Too busy?

Fathers attendance for family

appointments
Jennifer Walters
a
, Fiona Tasker
b
and Sheila Bichard
c
Fathers are often less likely to attend for appointments with their referred
children at family and child psychiatry clinics than are mothers. The liter-
ature related to this topic is examined. A study of fathers attendance at
family sessions is reported, in which attenders are compared to non-
attenders. It is concluded that conventional suppositions regarding
fathers attendance, such as work hours and family roles, are not as
important predictors of fathers attendance as fathers relationships with
their own fathers and current relationships with their partners. Clinical
implications are examined.
Introduction
A frequently cited problem when working with families where chil-
dren with difficulties are referred is engaging fathers in clinical
work. A high proportion of families are now headed by lone parents
and many of these are mothers. However, in many families there are
still two parents
1
and in a substantial proportion of lone-parent
families fathers remain involved with their children to some extent.
None the less, fathers are easily excused by clinicians from atten-
dance at appointments due to having work commitments or
because they are not the prime caretakers of their children. There
are various reasons for this, one being the historical research bias
whereby researchers have concentrated more heavily on mothers
than on fathers (Phares, 1992). Clinicians also tend to focus on
mothers histories in relation to their children rather than those of
2001 The Association for Family Therapy and Systemic Practice
The Association for Family Therapy 2001. Published by Blackwell Publishers, 108 Cowley
Road, Oxford, OX4 1JF, UK and 350 Main Street, Malden, MA 02148, USA.
Journal of Family Therapy (2001) 23: 320
01634445
a
Consultant Clinical Psychologist, Child and Family Consultation Service, John
Scott Health Centre, Green Lanes, London N4 2NU, UK.
b
Senior Lecturer in Psychology, Birkbeck College, University of London, UK.
c
Consultant Clinical Psychologist.
1
Burghes et al. (1997) reported that more than four out of five (85%) fathers
live with their children under the age of 18 in the UK. Phares (1999) reports that
61.1% of children under the age of 18 in the United States live with both of their
biological or adoptive parents.
fathers, and mothers are usually more forthcoming in telling their
stories. Kerr and McKee (1981) point out how mothers are
accepted as childcare experts in dealings with health profession-
als. It is mothers who seek out the health professionals and who in
turn are sought out by them (Graham, 1984). Fathers attend for
child health issues when asked by their partners, or when there is a
serious developmental issue to consider (Kerr and McKee, 1981),
and family stress levels might need to be exceptionally high in some
cases for some fathers to attend (OBrien, 1994). A father quoted in
feedback from a group for parents of anorexic children (Nicholls
and Magagna, 1997) stated: the hospital should insist that fathers
take part in these meetings. Of course, they are too busy, but then
maybe they have been too busy for their children too.
Attendance by fathers
Having the peripheral father attend and then engage in work is a
key task for workers with families. Carr (1995) sees the problem as
embedded in the context of Western society where fathers are more
likely to be engaged outside the home and to live in a culture which
separates them from their children. In reviewing ten empirical
investigations of Milan Family Therapy, Carr (1991) refers to a study
by Bennun (1989) in which the perceptions of the therapist were
researched in thirty-five families. He concluded that the percep-
tions of the therapist held by fathers had a much stronger associa-
tion with therapeutic outcome for families than those held by
mothers, except where the mother was the identified patient.
Where fathers viewed the therapist as competent and active, provid-
ing direct guidance, the outcome of therapy was more likely to be
successful. Carr (1991) concludes that engaging fathers early in the
therapeutic process, through the adoption of a competent and
directive style, should be a priority (p. 249).
An early but important study by Churven (1978) on the east end
of London population investigated twenty-five referred families who
were visited at home prior to clinic appointments. All but one father
participated in the home interviews. Twenty families were prepared
to attend as a family (positive group) and five not (negative group).
Fathers were more reluctant to participate than mothers. All the
mothers and half the fathers of the positive group attended the
clinic versus only three of the mothers and none of the fathers from
the negative group. In general, there was a tendency for positive
4 Jennifer Walters et al.
2001 The Association for Family Therapy and Systemic Practice
parents to be of higher social class, to be referred less often with
children who exhibited antisocial behaviour and to have initiated
the referral for their child themselves. Churven comments that
attendance at childrens medical services is seen in this community
as part of the maternal nurturing role. Another early study by Berg
and Rosenblum (1977) analysed sixty family therapists views about
fathers in treatment. The therapists reported that about 30% of
families came to the first interview without fathers, and that fathers
were more resistant than mothers about subsequently returning to
the clinic. In another study it was found that attendance by fathers
at a child community sleep clinic was 31% and that two-thirds of
these fathers were in the professional occupational group (Walters,
1993).
Telephone interviews by Guillebeaux et al. (1986) surveyed the
experiences of thirty-five men who had attended at least one marital
and family therapy session. The men were predominantly middle
class, white, in their thirties, highly educated, and married. The
study found that the main considerations men listed as influencing
their decision to enter a particular type of therapy were: price (this
was an American study), recommendation from others, distance,
type of centre, and therapists reputation. Openness to therapy was
found to be related to prior experience with therapy, threat of
divorce by partner, early childhood socialization, and problematic
marital interaction. It was found that a quarter of the men surveyed
did not agree to therapy until their partner threatened separation
or divorce.
Ferholt and Gurwitt (1982) talk strongly of the need for fathers
to attend for therapy with the family, being indispensable sources of
information about their children. Littlejohn and Bruggen (1994)
talk of the father being the key to engaging the family. Heubeck et
al. (1986) state that there is no shortage of arguments for the inclu-
sion of fathers in assessment and treatment; they cite work by
Gurman and Kniskern (1978) who note that the fathers presence
clearly improves the odds of good outcomes. In a review of
research findings Heubeck et al. (1986) identify four areas as impor-
tant as to whether fathers attend or not: the personality of the
father, his family role, his work role, and the ethos of the clinic.
Most interestingly, Heubeck suggests that a fruitful line of research
would be to investigate the meaning that participation in therapy has
for fathers and whether treatment leads to changes in their self-
concepts and motivations.
Fathers attendance for family appointments 5
2001 The Association for Family Therapy and Systemic Practice
Focusing on the institutional features of the clinic in relation to
whether fathers attend or not, a moving account by Herbert and
Carpenter (1994) tells of fathers of families with a child with Downs
syndrome, many of whom felt excluded from hospital appointments
that their wives attended. One father described himself as the
secondary partner. Several factors may contribute to the fathers
negative perception of the institutional features of the clinic, and
many of these may be related to the characteristics and attitudes of
therapists. Many professionals working in the child sphere are
female. Atkins and Lansky (1986) state that therapists may create a
counter-productive atmosphere by unconsciously sharing a societal
belief that expressing concerns about fatherhood or husbandhood
is indicative of weakness or femininity. Indeed some therapists have
been noted as feeling discomfort when treating men (Kirschner et
al., 1982). Frosh (1992) talks of masculinity intruding upon the
therapeutic process, never advancing it (p. 160), as the male ther-
apist depends on the female patient to allow him to demonstrate
his mastery and expertise, while the patient, aware only of her
distress and loss, needs the therapist to tell her what to do (p. 163).
Brearly (1986) describes female qualities of listening and receiving
in therapy which men find difficult as therapists, and notes that
male clients have a tendency to be more cut off from feelings and
so are unable to identify sources of their misery. Little is known
about gender and therapeutic relationships, although it is notable
that male therapists are more likely to be involved in marital, family
and group work compared with female therapists who are repre-
sented more in individual work. Heubeck et al. (1986) assert that a
male therapist has more chance of facilitating whole family engage-
ment where fathers feel they have an ally. There is also evidence that
men prefer a more structured approach to therapy and find it
harder to engage in more free-style, exploratory styles of therapy
(Blackie and Clarke, 1987; Vetere, 1992). However, there is little
hard evidence on the topic. Indeed it would be too simplistic to
expect that simple gender issues were of overriding importance as
so many other factors, such as therapist warmth, skill, age, and the
characteristics of the patients, are important. In one authors (JW)
clinical experience it is not unusual for men to request to see a
female therapist when offered individual work. It may therefore be
that it is not disadvantageous being a woman therapist and working
with men in families. Biker (1993) suggests that female therapists
are more likely than male therapists to be rated as having skills
6 Jennifer Walters et al.
2001 The Association for Family Therapy and Systemic Practice
related to patient satisfaction and successful outcome, whereas
nothing comparable has been found for male therapists. However,
it should be noted that experienced therapists of both genders are
seen as possessing favourable qualities for engagement of men in
therapy. Competence, an understanding of the patients problem
and developmental stage, and gender perspective are qualities of a
good therapist of either gender, as are empathy, support and accep-
tance (Frankenburg, 1984). In addition, men place high values on
status and training of counsellors, and are more likely to expect and
feel comfortable with directive counselling and advice giving,
reflecting their orientation to public arenas characterised by the
achievement of measurable goals (Brannen and Collard, 1982:
201).
B. M. Erickson (1993) points out how essential it is for us all to be
mindful of our own beliefs regarding our own families of origin
and, when working with men, of these male relationships in particu-
lar. She talks of her own family experiences with her father and
brother having both aided and detracted from her work with men
and her need to be mindful of both. It should not be forgotten, as
Ferholt and Gurwitt (1982) comment, that therapists themselves
are powerfully affected by their own experiences of parenting (both
parenting and being parented) and this will inevitably affect their
attitudes to fathers in a promoting or inhibiting way. This view is
supported by Vetere (1992), who urges therapists to examine the
extent to which ideas about differences between men and women
are based on sexist stereotypes. She extends this by pointing out
how the importance of gender role stereotyping affects the whole
system with relationships within the family, relationships with the
therapist, and with institutions outside the family to whom individ-
uals are connected.
A survey of a group of family therapists by Flynn (1988) regard-
ing attitudes towards the participation of mothers and fathers in
family therapy found that, although therapists were enthusiastic
about the idea of engaging fathers and felt it to be of great impor-
tance, their behaviour did not always reflect this. In Flynns survey
therapists were found to be much more likely to make initial
contact with the mothers than with the fathers and to rely on moth-
ers to make contact with fathers if the father was absent from a
session. He concluded that there is little evidence of fathers being
more fully integrated into family therapy as yet, despite therapists
accepting the need for the increased involvement of fathers. In
Fathers attendance for family appointments 7
2001 The Association for Family Therapy and Systemic Practice
addition, it was felt that improvements could be made by a greater
flexibility in the working arrangements of family therapists to
accommodate out-of-hours attendance by families, and the active
involvement of fathers by therapists at an earlier point in therapy.
Engagement of fathers
We will now turn to the literature which suggests ways in which
fathers can be helped to become engaged in family work. There are
a number of practical measures which seem to facilitate the engage-
ment of fathers in therapy. Those mentioned are to acknowledge
the positive motives of both men and women in coming to sessions
and the personal costs to them (Vetere, 1992). Littlejohn and
Bruggen (1994) suggest that a specific invitation may help,
although it is pointed out by Heubeck et al. (1986) that too specific
a focus on fathers can also have the effect of reinforcing the fathers
position of power in the family, and may disempower the mother.
Setting appointments at suitable times is also of crucial importance
but this can apply to mothers as well as fathers. Churven (1978)
places value on home visits prior to clinic appointments. Byng-Hall
(1991) talks of telephoning clients in the first instance. Heckers
(1991) suggestions for encouraging and engaging fathers include
clarity of expectance of fathers involvement from the outset,
normalizing the lack of enthusiasm for family therapy on the part
of the father, and extolling the fathers capabilities as an expert with
regard to his children.
Foote et al. (1998), reporting on a training programme for
parents with young children, claim that some fathers feel they have
little to contribute, and doubt their own value in the therapeutic
process. These workers therefore engage the father by gaining his
perspective of the childs problem.
reinforcing his concern, and underscoring the importance of his involve-
ment in treatment. We have found that once fathers feel valued by the
therapist and believe that they can play a role in therapy they become
active participants in the programme. In addition, we have found that
families are less likely to drop out of treatment when both fathers and
mothers participate.
(Foote et al., 1998: 368)
Dienhart and Myers Avis (1994) note how there is a dearth of
literature dealing specifically with therapeutic interventions for
working with men. They undertook an exploratory study to provide
8 Jennifer Walters et al.
2001 The Association for Family Therapy and Systemic Practice
a beginning formulation of ways to work more effectively with men
by identifying those interventions currently used by a group of
thirty-six gender-sensitive family therapists to engage and challenge
men, and what interventions the group considered most effective
and important. We acknowledge the possible limitations of their
sample characteristics which included highly educated Caucasian
therapists working mainly with middle-class clients. The therapists
generated a wide variety of ideas to encourage affective expression
in men but did not always agree on their appropriateness or effec-
tiveness. The overall results support what the authors call a connect
and challenge approach in which they begin by joining with the
mans pain and then challenge his learned patterns of control and
power. Methods favoured were reframing, empowering, and linking
family-of-origin issues with learned attitudes and behaviours rather
than approaches traditionally associated with masculine models,
such as confrontation.
A further way of engaging fathers might be through exploration
of their own history, particularly any losses, and how they might
relate to the current family situation. Gunzberg (1994) has some
important views in respect of this idea, although his comments
embrace both male and female clients. He argues that therapy has
been influenced by considerations of expertise and techniques
aimed at solving problems and what he terms a paternalistic
model of doing things to the client. He proposes a more shared
conversational style of work which respects personal autonomy and
creative solutions. He suggests that loss is a covert agenda for many
people seeking help and looks at this in terms of unresolved grief.
Through exploration of this issue, Gunzberg believes that thera-
peutic change can be effected. Although many men may find it
difficult to express their feelings, talking about loss can sometimes
be an acceptable way of expressing emotion. Certainly acknow-
ledgement of this can be an important way of engaging both moth-
ers and fathers (Walters, 1997). There is strong evidence (Bowlby,
1980; Holmes, 1993) of the relationship between acute loss and
increased vulnerability to depression. In turn, depression in a
parent may have strong links with marital difficulties, and thus
problems in children. B. M. Erickson (1993) addresses this issue by
stating that loss is at the heart of much of what brings people into
psychotherapists offices; it has extra impact where men are
concerned because of their socialization against expression of
emotion. She quotes Keen (1991): Men have much to mourn
Fathers attendance for family appointments 9
2001 The Association for Family Therapy and Systemic Practice
before they can be reborn. One of the losses Erickson addresses is
loss for men of their own fathers; this is not necessarily an obvious
loss through death or divorce but may be seen in an emotional
distancing and grieving for the lack of a connection.
The research
Method
As part of a larger study, forty fathers whose children between the
ages of 3 and 9 were referred to a Child and Family Consultation
Service in Londons East End were interviewed regarding their
child, their parenting of the child, the fathers own history of
parenting, and fathers mental health (Walters, 1999). There were
twenty fathers of boys and twenty fathers of girls in the group.
Ethnicity was mixed, with twenty-seven fathers being white and the
remainder being from minority cultures. There were fourteen
fathers in social classes IIIInm and twenty-six in social classes
IIImV. Six fathers were living apart from their children.
A semi-structured interview constructed by Walters was used in
combination with an adapted version of a parenting interview
schedule (Quinton and Rutter, 1988). The fathers were also asked
to complete questionnaires on their current mental health (Beck
Depression Inventory: Beck et al., (1961); a general health ques-
tionnaire (Goldberg et al., 1970); recalled parenting by their
mother and their father (Parental Bonding Instrument: Parker et
al., 1979); parenting stress (Parenting Stress Index: Abidin, 1990);
current attachment style (Simpson Attachment Measure: Simpson,
1990); behaviour of child (Rutter A scale: Rutter et al., 1970), and
marital state (Golombok Rust Inventory of Marital State: Rust et al.,
1988). These self-report questionnaires were completed by 88% of
fathers interviewed. The attendances of children and fathers at
clinic interviews were recorded.
Results
Attendance
A percentage of attendance by fathers at appointments was
computed for each family by taking the number of appointments
attended by the father with the family and the number attended by
10 Jennifer Walters et al.
2001 The Association for Family Therapy and Systemic Practice
family members without the father. In this research population the
mean attendance rate was fairly high, perhaps because those agree-
ing to participate in a research interview were also those more likely
to attend the clinic: 67.1% of appointments were attended by
fathers (SD 38.4, Median 83.75%). The group of forty fathers
included five fathers who did not attend appointments at all and
nineteen who attended every appointment.
Reasons for not attending
Nearly 75% of the sample said they thought it was important for
fathers to attend at their childs appointment. Fathers were also
asked why they thought it might be difficult for some men to attend.
Many interesting reasons were given for men not attending clinic
sessions. Work was frequently cited as a reason. Feeling awkward or
redundant was mentioned. Having their masculinity attacked, feel-
ing the clinic atmosphere is particularly controlled by women, not
wanting to admit to problems, children being closer to their moth-
ers, feeling its not their business; men are lazy and ignorant and
cant discuss their feelings was one mans opinion. Another
believed that men think things will sort themselves out without
intervention. Further comments were: men being more secretive;
feeling that the children are not their responsibility; being too
macho, and women being quick to take the burden.
Comparison of types of attenders
Data were examined contrasting those attending above and below
the median rate on various demographic characteristics. There
were no statistically significant findings in relation to attendance
and gender of child (c2=.400, df=1,ns), family size (r=.180, n=40,
ns), whether the father was living with the family (c2=.784, df=1,
ns), whether he was in or out of work (c2=.125, df=1, ns), or
whether his partner was working (c2=.624, df=1, ns). All those who
never attended their childs clinic appointments identified their
ethnicity as white British.
Correlations with percentage of attendance showed no statisti-
cally significant links with childs age (r=.246, n=40, ns), no relation
to fathers social class (r=.233, n=40, ns), and no relation to the
extent of childs problems as reported by the fathers on the Rutter
A scales (r=.240, n=34, ns). During the course of the face-to-face
Fathers attendance for family appointments 11
2001 The Association for Family Therapy and Systemic Practice
research interviews, fathers were asked how worried they were
about the presenting problems in their child and they were also
asked to report how worried they thought their partners were at the
point of referral. There was no association between fathers
reported level of concern and their attendance at the clinic (r=.150,
n=39, ns). Fathers also reported that their partners were more
worried than they were about their childs problem. No relation to
the fathers reported experience of parenting stress (r=.210, n=34,
ns), or depression (r=.093, n=35, ns) and no relation to the inter-
viewers rating of the quality of his parenting was found. Parental
load-taking was another variable rated from the parenting interview
and, not surprisingly, this was positively correlated with attendance
(r=.379, n=40, p<.01), indicating that fathers who share the parent-
ing load are more likely to attend clinic sessions with their child.
Furthermore, there were non-significant trends in the data, indicat-
ing that lower rates of marital satisfaction as reported by the father
or the mother on the Golombok Rust Inventory of Marital State
(fathers: r=-.287, n=33, p<.10; mothers: r=-.320, n=30, p<.10) were
associated with lower rates of attendance, possibly indicating moth-
ers mediating role in whether fathers attend or not.
Fathers history and attachment
Fathers were interviewed extensively regarding their relationships
with their own fathers and mothers. The history of their relation-
ship with each parent was broken down into three sections: rela-
tionship with father/mother as a child, relationship with
father/mother as a teenager, and adult relationship. All these vari-
ables were rated on a scale of 14, with 4 indicating a very good rela-
tionship and 1 a poor relationship. The results were correlated with
fathers attendance rates at family appointments. The results are
shown in Table 1, from which it can be seen that there are no statis-
tically significant correlations between recollected relationship with
mother and percentage of attendance at clinics (r=.078, n=40, ns);
however, the reported quality of relationship with the father is
significant, both overall (r=.433, n=39, p<.01) and at all three levels
(childhood: r=.521, n=39, p<.001; teenage: r=.544, n=39, p<.001;
adult: r=.582, n=35, p<.001). Similarly, the relationship between the
care-from-father dimension of the Parental Bonding Instrument
showed a positive correlation with attendance (r=.343, n=32,
p<.05). Fathers were also asked how they viewed their own fathers
12 Jennifer Walters et al.
2001 The Association for Family Therapy and Systemic Practice
as a parent, and how they viewed their own fathering in relation to
their son or daughter. Those fathers who saw their own fathers as
good fathers were more likely to have higher attendance rates
(r=.401, n=40, p<.01) but not more likely to see themselves as better
fathers (r=.032, n=40, ns).
Fathers attendance for family appointments 13
2001 The Association for Family Therapy and Systemic Practice
TABLE 1 Correlations of measures with percentage of attendance of fathers
at family appointments
Scale Correlation Scale Correlation
Rutter A .240ns n=34 Simpson attachment .123ns n=35
secure
Parenting Stress Index .210ns n=34 Simpson attachment .255ns n=34
avoidant
PSI parental distress .025ns n=34 Simpson attachment .060ns n=35
anxiousambivalent
PSI parentchild .247ns n=34 Relationship with .433** n=35
difficult interaction father
PSI difficult child .222ns n=34 Relationship with .078ns n=40
mother
Expressed warmth .214ns n=40 Rel.fatherchildhood .512*** n=39
Overall fathering .203ns n=40 Rel.fatherteenager .544*** n=39
quality
Emotional .156ns n=40 Rel.fatheradult .582*** n=35
involvement
Beck depression .093ns n=35 Rel.motherchildhood .121ns n=40
inventory
GRIMS marital .287+ n=33 Rel.motherteenager .052ns n=40
scale: father
GRIMS marital .320+ n=30
scale: mother
Parental Bonding .343* n=32 Rel.motheradult .149ns n=40
Instrument fathers
care
PBI fathers .165ns n=32 Rates of play .097ns n=40
overprotection
PBI mothers care .106ns n=33 See self as father .032ns n=40
PBI mothers .156ns n=33 See own father .401** n=40
overprotection
Fathers concern re .150ns n=39 Social class .233ns n=40
problem
Notes: p<.10+; p<.05*; p<.01**; p<.001***
Current attachment styles were measured using Simpsons attach-
ment measure, and no significant results were found when the
subscales of secure (r=-.123, n=35, ns), anxiousambivalent (r=-.060,
n=35, ns), and anxiousavoidant (r=-.255, n=34, ns) were correlated
with percentage of attendance. However, of the ten poor or non-
attenders who completed this questionnaire, seven (70%) reported
insecure attachments (either anxiousavoidant or anxiousambiva-
lent). Of the nineteen men who attended 100% of their childs
appointments, fifteen completed the self-report questionnaires on
attachment and ten were rated as securely attached (66.6%).
Fathers who had experienced separation of any kind in their
childhood or teenage years (divorce of parents, death of a parent,
major moves, boarding-school) were significantly more likely to be
poorer attenders than those without experience of separation
(t=3.57, df=37.86, p<.001). Fathers who had experienced parental
divorce or separation during childhood or teenage years were more
likely to be lower percentage attenders than those from non-
divorced families (t=4.86, df=38, p<.001). Fathers whose parents
had divorced were significantly more likely to be separated them-
selves (c2=7.00, df=1, p<.01). However, we have seen earlier that
there were no significant results when fathers own divorce status
(i.e. whether or not the father was currently resident with his
family) was examined in relation to attendance rates. Although
numbers were small, only one out of these six non-resident fathers
was a complete non-attender.
A significant link was shown in relation to fathers scores on the
Beck Depression Inventory and concern about their childs difficul-
ties, with a significant tendency for fathers who expressed more
worries about their childs problems and the need for referral to
score higher on the BDI (r=.443, n=34, p<.01). It is possible that
fathers who were more concerned about their child experienced
more disturbance in their own mental health, or vice versa, or there
is perhaps an underlying variable affecting both concern for the
child and their own mental well-being, although that does not mean
that they attend for help.
The concepts of emotional involvement, overall quality of
fathering, and expressed warmth were derived from overall
impressions during the interview. Emotional involvement is a
rating of the extent to which family life and the emotional func-
tioning of the father is centred in the child. The overall fathering
quality is a rating of the quality of interaction between the father
14 Jennifer Walters et al.
2001 The Association for Family Therapy and Systemic Practice
and the child, and is based on the impressions of the interviewer
gained from any aspects of the fathers description of their rela-
tionship. Expressed warmth is a rating of how warmly the father
describes his child throughout the interview. The ratings are
derived from the parenting interview (Quinton and Rutter, 1988)
and have established good inter-rater reliability in previous
research. There was no correlation between emotional involvement
and percentage of attendance (r=.156, n=40, ns) nor between
percentage of attendance and overall quality of fathering (r=.203,
n=40, ns) or expressed warmth (r=.214, n=40, ns). Similarly, the
amount of involvement through play with their children ascer-
tained from detailed interviewing showed no correlation with
percentage of attendance (r=.097, n=40, ns).
When fathers were interviewed regarding any preferences for
gender of therapist, most men (85%) reported no preference. The
remaining 15% all stated that they preferred a female therapist and
no one specified a male therapist. Of those who preferred a woman
said, Theyre more maternal, they understand more about chil-
dren, after all they bear them. Another father said, I dont trust
men. Women are more thorough. A further comment by one
father was that women are more able to understand, more
emotional, more creative, and less rigid.
Of the fathers who had 100% attendance (nineteen), eight were
being seen by a male psychiatrist. This could suggest that men are
more easily engaged by a male therapist seen to be of high status.
However, it may well be a reflection of other factors, such as the will-
ingness of high attenders to participate in a research interview or
the ability and authority of a male doctor to recruit to the research.
It will be important in future research to examine the gender factor
of therapists in engagement of fathers, although it is likely to be
only one of many factors relevant to engagement.
Case vignettes
Case vignettes are presented to provide individual descriptions of a
father who attends few clinic appointments and one who attends all
appointments.
Carl is in his twenties and lives some of the time with his mother
and some of the time with his family. His daughter, aged 4, was
referred with behaviour problems. Carls father left the family
home when Carl was very small, although Carl reflected that he did
Fathers attendance for family appointments 15
2001 The Association for Family Therapy and Systemic Practice
not think it had affected him very much: Im not the only one in
the world. However, he did go on to mention that things might
have been better had he had a father around: I might have viewed
things differently. He had, and still has, a very close relationship
with his mother: Whenever I need her basically shes there. Carl
was categorized as avoidant on the Simpson scale and in the
dysthymic range on the BDI. His relationship with his partner was
rated as severe on the GRIMS.
Carl had been to clinic appointments, but very few. He felt that
things had improved with his daughter but that for him work got in
the way of attending appointments. He was in fact unemployed at
the time of interview, but was looking for work and was trained as a
plasterer. He said he felt that a lot of men would feel intimidated
by the clinic and if they say something wrong . . .. For a short
period following the interview, Carl attended appointments but
then became a non-attender.
In contrast, Kevin, a father in Social Class V working full time,
attended all the appointments with his daughter, aged 8, referred
with anxiety symptoms. He reported a good marriage, did not
report any symptoms of depression, and on the Parental Bonding
Instrument rated high care from his father and mother in child-
hood. Of his father he said, he was always there any time I needed
him. As a teenager I was a bit rebellious but no less close to him.
Kevin presented as a caring and concerned father and was easily
engaged in the therapeutic process.
Conclusions and clinical implications
These findings are from a limited sample size and require replica-
tion with larger numbers. However, some possible implications
emerge for those working therapeutically with families in child and
family settings. The results clearly point to fathers own history of
relationships playing a significant role in determining their atten-
dance. Cowan et al. (1996) emphasize the need for family therapists
to look at intrapsychic factors in the parents (internal working
models of intimate family relationships) when thinking about
change in dyadic interaction patterns, which in turn relate to chil-
drens socioemotional adaptation. In particular, the finding in this
research that the fathers history with his own father is linked with
attendance rates may be of paramount importance. We have seen
that fathers who recall more positive fathering from their own
16 Jennifer Walters et al.
2001 The Association for Family Therapy and Systemic Practice
fathers are more likely to attend clinic appointments; those who
attend less often are more likely to have experienced parental
divorce themselves, and report less satisfying marriages with their
partner. The small group of fully attending fathers were more likely
to be securely attached, and those who were non- or poor attenders
were more likely to be avoidantly attached. It may therefore be that
energies of therapists should be directed to creative ways of encour-
aging attendance by fathers; this will inevitably be difficult for those
families where fathers are complete non-attenders, but where there
are fathers who are poor attenders active engagement strategies by
the therapist may be crucial. In our own research it was notable that
fathers were often positively engaged by participating in the
research interview and sometimes subsequently attended a family
appointment where they had not previously been engaged in family
work with their child. This indicates that taking a special interest in
the father and his history and, in a clinic session, positively connot-
ing his role, is likely to be very important. In the light of the finding
from the present research that those fathers who were poorer
attenders were more likely to report less good marital relationships,
it would also seem important to address this by making direct
contact with the fathers themselves, rather than through the
mother, and connoting the importance of their contribution to
clinical work with their child. The attachment paradigm for engag-
ing families outlined by Byng-Hall (1991) is likely to be highly rele-
vant for fathers with poor histories of relationships with their own
fathers. However, the work required to modify insecure attachments
to more secure models may be substantial.
A further agenda to be addressed in therapy is one espoused by
Gunzberg (1994), who finds that loss is a covert agenda for many
clients, both male and female. Bowlbys (1980) view that depression
has a strong relationship with loss suggests that exploration of this
may represent fruitful inroads for therapy with men as well as
women. This theme is pursued in a paper by one of the authors
(JW) referring to clinical work and men in families (Walters, 1997).
Although no direct relationship was found between attendance
rates and depression, it was perceived that concern about their
childs difficulties and fathers depression were linked. This would
therefore seem an important area for clinicians to address.
In conclusion, it seems likely that fathers experience of their
own fathering is an important factor in attendance patterns of
fathers at family appointments for child-focused problems. Despite
Fathers attendance for family appointments 17
2001 The Association for Family Therapy and Systemic Practice
common assumptions by clinicians that fathers may be too busy to
attend and that attendance can be excused, clinicians should look
beyond these reasons and attempt to work on making fathers feel
their role is far from peripheral.
Acknowledgements
Very many thanks are due to the fathers who agreed to be inter-
viewed for the research and to colleagues, particularly Dr Karmi
Saedi, who helped to recruit fathers to the project.
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