when he or she can show appropriate respectful behavior. Endearingly, the author talks about his own upbringing and emphasizes that coming from a flawed background is not something to be ashamed of but, rather, something to overcome. Family First is a good book and contains sound suggestions for families and for mental health professionals who work with families.

When I became a licensed psychologist many years ago there was profound bias against media roles for professionals in our field. Reasons for this bias ranged from a belief that such roles were self-serving ("They're giving psychology away") to the view that readers needed to be protected from cursory remedies that might be more damaging than helpful. Radio shows and newspaper columns that responded to questions that required clinical assessment and therapeutic interventions were considered unethical. The upshot was that advice columns were left to nonprofessionals or those lacking adequate credentials. For the most part, qualified clinicians continue to remain righteously silent.

Phil McGraw is not, as the book's blurb boasts "one of the world's foremost experts in the field of human functioning." He is, however, a well-credentialed and effective media star who serves a very useful purpose. His television program, like his book, reaches millions of people who have parenting problems and who would not otherwise seek professional counsel. McGraw claims that this book is responsive to the needs for assistance and information that emerged in a survey of 17,000 parents.

McGraw's message is largely unassailable: Don't make the mistakes your parents did. Take control, set limits, understand that your family should have central importance in your life. Raise children with structure, respect, appropriate expectations, equitable treatment, consistency, and love. His book presents communication techniques, cognitive reframing, negotiation skills, step-by-step action plans, and actual language that parents can use. He teaches parents how to eliminate negative behaviors by using common behavior modification techniques. The book is largely a model of good sense, told in language that readers can understand with examples to which they can relate and viable solutions that they can implement themselves.

For ordinary families that have the usual range of childrearing problems, this book can be very valuable. However, there is one gross defect. As he did in a Family First-related television show, Dr. Phil tends to underplay the significance of early interventions for some obvious prodromal signs of decompensation. There is a table of "hot warning signs of crisis," categorized as behaviors that endanger self or others, depression, drug abuse, and the like. Many items in this table are predictors of severe psychiatric disorders. McGraw's warning signs include suicidal ideation, memory loss, nightmares, emotional numbing, and even a child's stockpiling of guns, poison, or sleeping pills. Yet his list of resources for parents mentions only spiritual leaders, teachers, other family members, the child's pediatrician, a school psychologist or counselor, and the local mental health association. Psychiatrists are identified primarily as helping the parents deal with the crisis rather than as providing early intervention for the child. There is a legitimate emphasis on coping strategies, but missing are the clinical resources essential for diagnosis and treatment. McGraw's suggestion that these behavioral disturbances are temporary crises that can be alleviated simply by a family's changing its behaviors or dealing with school counselors detracts from an otherwise helpful book.

Dr. Ruiz is professor and vice-chair of clinical affairs in the department of psychiatry and behavioral sciences at the University of Texas in Houston.

Dr. Vogel-Scibilia is affiliated with Beaver County Psychiatric Services in Beaver, Pennsylvania.

Dr. Peele is chief psychiatrist for Montgomery County, Maryland.

Dr. Heru is with the family program at Butler Hospital in Providence, Rhode Island.

Dr. Lefley is affiliated with the department of psychiatry of the University of Miami School of Medicine.




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