Developed to allow multiple perspectives on how curiosity might be exercised, the case of Dana is also used below to provide an overview of the main elements of short-term work for therapeutic change, perhaps the most common outcome of a systemic assessment. We begin with the formulation previously illustrated, but now annotated with the therapist’s accompanying additional thoughts (in parentheses).
Well thank you for coming today. It’s been a long session but I think we all feel that we’ve made sense of the problems that took you the GP. Tony, I know you’re about to return to University, do you feel that we’ve done a good-enough job today? That you’ll be able to go back to Uni without worrying about them so much? … (How much time have we got before he goes back? will his further participation be essential?)
I’d like to summarise what we’ve been talking about, and how it fits together. We couldn’t have done that without all of you feeling you could be open, and sharing important things about your family and yourselves. We’ve got a few minutes left, so after I check out whether what I’ll say represents what we’ve agreed, we could spend a couple of minutes talking about where we should go from here. Would that be alright? … (I’d like to get a clear direction for the family so some stuff can happen before Tony goes.)
OK. Well, I know we’ve spoken quite a lot about this already. I suppose to start with, the main thing today is how important what each of you’ve brought from the past and what each of you bring now, at a very different time of your lives. And how openly you’ve been able to talk about all this; without that we couldn’t have got to where we are now … (Not sure we need to do more talking. Maybe between Alan and Linda? Or they might now talk a lot more between themselves? I’m maybe thinking too much like Tony myself! Not completely confident his parents can make that step on their own.)
As parents, will Dana be able to make a success of her teenage years like her elder brother? As a family, will the very different experiences within the family of what it takes to become independent be useful? As Dana’s mum and dad, you’ve had very, very different experiences of growing up, yet both of you have each experienced a lot of loss and uncertainty, which you’d hoped to make good in becoming a unit … (Yes, that’s where most of the work ahead still lies – between Alan and Linda.)
Linda, growing up without a mum but being looked after well by your grandmother and her sister, returning to them after your first marriage turned out badly (Tony, you’re obviously turned out very different to your dad!), but losing them both so quickly, and so soon before Dana came along … Tony was there for you as you cared for Auntie Isobel after her stroke, Alan – who’d never had a family of his own – was very understanding. But your pregnancy with Dana came too soon after, it was really hard to connect with her as a baby (you wondered if your own mother had the same problem – perhaps she had been depressed too), but Alan was there for you. And he was there for Dana … (Everyone needs to come out of this well.)
So you thought, well maybe Dana’s got enough – at least she’s got her dad. And Alan, you too were relieved to see that this was a help to Linda. It was difficult for Alan to know how to help you otherwise. Linda’s low mood, her loss of the two who brought her up, that was hard to know what to do, how to get close to her. Linda’s close relationship with Tony seemed to do both of them good, and you got to know Tony and respect him – even if that didn’t involve hugs! … (Who knows?! There are different types of hug, I think hugs have happened here today, just not called that …)
So we talked about how you looking after Dana was much more than a responsibility. It was a “gift” that gave you treasured experience of what family attachments can mean, changing her nappies, picking her up if she woke at night, looking after her when she was ill … We haven’t talked, maybe we don’t really know why neither of your mothers was able to do the same, but neither you, Alan, nor your employer, had problems with time-off. He knew how hard-working and reliable you were, which were qualities Linda recognised when she met you … (They’ve both done so well. Optimism’s going to be very important for what happens next.)
We then talked about how that both helps and doesn’t always help when kids grow up. I guess Alan’s respect for Tony will be even greater after what Tony said about that … (Am I getting Alan ready to thank Tony and say he can now go? That they don’t need him to stay around to solve things …)
Alan – Linda hadn’t seen you cry like that, and you knew that Tony wasn’t judging you when you did. Letting go of the apron strings is very hard … (I think I can say that, it’s been in what he and Dana have been saying …) it’s been very muddling for both you and for Linda … (bring her back in …) who wasn’t sure good she could ever be a good mother to Dana … (That’s enough, round off with why they came and the turning point in the session …) So Dana, when you said “It’s OK being close to your Dad, but you want to be close to your Mum as well” that went to the heart of your whole family’s history, didn’t it? It wasn’t the complaint of a difficult teenager, or an angry one, was it? She wanted things to be different, all of you do … (setting out the contract …) her behaviour brought you all here, so even though Dana’s the youngest person in this room, in her own way she’s quite wise! … (the referred patient as family problem-solver …) She’s looking pleased at that! You too Linda! …There’s a clear direction of change, whatever her diffidence/ambivalence she’s there, going to help make an early change in how things have been …) I don’t know which way to look but I sense there’s a hug or two coming up from somewhere! … (not to forget Alan.)
Is that going to be OK, or a bit frightening? Going too fast? Yes. Was that OK, admitting that? … OK, so one step at a time? … Would going back to arguing feel easier? or just more familiar?! (… tentative but so much more relaxed, ready for change and that it can be nice not frightening.)
So when you get home, what do you think will happen? (There’s no need to spell out the treatment goals, or set tasks – they’re on their way) How do you want this to continue? … (let’s see what’s might to stop change happening) And what will you say to the ‘little one’ who you had worried wouldn’t understand? 8 years old – maybe he would understand … (not need protection, change is good for everybody)
Although family transactional patterns were long-established, it was only Dana’s adolescent development that indicated their obvious limitations. To maintain therapeutic engagement, the order of change
- would begin with an early reduction in concern about Dana’s adolescent behaviour
- then what else matters to the family
- finally anything else that occurs to the therapist arising from the formulation.
Other stuff may emerge over this time, but that’s up to the family and what they want to do about it. Most families value some time at the end of their therapeutic contact to look forward, which might include stuff they have just recognised but perhaps now feel able to resolve themselves over time.
The anticipated required changes to help Dana and her family move on were:
- to consolidate Dana’s confidence that her parents took her concerns seriously
- likewise she with those of her parents
- Dana and her mother taking time out to be with each other and learn more about one another
- Linda and Alan refresh their closeness as a marital couple, which – because he was having to stand back a bit from Dana – would include Alan’s pride in Linda’s greater self-confidence rather feeling threatened (discarded) by it.
Four sessions, including two for Linda and Alan on their own, would be sufficient to support all these changes, including reflecting back on their journey in therapy and to briefly look forward to anticipated further life cycle changes.
This summary of the key elements of how helpful changes may occur in Dana’s family provides an indication of the importance attached to contracting, the formulation that lies behind it, and to their brief post-assessment therapeutic contact.
Technical points: an understanding developed between family and therapist that any change in relational behaviour might best occur as small steps; with the direction of travel well understood; that new steps develop more effectively from success rather than disappointment; that greater mother-daughter involvement rests upon both more time together and on communication, both likewise best achieved in a graduated way; Linda and Alan talk to one another afresh, i.e. careful listening and talking without old assumptions intruding, with early recognition (and reality-testing) of projections each have included in responding to the other.
Families, without profound and unresolved early emotional trauma, often quickly take on board the principles of effective change that apply to them. So like Dana’s family, they may not require more than a few sessions to implement the changes they come to understand are necessary.
All the above had been derived from the assessment undertaken, which constituted from the family’s first contact i.e. an indication of the importance of each phase of that contact – what was found, and what was agreed and by how the assessment had been undertaken (rather than an indication that significant change had already occurred).
Reflecting on whether Change began during the Assessment
We consider even the most linear question gains systemic value by being embedded within a family session, so the exercise of curiosity necessary to complete an assessment inevitably has an impact that may prepare the ground for change.
Our position is that it deepens the family’s understanding of themselves and provides the basis of greater adaptive-flexibility upon which any contract must depend (perhaps even demonstrating its presence where previously little or none had been evident). Furthermore, a focus on exceptions may indicate the presence of more, facilitating a very different (usually much more hopeful) understanding of themselves. However, we no more accept insight alone can make change happen than CBT, IPT, cognitive-analytical or psychodynamic psychotherapy – all require ‘working through’ issues.
To demonstrate this, we briefly review the different types of question that may have been asked during the first meeting with Dana and her family, according to each of the six perspectives we had introduced.
McMaster: curiosity about problem-recognition and agreement, how discussion occurs and the family roles were involved, prompting different family members to respond to what was emerging: ‘can you tell me more about that?’, ‘did other people know?’, ‘what do you think about what you’ve just heard?’, ‘can we talk about whether that happens in other places/times?’ ’are there times when Dana and mum get on/do things together/solve a problem together?’ …
Unarguably, these questions would have highlighted the comparative emotional under-involvement between Dana and her mother and perhaps the family-of-origin influences upon her parents. However that is a far cry from changing their habitual ways of relating, indeed far from establishing the much fuller formulation developed above.
Structural: the unusual family alliances would have become apparent and openly labelled, with Dana’s statement regarded as breaking out of a position triangulated between her parents. Tony’s silent support of his sister co-opted to help Dana stick to her message, though perhaps as much to strengthen the weak boundary separating parental and sibling subsystems as any immediate intention to learn more about underlying issues.
Tony’s co-opted role in the session might imply that it should continue, and any inducement to Linda to relate more directly with her daughter likely to be experienced as challenging for both her and for Alan.
Psychodynamic: where exploration of feeling would be the predominant approach, asking family members to indicate how one-another were feeling, cross-checking between members as this happened and from time to time using a particular observation to make a more general enquiry: ‘does X ever/always get …?’ ‘whenever Y happens/doesn’t happen/feels lost’, etc. The emphasis would be on communication (‘what happens when mum’s feeling down?’ ‘how people know/do you think other people realise’ …) and would extend to asking about the past (‘Linda: that feeling of being lost, overwhelmed, which you’re feeling right now, I’m wondering if that also goes back a long way? Is that something you recognise from the past, perhaps even before you had Tony or met Alan?’)
A fuller formulation than that provided by a structural approach would result, the parents in particular likely to feel more understood, but there would be no clarity about what should happen next, beyond to keep talking and a resolution that all family members should try harder to get on.
Social Constructionist: picking up what the therapist thought had been a wish rather than a complaint as an opening to explore the different family stories about closeness and talking (‘when Dana – you said – ‘It’s OK being close to your Dad, but you want to be close to your Mum as well’, there seemed to be very different ideas about what that meant … Tony, I’m curious to know what you thought.’) The therapist remaining watchful to ensure their individual stories were allowed to be expressed uncontested, modelling respectful listening, also directing conversation to construct new, hopeful relational processes.
It’s likely that all would have felt that they had been listened to and had learnt new things from and about one another and that each might resolve to keep talking and be less impatient with each other. Also it is likely that unexplored territory for new ways of relating would be constructed.
Constructivist: similarly seeking to explore and build upon positive experiences of closeness within the family, using questions, to construct a new reality of personal competence for each of the family members e.g. ‘what (asking Dad) pleased you when Dana was close to her mum that time? What difference did this make to you? And what difference did that make to you? What difference did this make to Dana? And what difference did this make to her mum?’ In other words, what a preferred future might look like and feel like and steps already achieved toward it explicitly noted.
The determined pursuit of this approach might take the family by surprise and perhaps facilitate perceiving themselves differently (perhaps later on asking each other new questions modelled on those they had experienced). Equally if this position was taken in isolation, it may threaten therapeutic engagement if the family’s long-established views of themselves were not felt to have been taken seriously.
Epigenetics and Neuroscience: facilitating recognition of a possible intrinsic pattern across three generations of women. Although the reported difficulties were not considered congruent with low mood, the possibility of a heritable disposition toward emotional vulnerability might also provide an opportunity to cement some common understanding between Dana and her mother that had not been possible before.
The latent good-will in the family might carry on this initiative, bringing better understanding of similarities and differences between family members.
It will be evident that worthwhile outcomes would have been possible simply as a result of how questions were asked. However, there can be much less certainty about what might happen next, whether any new understanding of themselves was equally distributed, whether any lasting change would occur and, if that happened, whether this would involve and benefit the family as a ‘whole’ rather than particular individual members of it.
In summary, the value of these questions for therapeutic conversations, i.e. technique, is not in doubt. However, this is a world away from a full systemic therapeutic encounter, which can only be provided by a full assessment and formulation, maximising the opportunity for significant and lasting change.