Again developed to allow multiple perspectives on how curiosity might be exercised, the case of Mandy and David is also used below to provide an overview of the main elements of medium-term work for therapeutic change, where the role of the therapist included becoming a temporary secure base for early attachment problems becoming resolved. This example of practice explores using a genogram as a therapeutic tool, annotated with the therapist’s accompanying additional thoughts (in parentheses).
Constructing a genogram with David and Mandy, David was an enthusiastic participant for the first time in therapy. He was keen to know more about his birth family and especially learn some of the unspoken narratives of his family history. Mandy, less keen, participated but with cautious consideration of each person she added.
Last week we talked about drawing a genogram or family map to help think about the people in your family. Is that still okay? It is … Mandy, you said David is most keen to have a go at a genogram. What might he be hoping this might help with? … You think he would like to hear more about his father. Is that right, David? It is … (Sensing danger here, as well as opportunity … This is a sore point for Mandy and we might need to take this slowly. It might also start an alternate story of a mum who can manage emotional pain and help David to have greater confidence in his mum to nurture him.)
Mandy, what might help us be able to talk about the stories David wishes to hear more about in a way that is helpful for him but is also okay with you? … Okay, we can make time to meet separately to talk more about the sore bits. Is it okay to start putting people on the genogram just now? … (Is this slow enough? Will need to watch out for destructive, dominant narratives overtaking other stories that David might need to hear.)
David, you have put a ‘close’ line between you and your dad. He is important to you? He is … What would he be saying about how your weekends together go? (Taking a risk here that Mandy could sabotage this sensitive topic if flooded with her own pain. She seems pleased that David is talking so it might be okay to carry on.)
Mandy, you have been very generous in giving this time for David to think about how he gets on with his dad when this has been sore for you. What would you like David to know about what you want for him and his dad? You want them to be close but worry that he might be let down in the future … Thoughts of how let down you have felt in the past get in the way of this for you sometimes? (Another big risk taking us close to really sore experiences from Mandy’s past. David is participating and Mandy seems to be coping with her pain. She looks upset but not overwhelmed …) Mandy, is it okay to carry on with this? It is … David, I can see that your mum is showing how much she wants things to change and how much she wants the best for you … (Trying to keep David engaged with talking about positive experience with his father and to reinforce that Mandy tolerating this is a change.) What does your mum see as the best part of your relationship with your dad? (Mandy and David share a glance and a chuckle as David states that on nights when he has seen his dad, he manages to sleep in his own bed). (Completely taken aback and had not heard this exception before at all! Want to balance amplifying the exception with exploring the barriers that have got in the way of this being every day experience. Dilemma! Perhaps transparency would be best here?)
David and Mandy, I am really encouraged that something about seeing your dad helps you to sleep in your own bed at night and I would really like to know more about how this helps. I can also see that something gets in the way of this on other nights and I would also like to know more about what happens. Which would you like to do more of today? Okay, you both would like to think more about what helps on days you see your dad. How about we do this now and come back to exploring your genogram and thinking about other people in your family next week?
Genogram – Mandy and David (at 12)
As in the previous case example, early transactional patterns for Mandy and David were already established and a change in life stage, going to secondary education, had highlighted the stuckness in one aspect of David’s development. Other contributory relational factors were maintaining this stuckness as well as bringing exceptions to the problem. As with the previous example, the order of change needed to align with therapeutic engagement:
- Amplifying exceptions to the problem brought hope that change would be possible without blame or shame
- Establishing permission to explore contributory relational factors at a pace the family could manage came next
- Lastly considering other aspects of the systemic formulation that could support and reinforce lasting change
Anticipated changes for Mandy and David to no longer need child mental health services were:
- To consolidate Mandy’s tolerance for David’s positive relationship with his father, then consolidate the factors that supported David’s individuation and reduced feelings of anxiety
- To increase Mandy’s capacity for bearing her own emotional pain and thus open up space more healthy emotional availability for David through adolescence
- For Mandy to be able to use her own resources to seek closeness from other people within her system of relationships
Therapeutic intervention in this instance was over a period of 8 months, beginning with twice weekly sessions, increasing to weekly sessions whilst focusing on sore emotional experience, then reducing to twice weekly then monthly appointments whilst consolidating change.
Change from an Integrated Model Perspective
While the overall therapeutic encounter drew on many aspects of the Integrated model over the months of therapy, each model became dominant or less dominant at different periods of time. Briefly we review the focus of our curiosity during the period of therapy from different positions within the Integrated model.
McMaster: how affective involvement is experienced and perceived within the family, exploring degrees of relational closeness, security and independence in relation to the life cycle. ‘Now that David is 12, what do you imagine will be the kind of comfort he will need as he gets further into his teenage years? Who else might he look for closeness with as he gets older? What might that be like for you? What have you noticed now that helps you find closeness in your other relationships Mandy?’
These questions would be aiming to facilitate exploration of independence, expanding the mindscape of relationships and highlighting barriers to drawing on external resources within the current mother/son relationship. While the overclose relationship between mother and son might become clearer, exploration aims to be without blame or criticism.
Structural: subsystem boundaries that have become diffuse rather than clear would be explored within this case example. ‘David, how will your mum know when you are tall enough to manage more nights in your own bed? Mandy, what will be the first thing you will notice when David knows that you are setting clear expectations for him?’
While asked with slight humour, these serious questions inherently bring into conversation the expectation of structural change within the family system.
Psychodynamic: unresolved emotional pain of loss and frustration within Mandy’s past mean that when David had taken steps toward individuation in the past, these had been quickly closed down by Mandy. Helping her explore and desensitise these painful experiences can broaden her capacity to tolerate emotional pain so that David can develop into a separate person. ‘When David wants to see his dad, what does that get you thinking about? How does this change how you see David as he gets older? What did you miss the most when your dad left the family? What would you have liked your mum to have told you about what happened? What was it like for you when you thought she couldn’t cope with your worries?’
In exploring the unresolved pain from the past, especially as it plays out in current relationships including within therapy, Mandy can then reduce destructive projections onto David of her own expectation of past hurt and frustration from males close to her. Then change and individuation is less likely to be sabotaged by out-of-awareness or unconscious material.
Social Constructionist: much of David and Mandy’s family stories had been left unstoried to avoid difficult conversation and to avoid emotional pain. Engagement in therapy provided an opportunity to develop a shared narrative, enriched by exceptions and times when closeness and individuation was simultaneously achieved and enhanced by inclusion of extended family members and friends. ‘Now that you have got the better of worry, what has changed the most at home? In school? With friends? For you David? For you Mandy?’
Mandy and David, over the course of therapy, were able to construct new meanings within their relationship and relational system, so that felt security increased and external resources were no longer perceived as a threat. As a result, worry reduced and security increased, freeing the family to explore their world with greater satisfaction.
Constructivist: Mandy and David made use of therapy to build on hope and on their own inner resources, constructing greater tolerance and greater capacity to adapt to life’s challenges. ‘What talents in David do you see now, Mandy? How is he developing these? What does he enjoy most about them? David, what do you notice now that tells you that your mum can cope with hearing about your dad? What is that like for David, Mandy? How does this help him when life gets tough?’
Taking time to develop internal resources and then consolidate these through later recognition increased David and Mandy’s resilience when setbacks occurred. For example, when David returned to school after the summer break, he was tempted to avoid school again. Mandy was also getting anxious and David was feeling less secure. However revisiting the ways in which they had developed their resources prior to the holidays had been enough to provide them both with hope to try again and meet challenges with further success.
Epigenetics and Neuroscience: within the family, a pattern of anxiety and a struggle to cope with challenges could have been framed as a neurological vulnerability, switched on by adverse early experiences for Mandy and triggered by unresolved loss for David in his early childhood. Emotional experiences that do not have the opportunity or emotional containment to be resolved tend to remain within the limbic system and are triggered by associated memories. Had Mandy and David not been able to desensitise the sore experiences through therapeutic conversation, both might have benefitted from more direct intervention to desensitise and reprocess specific experiences and alter core beliefs about themselves and others, i.e. through EMDR or CBT. However given that both Mandy and David had the emotional and family resources to assist them through therapy, they did not require this additional intervention.
Children and adults who have experiences of extreme neglect, abuse and other forms of trauma and who lack the emotional resources to be able to explore these through systemic family therapy often require additional intervention such as these to cope with and resolve their experiences.
Using the Integrated Model, the therapist was able to weave coherently in and out of the different positions according to the need of the family at each point within therapy. That is not to argue that each aspect of each position was always explored in depth or that with a different family, different aspects of each position would not be privileged over the ones identified here. Rather, the Integrated model offers a range of possibilities enabling best fit with a family and therapist and optimising possibilities for change.