Adaptive inflexibility may indicate how deeply ingrained are some family transactional patterns. It might also be an indication of how ‘stuck’ particular members of it are e.g. because of persistent low mood, mistrust, use of alcohol, undisclosed personal difficulties in their current life, or as a result of developmental trauma. Some of these may only emerge over the course of therapy. Their earlier emergence – an indication that at least they can be talked about – offers the possibility that their salience to the formulation can be worked through within a relatively short timescale, including the introduction of new initiatives from elsewhere (e.g. an SSRI, marital work, alcohol counselling, individual support or therapy).
The first case-example in ‘thickening the description’ illustrates this. A young girl whose previously undiagnosed ADHD had, on belated reflection, contributed to the impact on her of witnessing violence during a traumatic early family life.
The first consultation, undertaken by two clinicians, established an understanding that much of the girl’s difficulties could be best understood as the result of developmental trauma. It had not been possible to take a developmental history about the girl (who was not present for the first meeting) without her mother becoming intensely distressed as she recalled the years of tension and violence. The girl’s own participation, at the second appointment, disclosed much that was salient to the formulation, with a demeanour that switched repeatedly between a bland (dissociated) manner, embarrassment, and coquettishness.
The outcome of the assessment was for one of the two therapists to undertake individual therapy for the girl (based on a formulation of developmental trauma), and to liaise regularly (and over the first few months weekly) with her mother; in addition, for both therapists to meet with the whole family on an intermittent basis. Over the first few months individual sessions for the girl were provided on a twice-weekly basis, necessitated as much by the strength of her manic defence as by any of the content of her communications. The additional steps to involve her mother and meet the whole family support were based on the perceived necessity to provide emotional containment, a task that was recognised should also not be time-limited. Subsequent understanding of the girl’s underlying neurodevelopment vulnerability extended that commitment over her years at school.