Therapist’s Notebook

Editor’s Note: Cases are fictitious. Any resemblance to actual clients is coincidental.

The Case of Henry and Sarah
By Marlene I. Shapiro, LCSW-C

Sarah and Henry were high school sweethearts. Now in their mid-30s, they are married young professionals in Los Angeles. Henry entered college first, breaking up with Sarah so they could “experiment” with other relationships. In college, Henry seriously dated another woman, but Sarah had no serious relationships during that time. After Henry graduated, he split up with his girlfriend and within a few months, Sarah and Henry began dating again and decided to marry. Due to the demands of professional training and financial issues, they didn’t marry until seven years later. They are now established professionals, are financially sound, and have a new baby.

Sarah and Henry have experienced several family crises. Henry’s father abandoned his family when Henry was 2 years old. Henry’s one sibling, who is three years older, became seriously ill at the age of 12 but survived, later married, and is doing well. Sarah’s parents unexpectedly separated after a 30-year marriage when Sarah started graduate school; their divorce was contentious. While Sarah and her two siblings are estranged from their father, Henry reconciled tenuously with his absentee father. Sarah’s mother, Irene, remarried but lost a second husband to illness after three years of marriage. Henry’s mother, Lisa, never remarried.

Substantial financial differences exist between the couple’s families. Sarah’s family is wealthy, and divorce didn’t affect their financial status. Henry’s mother was left with nothing and struggled for years with legal and financial issues. Also, Sarah’s family was highly structured and obsessively organized. Henry once noted, “No one says no to Irene.” Henry’s mother was more laissez faire. She had rules but left room for negotiation, and if the breakfast dishes sat until she returned from work, that was OK with her.

Stress between the young couple and Lisa surfaced after Sarah’s stepfather died. While Sarah went through her parents’ divorce and stepfather’s illness, Lisa stepped aside. She thought it was normal for Sarah to want to spend as much time as possible with her family during difficult times, and Lisa participated in some of these family events. Eventually she felt she didn’t see enough of her son and Sarah, especially since they always stayed at Irene’s house when visiting for the holidays, and began to ask for more time at her home for holidays. She also worried about access to her grandchildren when they arrived.

Sarah was upset with Lisa concerning this decision and went along reluctantly but could not hide her distress about any separation from her own family. Visits were endlessly negotiated. Henry, who was stuck in the middle, tried to referee with little success. The grandchild’s arrival exacerbated the problem. Lisa felt out of the loop because the young family always stayed at Irene’s home. She pressed for more time, but Henry and Sarah believed they had made enough concessions. When the baby was 1 year old, Lisa “blew” and sent an ill-advised, angry e-mail to Henry listing the problems she believed were caused by Sarah’s resistance to more equitable visits. Communication ceased for several months. Henry and his mother resumed communication via e-mail because phone calls ended in heated arguments. Sarah avoided direct discussions with Lisa, but Henry made it clear that he spoke for the couple. The family couldn’t negotiate a solution, and a crisis was precipitated when the couple decided that Lisa couldn’t see the baby until their problems were resolved.

Lisa was frantic. She asked Henry to consider family therapy. He agreed to look for a therapist covered by his health plan, but after six weeks, he had not found anyone. He suggested a previous therapist the couple had consulted about this problem, but Lisa felt strongly that they should start out with someone new. The couple permitted Lisa to look for therapists. She found several good ones, but the couple presented more obstacles. They wanted brief therapy; they had very narrow frames for dates and times of the consult. They insisted they just needed a “good enough” therapist in their health plan and wanted to choose someone at random from their insurer’s list. Lisa resisted this and found a more promising referral.

Dr. Williams came highly recommended and met the couple’s requirements. Despite their adequate income and insurance to cover the cost of a therapist (and Lisa’s offer to split the fee), the couple objected to the cost, which was substantial since Los Angeles is an expensive city. Henry and Sarah refused to contact the therapist directly, expecting Lisa to settle things. After much discussion, Dr. Williams suggested the family negotiate a fee when they came in. When Henry and Sarah balked at this admittedly unusual suggestion, Lisa agreed to pay the full cost of the first consultation. The first appointment was made.

Dr. Williams had a challenging problem. First, how could he get this family into treatment? Using the strategic/structural model of family therapy, the therapist focuses on the family member who is deemed to have the most power to bring the family into treatment and keep them there for subsequent sessions. So who brought this family in—Henry, Lisa, or Sarah? It appeared to be Lisa, but since the couple was negotiating behind the scene, perhaps they all had a role.

Second, Dr. Williams called their first meeting a “consultation” and not a session because of a reluctance to engage in a long-term process. His business card indicated that brief family therapy was his specialty, and he expected this problem would need about five 2-hour meetings. Longer sessions underscored sober attention to this serious problem and provided enough time for everyone to talk and addressed the distance Lisa had to travel. The therapist would have more time for assessment and intervention, to deal with the high level of expressed emotion in the family, and to begin to develop therapeutic alliances. 

Dr. Williams was descriptive, clear, and positive about his experience and success rate to the point where he appeared to be somewhat boastful. This sometimes has a paradoxical effect on reluctant family members. The family’s unexpressed or expressed thinking goes something like this: “OK, he thinks he can fix this! We have tried everything. We are going to agree to this consultation to demonstrate how wrong he is.”

Finally Dr. Williams continually expressed a high level of concern for the family’s “urgent problem” as well as his desire to be as flexible as possible to accommodate them. The family has met once with him and while it was stressful and filled with a high level of expressed emotion, all parties agreed to return.

The above-mentioned maneuvers constituted joining with the family even before therapy began. “Joining is letting the family know that the therapist understands them and is working with and for them. Only under his protection can the family have the security to explore alternatives, try the unusual, and change. Joining is the therapeutic glue that holds the therapeutic system together.” (Minuchin & Fishman, pp. 31-32). “Joining can be a tricky concept to employ when a problem is acute and long-standing.” To take sides is to alienate the other person; to take neither side creates the risk of letting the conflict continue out of control, increasing the conflicting members’ sense of hopelessness.” (Minuchin et al, p. 42). It is a delicate, artful dance.

“When a family comes to treatment, it … is stuck. ... Demands for the status quo constrain the family members’ ability to deal creatively with changed circumstances. Adherence to rules that were once more or less functional handicaps the response to change. One of the goals of therapy is … to move the family to a stage of creative turmoil where what was given must be replaced by a search for new ways. Flexibility must be induced by increasing the system’s fluctuations … moving it to a higher level of complexity. In this sense, therapy is an art that imitates life. Normal family development includes fluctuations, periods of crisis, and resolution at a higher level of complexity. Therapy is the process of taking a family who are stuck along the developmental spiral and creating a crisis that will push the family in the direction of their own evolution.” (Minuchin et al, pp. 26-27).

— Marlene I. Shapiro, LCSW-C, is the program director of a partial hospitalization program for patients with psychotic disorders at Sheppard Pratt Hospital in Baltimore, MD. In addition, she sees patients and families in a private practice.

Reference
Minuchin, S. & Fishman, H. C. (1981). Family therapy techniques. Cambridge, MA: Harvard University Press.

Discussion No. 1
By Donna M. Ulteig, MSSW, LCSW, ACSW, DCSW

How well I recall my days of graduate school and the early professional years when family therapy colored the clinical landscape with excitement. While training at a field placement setting, our supervisors had us sculpting families, assigning seating arrangements, designing paradoxical interventions, and becoming the alter egos of family members. There was talk of structural family therapy and then strategic and systemic. I found myself puzzled by these complicated techniques that seemed to work mostly because of the therapist’s relational skills rather than the strategies involved.

Moreover, this was Madison, WI, the home of Carl Whitaker and his colleague Gus Napier, who demonstrated a more symbolic/experiential approach to treating families. Napier provided family therapy training sessions to those of us who worked in a highly specialized children’s treatment center that used behavioral methods to help children live successfully in the community. Later I became enamored with Maggie Scarf’s work and David Olson‘s Circumplex Model. More recently, John Gottman’s relational model has held some truth for me. It is no wonder that my ability to distinguish specific treatment approaches has diminished so that I must label myself as an eclectic. What I do now is such a broad collection of various approaches, it is difficult for me to look at Sarah, Henry, and family only through structural/strategic eyes.

This is what I see when I read about Sarah and Henry and their absent fathers, their mothers, and their siblings. Henry, whose father left when he was 2 (developmentally not a good time, if there ever is one), seems to have grown up in a “flexibly separated” (Olson Circumplex Model language) family, a type that is balanced and healthy, as evidenced by Henry being able to reconcile with his father and by his mother’s flexibility and now leadership in addressing the issue of better equity of family time. Sarah, on the other hand, comes from a rigidly enmeshed family, one in which parents are highly controlling, time together is emphasized, and negotiations are limited. Henry seems to have connected with Sarah’s family and in fact speaks for her with his mother. However, he and Sarah have not found a balance that effectively merges the two family styles and carries them through this developmental milestone and that of having a child.

All good treatment begins with an accurate description of the problem, which I approach by looking at family patterns. In both families there is a history of loss. Henry’s father abandoned his wife and two sons, and Henry’s mother Lisa had to assume the role of both parents. The family had a near loss of the older son when Henry was 9 and his brother was 12. It appears that emotional connections are important to Henry, so much so that he reconciled with the father who abandoned them. In addition, Henry reconnects with Sarah after college graduation and a period of disconnection in that relationship. His response to loss is to try to flexibly reconnect.

Sarah’s family, on the other hand, experienced more recent losses. When she was 22, her parents separated and struggled through a contentious divorce after a 30-year marriage. Her mother, Irene, remarried, and the second husband died within three years. One would suspect that Irene‘s grief was visible to Sarah and that Sarah was sensitive to her mother’s need to avoid further losses. She and her two siblings handled their parents’ divorce by becoming estranged from their father, one could assume out of loyalty to mother. I would conjecture that Sarah stays close to Irene to provide comfort to her and protect her from further loss. I ask myself, with Sarah’s family pattern of estrangement from the member who exits, is Sarah afraid that she would be banished if she spent more time with Henry’s family?

There is decidedly a failure to accommodate a new developmental stage, which becomes a crisis with Lisa’s blow-up about lack of access to her son and his family. When Sarah and Henry have a child, this problem is exacerbated. Lisa is banished from seeing the grandchild and is put in the position of being the potentially estranged person. Her drive, like that of Henry with his estranged father, is to reconnect. She flexibly persists until after a couple of months of negotiation about who the therapist would be, there is a family session (consultation) with a therapist and all agree to meet again. Here is the opportunity for family patterns to become more cohesive and flexible.

Given the agreement to work with the family therapist, who requests a commitment to five 2-hour meetings, I see a need for some consensus about a desirable outcome. The fact that Henry’s and Sarah’s parents want time with their adult children and their grandchild is a strength that predicts a positive outcome. But can everyone imagine possible solutions about the kind and amount of contacts and not characterize time with this young family as a competition? Interestingly enough, Irene is not invited to the meeting, about whom Henry had said, “No one says no to Irene!” Irene is a critical player who must be included to resolve the family conflict. In fact, Whitaker would not only have included Irene but all of Henry’s and Sarah’s siblings, their grandparents, and more. Irene and Sarah’s enmeshment must be understood and addressed to achieve a desirable outcome to this conflict.

Rather than polarization of the families about time together, I would want to see some increased cohesion among members of the extended families. They have a long history, with Sarah and Henry having been high school sweethearts. Perhaps Lisa and Irene could spend time together and get to know each other better. Even though Sarah and Lisa have known each other for some time, perhaps they have not had time together without Henry. Would the young couple ever allow time with Lisa as a babysitter while they had some time for each other? A sure sign that the couple was making the transition to this new developmental stage would be the ability to set boundaries and say no to Irene, not only to Lisa. These structural changes could all be addressed in family therapy with Dr. Williams, and he is sure this could happen in five 2-hour sessions!

— Donna M. Ulteig, MSSW, LCSW, ACSW, DCSW, has been a partner in the private practice group Psychiatric Services SC in Madison, WI, for 23 years.

Discussion No. 2
By Jeannette Sinibaldi, MSW, LCSW

In this case, we are presented with a fairly common scenario of a couple facing difficulties with extended family and conflict between two families of origins. The couple, although from the same town, come from fairly different backgrounds where their parents would not have been friends or traveled in similar circles. Over time, the problems presented have been exacerbated by the addition of a grandchild.

We are given a good family history of the couple. We can surmise that underlying issues may be creating the crisis that has culminated in Henry’s mother wanting some sort of resolution to these problems.

Henry and Sarah are described as childhood sweethearts, but theirs is not a fairy tale story. There was a breakup and Henry was involved with someone else throughout college. He did return to Sarah, but we have no details regarding this. It is unusual that another seven years passed before a marriage commitment was made due to professional training and financial demands. Sarah had no other relationships in her life and came from a traditional family background. Henry had been serious with someone else. What happened? Seven years in a previously broken relationship in one’s early years is a long time. There are some issues with this couple that seem to be under the radar and unaddressed. It is possible that there are emotional reverberations from the couple’s past issues that affect the present problems regarding equality of both households and marital behaviors.

When we look at the mothers-in-law, we have yet another layer of issues. We learn both mothers were divorced but lived in very different economic situations. Lisa has struggled financially with little emotional support. Irene was financially secure and eventually remarried. She experienced few of the struggles that Lisa did. It seems that when Henry and Sarah comes home for holidays, a competition arises between the mothers-in-law about who wins time with the couple. It is at this point that we see the situation more from Lisa’s involvement in our discussion. She has complained about being left out and now has been told she could not see her grandchild.

The history indicates that Lisa was included in holidays but appears to initiate a competition with Irene. Sarah makes her wish to spend her time with her mother clear. Henry tried to referee, with little success. The reality is that Lisa is his mother and if he wants to see his mother and have his child see his mother, he can go over for a short visit at her house. But he chooses not to. Lisa deflects all the problems to her in-laws. Henry does not want to create any conflicts with his wife and loses contact with his mother. Lisa’s concern over spending time with her grandchild is a bit dubious. Any grandmother can tell you that writing the letter she did would certainly alienate the child’s mother and put her out in the cold. Her son would not align himself with her. Also, since she is willing to drive all this way to see a therapist, why wouldn’t she just drive out to see the grandchild and spend quality time with the baby? Lisa’s feeling of being rejected on the holidays is more an issue about her relationship with her son.

Henry and Lisa’s mother-son problems are evident with Henry’s avoidant behaviors. After six weeks, he still could not find a therapist for his mother and family to see. He suggests to his mother a previous therapist he and Sarah had seen about this problem. Lisa feels threatened and wants a new therapist. This was unfortunate because it puts the situation into a power play rather than Lisa joining the couple in wanting to resolve the issue. She may have feared that the therapist would have heard terrible things about her and be biased. The couple now negotiates their terms with her. It appears they are not really interested for they have little time available. They are professionals with a baby; that is a stressful life. But Lisa keeps pursuing and insisting. Henry had said “No one says no to Irene,” and it appears that no one can say no to Lisa either.

How does a therapist deal with a family situation like this? The therapist will not go through the whole history of the family drama but help resolve the main issue in a timely manner. We have a family with a history of difficulties, so what this family needs is someone to help them mediate the problems at hand.

This family is ideal for the work that Jay Haley epitomized in his Problem-Solving Therapy. Haley evolved a brief treatment model that was a strategic type of therapy. He called his work strategic because the therapist can initiate what happens in the therapy. The therapist can create a specific approach for a client’s or a family’s problem and will directly influence the client or group. Haley’s works were greatly influenced by his mentor, hypnotist and therapist Milton H. Erickson, MD. Erickson worked on the premise that everyone has the power to heal themselves through the answers in their own consciousness.

A strategic therapist will identify the solvable problems at hand, set reasonable goals, design the interventions to achieve these goals, closely examine the responses, and examine the outcome of the therapy. In certain ways, the therapist is a mediator who helps clients reach agreements. Discussions help people look at the family conflict to explore options for resolution of the problem that will meet the needs of all involved.

The therapist must negotiate certain terms with this family if therapy is to be successful. What exactly are the family’s goals? They must be mutually agreed upon yet be realistic enough to be met in a certain time frame. I would advise any therapist to avoid the power struggle with Irene and to focus on Lisa’s reunification with the grandchild as a major issue for brief therapy to be successful. Goals must be concrete and attainable. The working relationship of these three people can achieve a new level of communication. There has not been much positive resolution of family issues according to the family history. With the use of the Problem-Solving Model in working with this family, the therapist can give them new communication tools as well try and resolve the present crisis. There are complicated relationships existing between each member of this triad and rather than using their previous methods of anger and avoidance, Sarah, Henry, and Lisa will be able to resolve future conflicts in new ways.

— Jeannette Sinibaldi, MSW, LCSW, is in private practice in Forest Hills, New York City. She specializes in loss of all kind and also supervises and lectures. She has been in practice for 26 years.