Bebe Speed introduced this term in order to encourage systemic therapists working in care and treatment services within the public sector to maintain an understanding of the determinants of emotions and behaviour that is broader than usually required for private practice work. ‘Thickening the description’ reflects the complexity of issues that often present to healthcare and social.
‘Thickening’ the description occurs across two relatively independent dimensions, which must be integrated in clinical practice:
- an individual, and their mental state (or inner world), is at one end of a dimension, beyond the descriptive power of any diagnosis and located within a human ecology i.e. from individual psychology and family dynamics to social science, an understanding of culture, and an interest in organisational functioning.
- the second dimension goes from the mind to the brain. So the question ‘what’s this person’s life been like?’ must go beyond a curiosity about individual development and family experience, to include any significant genetic factors and unfavourable early life experiences that might have affected the developing brain (and thus in turn, how life then became experienced, how that experience thought about, and how it is talked about now).
We provide two case-examples, where the impact of early psychological trauma played an important part in later life problems. The first, a primary school pupil referred because of possible ADHD. In the second case-example, early and sustained psychological trauma arising from childhood sexual abuse had shaped mood and emotional regulation at mid-brain (amygdale and hippocampus in particular), diminishing the woman’s capacity as an adult to self-sooth under stress, with dissociation and repeated recourse to self-harming.
‘Thickening the description’ also facilitates effective communication with any other NHS or social care professionals also involved in the case who, like families, prefer the use of plain language rather than reductionist propositions (usually passed-off by MH clinicians as professional ‘short-hand’).
Finally, ‘thickening the description’ also provides a fit with the current emphasis on collaborative relationships with clients (which the 1985 publication had anticipated). The end-user experience is extremely important, not just the voice of the patients/clients heard but that ‘we felt listened to … understood’, ‘our concerns were theirs’; in the words of Martin Buber, a real meeting of one-another. Theory and technique enhance the capacity to persist with very difficult problems, but both must remain subservient to the task of really meeting one-another, allowing shared sense-making.
The value of integrating models: thickening the description requires good engagement, assessment, and formulation skills, but also an ability to draw upon a diversity of systemic current models of understanding family-based issues (for example as these explore individual resilience and vulnerability), to selectively draw upon these in working through with the each family.
In social care, an understanding is required of the issues arising from deprivation, trauma, and related legislation, and within the NHS some understanding of illness-experience and disease progression.
Specifically within mental health services, an understanding of how influences at the brain level create individual differences in thinking, emotion and behaviour and how these interact with family-based and organisational factors can be extremely helpful.
Neuroscience and epigenetics: disorganised behavioural responses secondary to less-visible excessive emotional arousal may reflect vulnerability at a brain level, whether acquired through openly-volunteered illness or adverse experience, or only recognised and understood after specific enquiry.
Addressing complexity in the 21st century need not be daunting. Legislative developments since the early days of family therapy, and the advances since in the understanding of brain functioning (especially after earlier trauma) can be regarded as thickening a description, rather than complicating it.
The task may be personally quite challenging at times, not least because of the continuing advances in knowledge. For example, how to put together the intriguing recent discovery of common gene variants among patients with schizophrenia on the chromosome that regulates our inflammatory response, with the evidence of how early trauma may predispose an individual to a psychotic breakdown and subsequent stress precipitate relapse. However, for families the details of possible mechanisms underlying interactions are less necessary than the broad ‘brush-strokes’ of the synergy between different factors. Most families understand the provisional nature of any formulation, and invariably appreciate what is currently possible to understand as a useful way to think about the problems which had concerned them.
The first is of a young woman where previously unrecognised ADHD had contributed to the impact of witnessing violence during her traumatic early family life. The second, of a repeatedly hospitalised ‘borderline’ patient, described elsewhere, illustrates how a systemic therapist might have explored their circumstances.
ADHD and past trauma: a 9-year-old young woman referred by her GP because her mother believed she may have ADHD. Her mother’s social worker, who had supported her to get out of a long history of domestic violence, advised that because of her client’s continuing vulnerability, it might be best if she accompanied her, and that the initial appointment should be offered without requiring the presence of the young woman herself. This advice was accepted.
The young woman’s mother provided an exasperated account of her daughter’s constant restlessness at home, fidgety and hyperactive from late infancy, increasingly oppositional behaviour at bedtime, progressively underperforming at school, always reluctant to sit and eat, and that she profusely wet her bed most nights.
It was not possible to take a developmental history about the young woman without her mother becoming acutely distressed as she recalled years of tension and violence; as a little young woman her daughter and elder son would become frozen with apprehension at the approaching sound of a returning car. Tearful adjournments occurred with reluctance to re-enter the consultation room; sitting outside with her (rather than leaving it to the social worker alone to support her), built enough trust to enable her return into the room. The 90 minutes spent together provided the basis for a second meeting to include the young woman.
On meeting the tense pale fidgety rather restless 9-year-old daughter, her small stature was striking. This was later understood as a consequence of eating so little; the young woman recalled a strong reluctance to eat from her earliest primary school years, that she couldn’t explain but thought sometimes was due to feeling a bit sick (he mother thought her complaints had a pre-school onset). Her beguiling sometimes coquettish manner seemed in keeping with her physical immaturity. She was evidently aware of her considerable educational delay but seemed to like school; equally she agreed with her mother’s account of bed-time battles, and justified these by saying how she “didn’t like or need much sleep”. Her emotional response to a discussion about the nocturnal enuresis, which often soaked her bed-sheets, was a curious mixture of embarrassment and bland agreement.
This response, together with her statement that she “didn’t like or need much sleep”, offered the possibility that the bed-time battles that preceded sleep (which she had talked of “fighting” against) might be linked to the enuresis that followed sleep. The young woman’s subsequent account supported that as – to her mother’s concern – she gradually spoke of frequent terrifying nightmares, from which she never awoke, that usually were terminated by her death (by being stabbed or run over by a train). Sleep always put her in danger of these; in the morning her bed was soaked.
Completing the assessment, it was not difficult to arrive at a provisional formulation in which PTSD, perhaps better described as ‘developmental trauma’, was central to the explanation for her difficulties, inhibiting her also from taking anything in – whether food or schoolwork. This made sense to all present; her mother accepted this formulation, to trump her original idea that ADHD was responsible, and that it would provide the guide to how her daughter should be helped. A therapy model was devised largely based upon psychodynamically-informed individual sessions, frequent at the outset together with occasional family therapy sessions to provide general family support.
This proved successful over an 18-month period: the nightmares and enuresis abated entirely, night-time battles stopped, a ‘healthy’ appetite became apparent and a normal growth trajectory re-established.
During individual sessions, her coquettish manner and a near unshakeable capacity to deflect remained enduring aspects of her functioning. And at school too, where teachers found her likeable but inattentive and distractible. Her educational under-performing continued, so it was agreed that she repeat her last year in Primary School.
The original formulation had been acted upon (i.e. treatment fully introduced), so a case-review as she was re-entering her last year now recognised what had still not been understood/explained or been resolved. It was only then apparent to the therapists that what before they thought had been fully understood had in fact not been (Joan Didion, a journalist, compared “the unexamined fact [it’s] like a rattlesnake; it’s going to come after you!”).
Having once dismissed the idea, to finally accept that an underlying ADHD, at least as a Disposition, was in fact probably present: it may have potentiated the young woman’s PTSD due to past trauma, for which treatment had been provided. Acting not just as a vulnerability factor but also now as a perpetuating factor (facilitating and maintaining the tenacity of her manic defence, deflecting the intense emotional distress experienced in early childhood by her prolonged exposure to domestic violence). The previous formulation (and subsequent treatment planning) had been incomplete; the review had belatedly ‘thickened’ the therapists’ description of the problems; a trial of methylphenidate was introduced, after which educational progress finally accelerated.
An inpatient with Borderline Personality Disorder: a thirty-seven year old woman admitted to an acute psychiatric ward under a Short Term Detention Certificate following renewed suicidal threats and life-threatening parasuicidal behaviour. Apart from one previous admission when she was detained for several months, after most of her many admissions symptoms quickly subsided. Her husband (a storeman with an alleged drink problem) had never met the Community MH team, but has been observed to sometimes visit her when she’s on the ward.
At the team’s request, a systemic therapist came to meet the couple, arriving unannounced on the evening when all knew that a ward-round next day will decide whether to discharge her or to apply for a CTO to full case description, and to exploring/expanding communication.
The systemic therapist introduced herself, the purpose of her visit, and after establishing their agreement suggested the couple continue to talk together about their situation ‘so I can get a feel of your concerns’.
Husband: so what do you think, will they apply for an Order?
Patient: don’t know, we’ll have to wait and see
Husband: are you feeling any better then?
Patient: not sure – maybe. I don’t know. We’ll just have to wait and see what they say
Systemic therapist: everything seems very uncertain just now, as if neither of you are feeling in charge of what’s happening
Patient and her husband agree
(as the therapist gather her thoughts) Husband: do you want me to bring in more clothes?
Patient: I don’t know. I might not be staying. No, you better had. But not that black lacy thing you brought me in last time! Drawing him back (he had turned away, so had missed her wry smile to him) she asks, Are you going to your brother’s at the weekend?
Husband: don’t know, probably. Depends upon what the bairns want – Sean’s got his football, don’t know about Heather
Patient: she’ll be staying at her boyfriend’s again?
Husband: I suppose so (looks towards the corridor leading out of the ward)
Systemic therapist: neither of you feeling in charge of what’s happening? Not about each other nor about the family
Patient and her husband agree
(as the therapist gather her thoughts) Patient: can I have a smoke? (her husband passes her a cigarette; she watches him digging in his pocket for a light, looks toward the smoking room but then sits back and puts the cigarette in her pocket, and looks down at her lap)
Husband (after a silence): who’s that woman across the way – the one who’s looking at us; do you know her? (looking up, she shakes her head) what’s she in for? (pursing her lips, she shakes her head again, a silence follows).
Systemic therapist: what happened just then? you (the patient) asked him for a smoke, he gave you one, I thought you were then going to get up, you didn’t, then he asked you about that woman, which seemed to upset you. I’m here to help you understand how things go wrong, and I’m really puzzled about what just happened. Can we go back to … well maybe to when you didn’t get up? Am I right, you were going to get up and leave but you didn’t? (to the patient, but looking to her husband too) do you know what I’m talking about? (both nod) Can we try to talk about what happens between you, using that as an example?
Patient: I thought he wanted me to stay with him. He obviously didn’t!
Husband: I thought you didn’t want to
Talking breaks off for the arrival of the tea trolley, then resumes. Several meetings more were required to establish an adequate formulation (not in time for tomorrow’s ward-round!), but that hastily-arranged meeting had got off to a good start and findings emerging from the next meetings could be fed back to the ward-team to shape further joint problem-solving.
Incontrovertibly, this case illustrated systemic issues of considerable relevance to the patient’s psychiatric care: on the complexity of communication, capacity for intimacy, emotional regulation, care authority and control (or power and helplessness) – set in a situation all too recognisable in psychiatric practice. That is, how repeated self-harm, organisational interventions and diagnosis (in this case Borderline Personality Disorder) combine over time in a circular way, whilst over that time most individual professional responses had been linear.
Whatever individual contributions the patient’s husband unwittingly makes to their relationship impasse (which most certainly includes his avoidance of any direct contact with his wife’s health professionals, the reasons for which hadn’t been elicited), like him most partners bring little detailed understanding of how past experiences profoundly impact individuals. If a family is to break out of the circular unproductive interactions so familiar to them, family members’ greater understanding is necessary. A ‘thickened description’ need not be difficult to understand, since its task is to make sense of the problems that brought them all to the department.