III - Family Psychology & Family Psychiatry - Psychotherapy
Types of Benexperiential Therapy
The best diameter to take is that of the period in time from which psychopathology arises. This could be: (A) at the level of the preceding family; (B) at the level of the present famil; (C) at the level of the succeeding family.
In each type, the therapy is linked with the time at which the events occurred, past (antecedental), present (actual), or future (anticipatory).
Therapy concerned with the resolution of events that occurred in the past. These are antecedental events, hence “antecedental” therapy.
Therapy concerned with the resolution of events in the present. These are present events, actual, hence “actuality” therapy.
Therapy concerned with the resolution of events that could occur in the future. These are anticipated events, hence “anticipatory” therapy.
(A) ANTECEDENTAL THERAPY
Therapy turns around resolution in the adult family members of the present family attitudes springing from the preceding families. Therapy is conducted with the preceding family or in its absence, by discussion concerning it.
The aim can be:
1.Complete resolution. A state of complete emotional health is restored to at least one partner of the presenting family. An example is:
A wife presents with depression. Examination exposes many other symptoms, both organic and psychic. Exploration reveals a difficult marital situation which has come to a head recently. It has been precipitated by a change in family circumstances, whereby it had been agreed that husband should emigrate in order to obtain a higher standard of living. The attitudes at work were – husband’s inadequacy, husband’s anger, husband’s sensitivity to being ignored, wife’s ambition, wife’s withdrawal. Briefly, the sequence of events was – wife’s ambition demands a higher standard of living, husband agrees to emigrate; his inadequacy is appalled at the risk he is taking and in his insecurity he becomes angry; husband’s anger makes wife withdraw; her withdrawal, because of his sensitivity to being ignored, makes him more insecure and angrier; the situation escalates, until she collapses with psychonosis in which depression is a marked feature.
The attitudes at work here spring from their respective families. Husband is the product of a family where the mother left the father because of his belligerence and so the patient was thrown into the care of this angry father. His father’s anger frightened him and yet this was better than his father’s ignoring of him in preference to his older brother. From this situation came inadequacy, his sensitivity to being ignored, his anger as a coping device.
His wife came from a family where the father ran off with the maid and subsequently married her. He lost his fortune. He became alcoholic. Standards of living fell. Quarrels were acute between husband and wife. The little girl coped by withdrawing and thus not being involved. Her father was kind to her and she identified with his aspirations. From this situation came her ambition to retrieve the family fortune and to withdraw from anger.
Each marriage partner represents his or her past and the weaknesses of each have to be played out in the present family. Further exploration revealed more handicaps, as well as assets, in both.
Therapy began by resolving the present immediate situation provoked by the decision to emigrate. This restored harmony to the standard of the pre-breakdown level. Stopping at this point would have left therapy at the level of dealing with the trauma in the present. Therapy could have gone a stage further; by dealing with the elements causing disharmony in the marriage, what is termed “focal resolution” (below) would have been achieved. In this case it was decided to go beyond this and to deal with all the unsatisfactory elements in both marriage partners arising from the preceding families. The aim was an ambitious one. Both were to receive a substantial guarantee against breakdown in most situations. Both were to be “made whole”. Technique is to be discussed later.
It is important to emphasise that even the wealthiest of communities and the best provided are only occasionally able to undertake this time-consuming enterprise which is so expensive of resources.
2.Focal resolution. Here the purpose is to effect a resolution in only one, two, or several elements coming from the preceding family and causing disruption in the present family or in the life of any one individual. An example is:
A wife presents with frigidity of one year’s standing. In addition she is depressed, she has anorexia, insomnia, amenorrhoea, etc. Furthermore, her husband is irritable, lacks concentration and his standard of work has deteriorated to the point where he has been warned that he may lose his position. Psychonosis in the children can be surmised from the boy’s enuresis and the girl’s asthma, starting in the last year.
Sequence of events becomes clear only with the exploration of the preceding families. In the mother’s family she was the only child of an agitated, hypochondriacal, rejecting mother, and a kind but withdrawing father. Faced by rebellion in adolescence by her daughter, mother used two weapons against her – feigning illness and making her feel to blame for it. These would always precipitate anger and depression in her daughter. Father came from a family with considerable emotional assets.
The immediate situation turns around a quarrel between the maternal grandparents. Grandfather threatens to give up his job and this threatens his wife’s standard of living. Maternal grandmother develops ulcerative colitis. She turns to daughter for help and daughter reacts as she did in adolescence to her mother’s illness – she becomes depressed. She loses appetite for life, food and sex. Husband, not understanding, reacts to her rejection of him. Marital tension and mother’s state leads to disturbance in the children.
Here, the resolution turns around two elements – guilt and sensitivity to mother’s illness. Grandparents are seen together, the quarrel is resolved. The ulcerative colitis clears up in maternal grandmother. Mother has no maternal grandmother illness to react to and her depression immediately clears up. Sexual intercourse is restored. Father responds. The whole family climate improves.
To guarantee against future breakdown, mother and grandparents meet to resolve mother’s feeling of guilt springing from use of illness by maternal grandmother. Parents of the present family, and then the whole family, meet to discuss the process that led to the impact on their relationship together with the children. Vector therapy is now possible – they ask advice as to whether the position is advanced by their moving to another town. This is advised, subject to discussion with grandparents, as it will reduce and formalise contact. Grandparents can tolerate the move, but want assurance about contact from time to time with grandchildren.
Here, the therapy is limited – only some elements coming from the past are resolved. The parents are not “made whole”, but the elements from the past that disharmonise family functioning are eradicated. You will note the flexible employment of therapeutic platforms – individual interviews with mother; dyadic interviews with maternal grandparents; family group interviews involving mother and her preceding family; dyadic interviews with parents; family group interviews with present family; vector therapy.
The above illustration involves a family. Occasionally, focal therapy is a matter for an individual alone. An illustration is:
In the course of family group interview, it emerged that the father had a disturbing secret never before discussed with anyone other than his wife. This was that he found it impossible to urinate if someone else was within hearing. This defect was of no concern to the family, but it was highly inconvenient to him. He asked for help. Exploration in individual interviews revealed that as a young child he had a very irritable, aggressive and hated governess. She would sit him on the pot in front of her chair and from behind coerce and demand that he pass water. He found great difficulty in doing so and the same difficulty has continued whenever anyone is within earshot. At school he contrived to get round it by asking to be released from the classroom during lessons, so that the toilets would be empty of other children.
Here, the focal therapy is continued with an individual alone.
It follows from the above examples that any of the following interviews can be employed – individual, dyadic and family group as circumstances determine. In addition, multiple family or general group therapy may be indicated. Furthermore, any of the above can go hand in hand with vector therapy.
It can be seen that A (2) above is a much more manageable operation than A (1).
(B) ACTUALITY THERAPY
At this level concern is primarily with happenings in the present family. Therapy is concerned with handling psychic trauma arising within and without the family in the present.
Psychic noci-vectors may arise in the global family transaction, in a relationship between two family members, and from outside the family. The present psychic noci-vectors act on a sensitivity coming from the past.
A few illustrations are given:
A mother presents with depression, the onset of which can be dated exactly. Her daughter has married into a much higher social set. Her patronising attitude distresses mother. The depression dates to the minute when her daughter telephoned that she had “arranged” a Christmas vacation for her mother and father.
A child finds himself bullied at school or unfairly accused of some misdemeanour.
A third party intervenes in a marital relationship.
A mother finds herself in employment where she is aware of pilfering by a fellow employee and is caught between loyalty to management or to fellow employee.
A father is all set to be ordained in the Church and then unexpectedly finds that he has received homosexual attention from a number of men, begins to suspect the nature of his own sexuality, has grave doubts about his suitability for ordination and develops a psychosis with acute anxiety.
Treatment at this level restores the family or individual to its pre-trauma standard. In some families this standard of health is very high and they were reacting to a massive or uncommon trauma. Other families have varying degrees of psychonosis resulting from the past. The management of present trauma does not of course change this pre-trauma standard.
The above may be practised in conjunction with therapy of the preceding family, eg in the last example above, father’s oversensitivity to homosexuality may be due to misplaced ideas of sexuality in his preceding family and this may require resolution.
The above can also go on in conjunction with vector therapy to be discussed later.
(C) ANTICIPATORY THERAPY
Here, the intention is to concentrate special attention on guaranteeing the health of the children who will be the participants in, and founders of, succeeding families. Children, as they represent the future and are more amenable to change, should always be given help. However, there may be times when therapy may be possible only at their level; eg the parental problems may be intractable, or intractable with the facilities available, or the parents may be unco-operative. Thus, for a variety of reasons, a situation has been reached when one must “cut one’s losses” and treat where one can.
An illustration is as follows:
A woman loses her husband in World War II. In her loneliness she marries a man a great deal older than herself. She quickly realises her mistake. Her elderly husband anticipates her possible desertion and makes her pregnant. She stays “for the sake of the child”, but rejects the child at birth – indeed she propels him out at the first uterine contraction with consequent cerebral haemorrhage in the newborn child and resulting limb paralysis. Following birth she rejects her handicapped child, who presents as a highly psychonotic and physically disabled child at the age of three. The family situation for a variety of reasons proved to be intractable. Father was unco-operative. Mother had no interest in the child. The child required urgent and considerable help, which was given in terms of individual therapy for him, general supportive interviews for mother, leading to vector therapy at the earliest opportunity, whereby the interviews with mother made it possible for her to accept that the child be brought up in a foster home.
In the next illustration the family is investigated as a whole, but therapy again concentrates on the child who represents a succeeding family of the future.
A man attempts suicide. An inadequate man, he married a balanced, kindly woman. He began to profit from her care. Then she became pregnant, in response to which he developed an urticaria and was ill in various ways for most of the pregnancy. He displayed no interest in the child other than intense jealousy. Christmas came and with it the maternal grandparents to bring gifts for the baby. Husband locked himself in the kitchen and when he eventually emerged two days later, demanded that the baby should be given away. She refused. He attempted suicide. He is adamant – she must now choose the baby or him. Interviews with both separately, then together, support her in making the only decision possible – she must keep her baby and is well able to look after him on her own. (Supportive help for mother and advice on remarriage will still be helpful, if resources allow it.) The future in terms of the child has the highest claim.
Work at this level can go on in conjunction with work at the two previous levels and in conjunction with vector therapy. It may be useful to emphasise again that treatment at this level, if always effective, could guarantee the health of succeeding families and thus of society in the future. Clearly, this can only arise by a steady improvement over a number of generations as therapeutic efficiency and resources increase. The work will be speeded up by using extra-interview procedures in vector therapy.
Yet again it may be necessary to emphasise that what is possible may not be dictated by the tractability of the situation, but rather by the resources available. It is unlikely that the highly skilled resources required to operate at level A (1) for all will ever be forthcoming; by that time work at level (C) will have made them unnecessary. To have, as in the present situation, ill-trained people handling the resources available is not only ineffective, but dangerous.
1. Indicator Therapy.
From time to time an indicator, a sign or symptom, of psychonosis, will itself be sufficiently life-threatening, inconvenient, painful or giving rise to such serious secondary issues as to require management or therapy in its own right. This can happen to an indicator of a psychonosis arising at any of the levels mentioned above. The indicator may be somatic or psychic.
In the case of a somatic indicator, measures can range from an hypnotic drug to relieve crippling insomnia to emergency major surgery for a perforated gastric ulcer.
The following illustrates a psychic indicator requiring help in its own right because of its social repercussions:
An adolescent boy presents with a propensity to steal women’s clothing from washing lines in his neighbourhood. With these he masturbates while conjuring up images of the desirable young woman to whom the clothing belongs. Soon he is caught in a police trap. The court seeks help in his management. The indicator of his disturbed behaviour, the stealing of clothing, has serious social and personal secondary effects – it promotes shame and guilt, and may affect adult sexual behaviour.
Exploration reveals that there is a severe father/son conflict. Father deplores most of the customary behaviour of an adolescent. The son’s behaviour is a coping device inevitable in this family situation. His father, because of an anomalous upbringing by a maiden aunt, deplores any sexual expression in adolescence. His mother on the other hand is a passionate, warm, outgoing person. The mother implies the need for strong heterosexual expression, the father makes it impossible. Thus, the boy is forced to resort to strong covert behaviour.
While there are other manifestations of disturbance, the presenting indicator of itself warrants attention because of the secondary effects. Thus a family interview is employed to relieve the son’s shame and guilt. Both therapist and mother emphasise again and again the inevitability of the son’s behaviour in the circumstances. Time, repetition, and insistence achieve the goal. Normal sexual expression is desirable. After a number of interviews, the therapist and the co-therapist, the mother, slowly and gently bring father to a position of security and relatedness where he can allow his son a dispensation – he can behave as other adolescents do and bring girlfriends home. No further sexual misdemeanours occur. The son still has other disturbing behaviour arising out of the father/son relationship, eg insomnia, a rash, panic attacks, lack of confidence. Having dealt with the damaging indicator, the father/son conflict is largely resolved through vector therapy – the son pursues his education away from home – a situation also of advantage to his newly gained freedom to behave in a normal fashion in heterosexual activity. Indicator therapy has been followed by therapy at levels (B) and (C) above. Lack of resources may, however, limit the management at any stage.
Occasionally indicator therapy can be achieved through behaviour therapy based on learning theory. While sometimes valuable, its limitations can be seen in the example above. To put the boy through a procedure that would prevent him stealing women’s clothing, eg by aversion therapy, while useful in avoiding the social repercussions, would still have left him with his sexual frustration, and the disturbed behaviour arising out of the negative and destructive father/son relationship. Aversion therapy does not resolve the psychopathological process. But there are times when it can help in indicator therapy – even if, as sometimes happens, there is a substitution of indicators; the new indicator may be more tolerable than the old.
2. General Supportive Therapy.
All persons and all families respond to encouragement, support, hope, praise, affection, interest and comradeship.
This may be all that can be offered in a particular situation and often in the past it has been the only ingredient of therapy, referred to earlier as the G factor. In all the measures mentioned to date, it is an essential and valuable component and, when the resources are denied, it may be the only measure possible.
Attention will now turn to further aspects of therapy. The therapist is considered first; this is followed by consideration of the organisation of therapy; and finally consideration is given to some elements in technique.