We present the treatment of a juvenile with an acute onset of symptomatology by focusing on the dysfunction of the hole family and by psychotherapeutically intervening on family as well as on individual level.
We feature issues such as:
Possibilities of preventive intervention in the context of a private physicians office.
Combination of psychotherapeutic approaches.
A Systemic view on psychopathology and problem definition.
Working therapeutically with a subsystem.
Co-therapy: Presuppositions and features
For all of the above we aim to demonstrate essential questioning as well present a multi-focus and multi-level way of treating in order to prevent the symptoms evolving and increase the psychological functionality of the identified patient and her family system as a whole.
Our Therapeutic Context
It is the context of a Child and Adolescence Psychiatrists private office that was established in 1995. The staff is the writer and his colleague K.D., who is a family therapist. We are both thoroughly trained in Systemic Approach and from 2005 are also involved in Psychodynamic Approach in Psychotherapy (trainees, analysants and under supervision). We have a common professional background from 1988 and very close personal relations. Our collaboration focuses on working together as therapists with couples, families and groups and also as trainers, constructing seminars of experiential learning. We had supervision from our teacher Vaso Vasiliou till 2007 (when she passed away) and since then we are functioning as a self reflecting couple of peers. For the individual therapy we conduct we are supervised (either together or separately) by G.P. (Psychiatrist, Psychoanalyst).
"Kleri and her Family."
A Clinical Vignette.
(Some years ago)
We receive a call from the Mother who is clearly upset:
"Kleri is staying in bed with her door and the shutters closed for 4 days now. She doesn't want to go to school. She is not talking to us. She doesn't want to be bothered by anyone. She cries! She is sad and angry. She only accepts food."
"I don't know what to do!!..."
*In order to **retain ** the anonymity of family members (for personal data protection), we have changed their names and professions.Parents:
Father: 52 years old, salesman working at a big firm.
Mother: 48, notary.
Divorced for 13 years now. They stayed together for 4 years.Children:
Kleri, only child, 15 years old. She goes to college. Excellent student.Ancestors:
Paternal grandfather passed away many years ago from cancer. Maternal grandfather 3 years ago, also from cancer. He is described as eccentric and ambiguous concerning his values and principles..
Maternal grandmother, 72 years old has been diagnosed with depression and is on antidepressants.
Paternal grandmother is around 90 years old.
Households: Mother, daughter and maternal grandmother live together. The apartment belongs to the grandmother. There is another smaller apartment at the same building which also belongs to the grandmother and remains empty(!).
Father lives with his companion at his own house for about a decade.
Father's presence is still intense in the maternal house. Sometimes he shows up without notice. There are several disagreements and arguments without any fights. Fair enough communication.
The father is described as "indiscreet". He sometime sleeps with his daughter in the same bed, regardless of which home they are in. He wants to have control and talk "like friends" with his daughter.
Mother is very "controlling" (she phones 5 times when her daughter she is out with a friend).
Relation with Ancestors:
Mother is in a difficult position concerning her father's inheritance. She is trying, for many years now, to clarify it and put it in order. She is very angry with him. "It seems to me like moving a mountain that I have to visit his birth town" she points out.
The relationship with her mother entails lots of ambivalence. There is a general dysfunction in communication and boundaries between them.
The grandmother is also considered "indiscreet". She enters her granddaughters room without knocking. She, in fact, keeps her own closet in there!
"Therapy starts before therapy". This is a self-referential, paradoxical statement declaring, through an exaggeration, that therapy begins before the therapeutic contract has been established or has become conscious. One could consider that therapy begins when the one asking for help gets the first piece of information about the therapist(s). It is then that images, fantasies, emotions and expectations are starting to emerge. These are going to influence our first conversation. For the therapist, therapy starts a little later: When the patient calls.
So we listen to this mother immersed in our own view: Our therapeutic approach. We can't help it and we consider it helpful that our first session would be with all members of the divorced family (Father, mother and Kleri) together.
We suggested to the mother to talk to the father and her daughter in order to attend the session together. The daughter knew that her mother had called us and was already eager to come.
First (Family) Session
People in the room: Therapist, Co-therapist, Parents, Daughter.
Father: Very emotional. He cries when referring to the way the 3 women live together.
"They should live without grandmother. There is an apartment for her downstairs" he claims.
Mother: She speaks freely. She calmly expresses her thoughts. She seems receptive and cooperative. She agrees that living with the grandmother in the same house is a problem-creating situation.
Daughter (Kleri): She remains almost silent. not even replying to our questions. When we address her she starts crying (tears are falling without a sound or a wince).
A new element that is unveiled by the mother is that Kleri is having bulimic episodes . The mother also speaks about her struggle to sort her father's inheritance. She describes her father as a peculiar person and her parents’ relationship as extremely confrontational. They were separated several years before her father died.
She was always enmeshed in this relationship.
Our stance is mainly enabling emotional and verbal expression. We experience Kleri's angst and we are worried about her difficulty in expressing emotions with words (her ability to symbolize). Father is experienced as emotionally fragile and mother as the "strong" one.
We are trying -as therapists congruent with the systemic approach- to highlight joint responsibility and to reframe the symptom.
We refer to the "father-daughter sleeping together" issue without any kind of confrontation or straightforward disapproval.
Mother and Kleri agree that they need help. The mother in order to help her daughter, and the daughter in order to deal with her psychological difficulty. Father considers that he doesn't need something for himself. He points out that the solution will come with the rearrangement of the way the 3 women share their everyday life.
Therapeutic View-Forming; Therapeutic Hypotheses; Evaluating the Therapeutic Context's potential
Mother seems to have put herself aside while involved in the previous generation’s dysfunctional conflicts and her own mother’s emotional needs. She holds the role of enmeshed child. Her anxiousness to resolve her parents’ relational conflicts has existed for some decades now. At some point her parents were separated. Her father left for his hometown -a small village- where he spent most of his time. Then her mother had her first symptoms of depression. Father was functioning as if he didn't care for the rest of the family. He created several relationships with other women, of which his wife was aware. He also went into debt and various legal problems. After his death, all these fell upon his daughter. So she studied law(!), something necessary for untying her father's knots. Something that she still uses in order to untie personal and relational parental knots.
How did these relational dynamics in the previous generations affect Kleri's generation?
A daughter (her mother) enmeshed (Minuchin S, 1974) with parental difficulties functioning either as a referee or as a protector. A mother (her grandmother) victimized, unable to entrench her role. A father (her grandfather) who escapes, separates from everyone, functions as a single person.
When Kleri's father leaves home, her mother brings in her own mother. Is it the devotion to her protective role? Is it her need to "have" her own mother? Is it an unconscious assignment of Kleri's upbringing to her mother as a payout for her services to her? Is it just another donation to her?
However, the ** repetitive relational pattern ** seems to be ** _enmeshment among women _ ** _with the simultaneous withdrawal of the men. _
Generations mix up. Roles are exchanged. Crucial living space is abolished. Feeling of loss is increased. Solitude is established. A "unity in isolation".
Kleri's father is halfway out of this system. He has created a new life context without being able to fully withdraw from his former one. He stands among five women (Kleri, ex-wife, present companion, companion's daughter, mother). What this might mean about his own needs and emotional gaps? About his being chosen by Kleri's mother?
He lays claim to Kleri, wishing to share her bed. Kleri has "the name of his mother". He acts out oedipal fixations istead of stopping at fantasies or at least at a verbalization of jealousness (in the course of the treatment he starts articulating). He is also in-between generations. His emotional investments are addressed undifferentiated to all three generations.
Grandmother represents the chronic dysfunctional part of the system. Fragile and victimized as a result of her relation with her deceased husband. It is obvious that her involvement in the next generations’ lives gives her a kind of existential meaning. Can she become aware of the way she becomes a burden to them? If not, who is to tell her so? ( If her daughter is not able to do so, it comes to us to be prepared for it).
It seems as if granddaughter and grandmother have a role in common. The role of the victim. They also have some fundamental differences such as: (a) the granddaughter enacts dramatically this role (sequestration-regression episode, bulimic attacks) declaring need for help; (b) her mother features a bright functional part of self, able to hear her daughter's claim and offer help to all, including herself. The amount of "power for life" she possesses prompts her to make good use of that part of the self; c) contemporary cultural context allows seek for help outside family or neighborhood borders.
We conceive Kleri's symptoms as a "cry for help", addressed to the whole family system. Sorrow, isolation, emotional locking, flirting with the "death chamber" and even the disorganized relation with food taking still don't shut down all the doors. She leaves an, easy to detect, opening for a glimmer. It is her wish for help. A wish that includes the whole family.
We conceive their request as a need for rearrangement, for re-construction of their way of living. Their life context. They have co-constructed a context in which they suffocate. Kleri declares it first in a dramatic way. But mother is also dissatisfied with her life. Their relations contain violent intrusions, loss of boundaries and at the same time the inability to assert them ** . As if it is forbidden for separate lives to exist. Only a common one is allowed. ** Kleri is the one that first expresses all that because —among other things— she is in a life phase dominated by the need for differentiation (Bowen M., 1972). Differentiation and growth through investing sexually and emotionally out of the family-parental system.
The issue of bed sharing between father and daughter is undoubtedly characterized as urgent. But we feel that in order to maintain alliance with the father we have to treat it with great delicacy.
We perceive mother’s role as central for the system. We are aware that we must not repeat the transgenerational trauma (Tisseron S., 2011. Millech T., 2011) that is represented in all the generations present. Her power, her self control and her ability for insight tempt us to do so. But it's time that she gets attention and care. That she has to rest "on somebody's arm" for a while and distribute the burden she carries to those who should bear them.
The instinctual knowledge of the father and his problem solving proposal should be subsumed to the "healthy parts" of the system and be deployed.
We feel that we have to built coalition with all members of the system by listening to their claims and respecting father’s need for distancing from the therapeutic procedure.
Exploiting our therapeutic context's abilities we decide to suggest individual therapy for the mother and Kleri (mother with K.D. and Kleri with me) and at the same time to ask for their availability for another family session when asked by us or requested by them.
We conduct a confidentiality contract, pointing out that:
The two therapists are not going to have detailed discussions about the content of the individual sessions. They could discuss about the progress of the therapy in general, and if they decide that something more specific must be discussed, they will first obtain the clients’ agreement. In this manner we are trying to exclude any kind of "triangular communication" (Bowen M., 1972) which brings back the enmeshment pattern, and support the establishment of a trustworthy relationship with both of them but mainly with Kleri, addressing her need for autonomy and separateness.
Course of Treatment
Individual therapy starts immediately on a weekly basis.
Kleri is generally silent during the sessions. She needs a lot of encouragement in order to start feeling more comfortable. She answers questions more than initiating a conversation. After a few sessions she starts being a little more open in expressing thoughts and emotions. She seems sad and angry: "I press 'delete' to my feelings" she says. Then she starts articulating her anger concerning her parents and her grandmother, whom she describes as being very pushy. She relates her anger with her bulimic attacks: "When I get angry, I eat". She talks about the pressure she experiences from her father also. Pressure for intimacy, for being "like friends". Her complaint about her mother is that sometimes she becomes very controlling or disrespectful by conveying her secrets to others (like she did with her friend X. and her grandmother).
She states certain desires: She wants to have her own house, to see her parents once in a while, to involve herself in music.
She talks about the shame related to her body and to her father's new companion.
Her trust is rising: "Nobody else knows the things I am telling you" she declares.
Mother talks about her entanglement with her parents, especially with father’s inheritance. She admits that she committed mistakes concerning her relationship with Kleri and gets, rather quickly, into the inquiry about herself, her life and her relations. She expresses her emotions in a very fruitful way.
Benchmarks during the course of the treatment.
After the 3rd session father asks Kleri to sleep with her and Kleri refuses.
After the 5th session, after hearing mother's suggestions and claims, grandmother agree to move to the other apartment. At the same time mother decides to visit the town her father used to live in an effort to resolve the financial problems she inherited.
At the 8th session Kleri talks about changes: "I don't want to be sad. I've started spending a little more time with a friend of mine".
After the 8th session we have a crisis: Father says to Kleri: "I want my child", reacting to her effort for establishing new boundaries and be more detached.
Father calls me one evening : "I am afraid I am losing my child!" he declares.
We suggest a second family session.
I work this out with Kleri and she easily accepts it. She only stipulates her right to remain silent, which is accepted of course.
The family session takes place after Kleri's 11th session. It doesn't last for long, given the fact that the main goal was to allay father's fear about the "loss" of his daughter- to me as a competitor, i.e. his 'fear of replacement'. So we thought thatwhat was really asked of us was to accept his insecurity and help him experience me as his ally. At the same time we had to respect and encourage Kleri's effort for increased autonomy. We tried to ** reframe ** (Minuchin S.,1981) the distancing as a successful attempt for more autonomy, giving credit to the father for his being able to endure and “allow” it.
From the 12th session onward Kleri speaks about hanging out with friends: "I start feeling closer to my friends, but this is strictly between us".
From the 14th session she starts talking about the closure of our working together. She wants to stop the sessions.
We stop after 17 sessions. We arrange a follow up session in about one month.
(After one month)
"I feel good, in general" Kleri says."The only thing that bothers me is that my grandmother is still intruding into my room".
The bulimic attacks are less frequent (about once a month). She connects them with "the house and the loneliness".
We agree that she will call me whenever she feels like it.
Mother continued her therapy for about one and a half year. A few weeks before leaving the therapeutic procedure she starts a love affair which seems like having a good potential.
Last time she called us was two years ago. She describes both her and Kleri's lives as being a lot better. Kleri "has also created a loving relationship with a boy and after passing some difficult exams she is now a student at the University."
Nowadays it is more or less accepted —setting aside the concept of therapeutic neutrality, with the therapist as a ‘white screen’— that we should consider the therapist as a person involved in the therapeutic process carrying his/her own feelings, thoughts, fantasies, desires, preferences. A person constantly interacting with the patient/s. A person influenced and influencing through the therapeutic process.
In systemic working with couples, families and groups, interactions are multiplied, producing a therapeutic field with more complexity than in individual therapy.
This brings us to the important question of what kind of relationships are produced in this kind of therapeutic context. I believe that the fundamental psychoanalytic concepts of **transference ** and counter-transference are experienced in certain ways by any person involved in a psychotherapeutic situation (and maybe in any other kind of human relation). While these concepts are thoroughly developed when they refer to a relationship between two persons, things become a little vague when trying to apply them to a systemic context (Gerson M.J.,2010). Transference develops simultaneously on different levels of relating. Nowadays, it seems that there is no major disagreement between systemic therapists for the necessity of therapist's ** insight ** . This insight refers to the relational process taking place ** between persons ** as well to the ** intrapsychic ** level of each person. That includes what is going on between therapist-patient and between patients as well (Kalliteraki E, 2015). It is obvious that it is extremely difficult and sometimes even impossible without a therapeutic team working together.
In our case, after receiving the request for help, we raised the following questions: a) How do I feel right now about what is happening, b) how is this feeling connected with each family member (connected with their feelings, thoughts, fantasies, expectations) and at the same time with the relational system they have constructed (roles, positions, alliances, communicational forms, hierarchy, history, c) how could I achieve a helpful and fruitful connection between us, d) how do I feel with my co-therapist and what makes me feel this way.
In other words, an attempt at:
a) increasing awareness about the identity and potentials of our own therapeutic context,
b) specifying characteristics of the patient's intimate relationships system (communicational patterns, roles, hierarchy etc.)
c) ** Joining ** (Minuchin S., 1981) and creating therapeutic alliance with each member of the system,
d) respecting the way the members of the family define their problem, (including their own differences about that) and at the same suggesting a new way of viewing it (reframe and propose a new systemic model about the meaning of symptoms),
e ) maintaining a constant procedure for more insight through self reflection, as our aim is also to become aware of as much facets of reality as possible.
In the case presented, symptoms and calls for help could have been dealt with some other way. It is our approach and our professional and human potentials that led us to a certain response. We tried to exploit our ability for co-therapy both for family and individual therapy.
The work we did with Kleri left us with some open questions. When she stopped her therapy I was worried. I could not accept that something important had been done. I thought that "she walked out leaving things undone". I was wondering about her abilities to function psychologically. "Can she do it without me? I wondered, or is it "can I do without her?" just as her father wondered in his own way. Was I experiencing father's narcissistic trauma? Leaving me after leaving father’s bed was something really worth reflecting upon.
What soothed us was the fact that Kleri had taken some great steps in a very short time: she became able to trust, to start recognizing and expressing her feelings, she put boundaries to her father, she moved successfully towards her peers, she became aware of certain psychological difficulties, she articulated them and started creating connections among them.
What seemed very promising was the positive connection-alliance with the Mother. Her great latent ability for setting boundaries and self reflecting and finally her commitment to work through not only as a parent but as a person in general. Her stance lessened our worry about father's fragility. May be we 'used' her, in some way, as an intermediate and a regulator of our relationship with the father. There was, of course, a decisive difference from the way she had been 'used' by her parents. In our case she was having her own supportive-empathetic context, where she could openly speak and work- through being accompanied in a therapeutic relationship. That helped her to break free from from her parents’ affairs and promote her self -differentiation. Mother and daughter where marching together, towards a new "relational condition" concerning both the relation between themselves as well as with others.
Given that prevention of children's psychological dysfunction is directly connected with prevention of parent's psychological dysfunction, the issue of the role of the therapist emerges. How shall we include parents in the preventive procedure? There are several answers to that, from organizing educational seminars about parenthood to clinical treatment for severe parental psychopathology. What is crucial is the way we contribute to the procedure of the parents undertaking their responsibility. It is crucial because this leads to the way they undertake their responsibilities and treat themselves in general. Becoming helpful to their children suggests that they should start openly inquiring about themselves and their lives. From my experience I can argue that the outcome of our preventive-therapeutic intervention is directly depended on that issue—to such a degree that sometimes it might not be necessary to work with the children, even if they have manifested symptoms (child's psychotherapy without the child).
The family session based on a systemic approach which focuses on the relations inside and around the family system, holding an "equal distancing" therapeutic stance for all the members of the family, does not blame the individuals but apportions responsibility for co-creating a dysfunctional relational network. In that situation everybody becomes "victim" as well as "abuser" and "savior" (Sakkas D., 2016) at the same time. This reframing seems to create a more appropriate context for the inclusion of the parents in the therapeutic process because it protects them from feeling extremely guilty.
The combination of psychotherapeutic methods seems to have worked positively for Kleri and her family.
Nowadays, many therapists agree on the need to combine psychotherapeutic approaches in a synthetic-integrative way (Gerson M.J., 2010, Slipp S. 1984)). It is really tempting as an idea, but under two presuppositions, I d' say: 1) You should have 'swam in the deep', whatever school of reasoning you use and 2) You should have in mind that more important than the reasoning system is the relationship you create with yourself as well as with the other.
One of the key factors in this particular therapeutic intervention was the ** co-therapeutic relationship ** . This allowed a high complexity multi-leveled collaboration based on the therapists’ alliance. This alliance works as a driving force for all the participants—during the session and between sessions. The image of the relational functioning is introverted as a relating paradigm as well as availability for complicated processes of transference and counter-transference. This image might further activate or suspend the therapeutic procedure's evolution (Roller, Nelson, 1991). At the same time this relationship depends on the relation each therapist has created with him/herself. That is, from his/her needs, psychological gaps and integrations achieved. Issues that demand an ongoing personal therapeutic process for both of them.
We could consider that, in the case described, the call for help has been dealt in a multifaceted manner.
The treatment was based on the evaluation and exploitation of our therapeutic context as well as on the evaluation and exploitation of the family's potential on a system and individual level.
Did we have a preventive effect? I don't know if that can be answered with accuracy because, I think, questions like "If this didn't have happened, what would have happened?" cannot have precise answers. Unfortunately, in our work as psychotherapists there is little room for certainties. We battle with possibilities and uncertainties. Our measure might be our experience and the articulated (oral or written) experience of our colleagues. Based on this experience, we claim that we may have prevented something. What could this be? It might be a worsening of Kleri's symptoms, the mother's breakdown, a worsening of the grandmother’s depression, a physical illness of somebody else.
Judging from the results, we can be certain that there has been a serious improvement in the lives of Kleri and her mother. There was no report from any other member of the family, so the question about their lives remains open.
We believe that crucial aspects concerning the outcome of a preventive and at the same time therapeutic intervention are the therapist's increased awareness about his/her own self, the dynamics and potentials of the therapeutic context and the help- seeker, through constant self reflection. But these aspects are really useful only when we find fruitful ways to implement them in multileveled, multi-focused human relationships.
Αs my colleague and dearest friend K. Dermitzaki used to say: "In the beginning (of time) there was relationship..".
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