More to the Story in Tales of Family Dysfunction: How Therapists Get the Whole Picture

  She never mentions the word addictionIn certain companyYes, she tells you she's an orphanAfter you meet her family~ The Black CrowesIn several recent posts (12/27/13, 5/27/14, 10/28/14) I brought up the idea that a story about someone’s family life that one hears from a patient in therapy, in a news story, in a letter to an advice columnist, or directly from friends and acquaintences, is quite often, shall we say, incomplete. The story is true as far as it goes, but it often leaves out details and information about the context in which it occurs. In therapy, as the therapist gets to know the patient, listens carefully, and employs certain techniques to help patients get past their shame, guilt, denial, and protection of family members, the whole story gradually emerges. As I mentioned before, the plot thickens. The added information puts everything the patient told the therapist before in a whole new light. This more complete information allows the therapist to do something called pattern matching. The full story will remind an experienced therapist of common dysfunctional family patterns that may apply to the patient’s situation, and about which the patient would have no way of knowing. The therapist can then mention that in other similar cases such and such explained similar family behavior that was otherwise inexplicable and confusing to the patient, and inquires if this is what might be going on with the patient and his or her family. This in turn may allow the patient to understand many things in ways they never thought of before.Before describing a commonly used psychotherapy technique (which is a version of the facetiously named Columbo style of questioning, named after a famous TV detective, described in the post of 3/13/12), I would like to refer back to a previous post, popular among readers, about parents pretending to be clueless about why their adult children are no longer speaking to them.In that post, another reader wrote in and mentioned some possibile details that perhaps the aggrieved parent may have conveniently left out.A more recent letter to advice columnist Amy Dickenson (10/14/14) is a bit more revealing. The cut off parent initially attributes the cut off to what she readily admits was a rather trivial argument. However, as the letter goes along, the parent reveals additional information that shows that she was not so clueless after all, and the advice columnists calls her on it: Dear Amy: The last time I spoke to my adult daughter was five years ago. I hosted a first birthday party for her son at my home and she severed ties with me after a petty argument. Since then, she has given birth to additional children, and for several years, I sent cards and gifts in the hopes of reconciling. I stopped giving because the only response I received was through secondary sources; she never responded directly to my e-mail or letters. I feel I had every right to be angry that day long ago. Both she and her husband were upset over my choice of party decorations (among other things). Post-fight, it came out that she felt unsupported during my marriage to my abusive ex-husband. And although I divorced him many years ago, it was evidently still acutely painful for her… — Wronged Mother Dear Mother: You have chosen this space to try to restate your original gripes against your daughter… I can't help but wonder, however, about your daughter's feelings. In the midst of all the detail you supply, you mention your marriage to an abusive ex-husband. Is it possible that this estrangement is based on your daughter's anger over your inability to protect her from an abusive situation?...Now in this case the mother had moved on from attributing the cut-off to the argument over party decorations and started getting into the important issues involved. But as mentioned, some patients in therapy or who are interviewed in news stories act like their initial explanation is the totality. It’s their story, and they are sticking to it.So how do therapists help patients give them the relevant details necessary for the therapist to make an educated guess about what is really going on covertly during repetitive dysfunctional family interactions? The technique is a simple one in principle but difficult in practice, because it requires a therapist to remember everything the patient has said since the very beginning of psychotherapy. My memory is unfortunately not that good, so I take extensive notes after every session. Just prior to the following session, I do a quick overview of all of my previous notes to refresh my memory.As patients talk about what’s on their mind concerning ongoing issues, they will often mention something in passing which seems to contradict something they told me earlier in therapy. This usually happens while they are discussing seemingly unrelated matters.  (I just happen to be paying closer attention to what they said than most people).As therapy progresses, they often mention the same or analogous contradictory information again. Some time later, when several examples of such ambiguities have arisen, I politely ask them to clarify for me how seemingly contradictory statements they have made fit together. I do this without accusing them of trying to obfuscate issues or to confuse me. In fact, I ask them to help me understand this from a position of my being confused, and perhaps just too thick to understand it (this was the technique Columbo used to get perpetrators to confess to crimes).This is when patients start to admit that they had not been completely candid with me at the beginning of therapy. The amount of detail, internal consistence, and new information that starts to come out shows me that they are not making things up to please me. If and when that happens, their story begins to fall apart.Another technique that helps clear up plot holes involves the responses the patient makes to any observation the therapist may make. This involves not only whether the patients are agreeing or disagreeing with what the therapist has observed, but what then follows.Back in the day when psychoanalytic therapies were king, we were taught that there were four possible patient responses to any observation or interpretation a therapist makes. First, the patient agrees with the therapist, and then a bunch of brand new information begins to come out. That’s obviously the best outcome. The second best outcome is that the patient disagrees with the therapist, but a whole bunch of brand new information nevertheless comes out. This usually means one of two things: 1. That the therapist is partially correct, but is missing something important. 2. That the therapist is bringing up something prematurely, before the patient is quite ready to admit to certain things for any of a variety of reasons.The second to worst outcome is when the patient agrees with the therapist, but then gets quiet, with no additional information coming forth. This usually means that the patient is agreeing with the therapist only for the purpose of telling the therapist what the therapist seems to want to hear. The worst outcome is when the patient disagrees with the therapist and then gets quiet. That usually means the therapist is way off, and it is time for him or her to ask for the patient's thoughts, and then shut up and just listen.

 
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