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Case Study - Page 3

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When There’s More to the Story

This rosy scenario abruptly collapsed at the beginning of the third session, when all three walked in with grim looks on their faces and sat down in angry, hostile silence. I could immediately feel dread in the pit of my stomach—were we back to square one? As it turned out, Sarah and her parents had had another major fight the day before, and the alliance had clearly broken down. Following the principles of FFT, I moved toward the black mood in the room and said, “The silence and tension I feel tells me that there’s more going on . . . ?”

This time, it was Ellen who spoke first. “I wasn’t going to come here today. I have to be honest with you, after our first visit, I was skeptical about the idea that we were all stuck in the same place. At home, I must say, I did feel different, and over the last two weeks, I even began to feel more hopeful. But yesterday’s fight convinced me that we need more in-depth help. We think Sarah needs medication. Now that things are a little better, maybe we can get the help we need.”

Then Ellen dropped her bomb. There were things about Sarah’s history I didn’t know, she said. By 13, Sarah had started to stick her finger down her throat, scratch herself, and throw up blood on a fairly regular basis. Fearing a more serious psychiatric problem, Edward and Ellen had taken Sarah to multiple psychiatrists and psychologists through her middle-school years. She’d received various diagnoses, including social anxiety disorder and bipolar disorder. Different doctors had prescribed different medications, but she’d refused to comply with any drug regimen. Each time, her refusal to take the meds, like her school problems and other behavioral issues, became the source of serious family conflicts.

When I heard about the self-harm, the psychiatric diagnoses, and the multiple prescriptions, I was both dismayed and disappointed. How did I miss this? I wondered. Had I gone too fast with this family? Once again, it was the FFT model that helped keep me from being pulled into a fearful, reactive position based on Sarah’s history. FFT’s core principle—that presenting problems are always relational—helped me see that Sarah’s history had shaped the family’s current interactional patterns. Now, when Sarah acted rebellious or oppositional, as she had the previous day, her mother panicked, frightened that her daughter was once again slipping back into a pattern of self-harm. But this was Ellen’s issue, not Sarah’s, and neither Ellen’s fear of the past nor Sarah’s misbehavior indicated that I should change the direction of therapy.

Turning to Ellen, I said, “This is very important. I think I finally understand why you’re so afraid. You’ve spent many years being afraid about what might happen to Sarah if you didn’t find a way to protect her. Now I understand why yesterday’s fight felt to you powerful enough to overshadow the big changes happening between the three of you over the last weeks. Also, I can see what your biggest challenge will be as we move forward: your fear is so big that it’s constantly with you. In fact, if I were to guess, I’d think this helps explain this fight. When your fear emerges, Ed and Sarah feel it and things quickly escalate, and the situation once again looks like it did when you first came here.”

Sarah, clearly angry, started to respond, but I stopped her and focused the conversation on her mother. Ellen sat silently for a moment, and then began to cry. “I just want her to be OK,” she said.

I responded to Ellen, “This feeling—the fear and hurt that you and Edward might lose her and she’d lose you—is the source of the struggle among the three of you, but it gets lost in the fighting, which is how each of you tries to find a way out of the struggle.” Hearing this, Sarah became quiet and the anger left her face.

This was a turning point for me. It would have been so easy to go back and join the family in feeling stuck. But framing Ellen’s concern as her own challenge actually helped us move to the second phase of therapy—behavior changes to develop competencies that would serve a protective function for the family.

Encouraging and Expanding New Behaviors

Behavioral approaches to families like Sarah’s usually focus entirely on communication, problem-solving, negotiating, conflict management, and parenting, but I began by teaching the family how to interrupt escalating interactions that typically occurred when Sarah came home in the evenings. I noted that the family could prevent or interrupt escalations by first negotiating limits to when and how long Sarah would be out on the street, and then learning how to manage conflict when she came home.

The perfect opportunity presented itself when, just before the fourth session, the family came in upset because, several nights before, Sarah had come home much later than she’d agreed, without letting her parents know where she was or when she’d return. When she finally did get home, the typical explosion occurred between father and daughter. Pointing out that this was a common struggle among them, I said, “I want to ask you to try something different in your discussion of this event. Sarah, this seems like an opportunity for you and your parents to negotiate a time to come home so they’re not worried and scared. Just trying to negotiate a coming-home plan might also help all of you identify a common set of rules in other areas, so you know what to expect from each other.”

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