Figure 8.1 Geneogram of the Tucker Family
That classical psychoanalysis forbids contact between analysts and their analyst and family has led to a feeling amongst some family therapists that contact with only one family member could not be considered an 'orthodox' family therapy. This polarised position grew from a dialogue between individual and family therapists which has also generated a wealth of creative thinking. The clinical reality often bears little resemblance to the polarised theoretical position. An individual, couple or family seek help from a therapist with problems in their lives. Defining or labelling their problem will not solve it. As practical therapists we must help in the solution of the problem brought to us. If one theoretical framework brooks no solution the framework must change.
Bowen introduced the concept of family therapy with one family member as an effort to modify the family relationship system when only one family member was available to attend therapy sessionsNote 1. Since 1960, few articles have been written about this particular method. Those which have, have tried to explain the work in the language of the Bowen TheoryNote 2. The rationale for this method of therapy resides in the interlocking relationships between family members. Any family member who changes a relationship between himself and other family members will change the entire pattern of relationships which has previously existed. Bowen coached family members to change their relationships with others in their family, thus altering the entire family system.
In the following detailed case report I hope to present an example of the use of transgenerational practice in which I treated only one member of the family. This type of work is similar to a case already described in chapter four, where only one session was required to alter existing relationships. The difference between this type of therapy and a more traditional individual therapy is that at no time do the intrapsychic mechanisms or psychology become a focus of treatment. Neither does the relationship between the individual and the therapist. Rather than encouraging a transference relationship to develop so that it could then be analysed and resolved, it is the real and imagined relationships
<end of page 160>between family members that are explored. The therapist uses the therapeutic alliance to act so as to generate a change in family interactions.
I shall present the case as it was presented to me and describe my work session by session. I have summarised my thoughts during the session in italics and include my analysis and afterthoughts of each session in separate sections. This format will be used in the two succeeding chapters.
Glen Tucker was a 32-year-old photographer referred to me by his general practitioner. He had been referred to social worker after a suicidal gesture had been treated by his G.P. She was unable to form a psychotherapeutic relationship with him and was instrumental in asking that he be referred to me.
The referral letter read as follows:-
Dear Doctor
Mr.Tucker is a very intelligent young man who suffers from lack of confidence and anxiety. His parents live in Sussex and though he described his father as perhaps a bit neurotic, there is nothing abnormal in the family history. He has always been a bit shy and introverted but has managed to conquer this fear in recent years and his social life is adequate. He has had difficulties in his sexual life for he has had a number of girl-friends, most of them involving short-lived romances.
He has more recently been subject to fits of despondency when he has had thoughts of suicide which culminated in a minor overdose (eight aspirin tablets) last March. He was visiting his family at the time and I wondered if there was some difficulty between them. Since then he has continued to feel depressed despite a small dose of amitriptiline. I wonder if you would see him and undertake some form of psychotherapy.
I began to analyse the referral by questioning the difficulties which might exist between the family members. He was a single 32-year-old son unfulfilled in his formation of relationships with women - possibly trouble in breaking or attenuating his bonds with his mother? He was unfulfilled in his work, lacking in confidence with a possibly neurotic father - trouble with authority? Identify crisis? I wondered why he had become despondent now - no mention of losses but something to look
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out for. Actually very little to go on in this referral letter. Could be anything from an organic condition or incipient schizophrenic episode to a family relationship problem. The G.P. seemed to settle on the family influence and a need for psychotherapy. No transgenerational data at all.
Mr.Tucker arrived late. He was a short, bearded man, casually dressed. During the first minutes of the session I read the referral letter to him and he agreed substantially with its contents. I did this in order to share what little I knew. It was also a response to non-verbal cues of suspiciousness on his part. The session proceeded along traditional psychiatric lines thereafter until I had satisfied myself that no organic psychotic illness was present.
I asked him to share as much of his family background with me as was possible and introduced the idea of doing a geneogram. He was both interested and relieved. The tension which was building in him receded. He grasped its use as a visual aid readily.
The information obtained is shown in Figure 8.1. Glen was the oldest of two brothers. I wondered why his character seemed not to fit that of an oldest sibling. His younger brother Cedric, had married two years
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previously and the period of his brother's engagement and marriage seemed to coincide with the overt development of Glen's symptoms. Was this exit-entry-shift in family relationships the precipitating event in the development of his problem? Sibling rivalry? Their ages are close. His parents married during the war in 1941. His father, Ian Cedric, trained as a lawyer. He had a sister, Bernadette, who was ten years older and lived in Canada. She had married recently after a long life as an eccentric spinster. I noted that his mother
couldn't have been pregnant when married unless there had been a miscarriage; also that his brother Cedric had been named after his father; and finally that his aunt had also married recently. Was there some moulding of his aunt's personality into him through his father? His mother had a married sister who lived abroad. Glen didn't know whether she was the younger or older sister or whether she had children. He and his family had lost touch with her long ago. His maternal grandparents had died many years ago and he had no memories of them. The details of his mother's family background were ill-defined and sketchy. He showed little curiosity in pursuing his lack of knowledge. I thought that some secrets must exist in this area but that it was not yet time to pursue it. Did it relate to his difficulty with his relationships with women? Information about his father's side of the family was equally sparse. He had never met his paternal grandparents since they had died prior to his parent's marriage. The resulting geneogram was a very incomplete one. I had in my mind at this point that his first task would relate to his lack of knowledge about his family.
First, I felt more attention must be paid to the initial engagement in therapy. After a brief discussion about his lack of confidence at work he returned to his heterosexual relationship problems. I offered him an initial formulation of my views of his problems. I said that I felt he was drifting from moment to moment without a clear understanding of his own motivation. He didn't seem to know what he wanted from his life. His brother's marriage had triggered his restlessness and despair, perhaps as a loss of a close relationship and a symbol of his own lack of bonding with anyone outside his family. I explained that his lack of interest in his background showed how little he understood the influences in his family which had moulded him into the person he was and maintained him as such. I felt that there was a danger that he might drift into therapy with no commitment as he had previously with the social worker. Before I agreed to treat him and possibly other members of his family I would need his emotional commitment to the therapy.
He reluctantly agreed with part of my formulation of his problem. He was unable to accept that his family could be involved in his
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problems, but he felt that I understood his feelings of despair and confusion. He explained that since he had left home seven years previously he had hardly seen his parents. He mentioned out of context that he had had little to do with his father since he had beaten his father in a game of chess when he was eight years old. His father thereafter avoided playing with him and they drifted apart emotionally. I felt at the time that he was steering me away from any task involving the family. As we talked he became more intrigued by the idea of therapy involving his family. I sensed underlying reservations but decided that he was making enough of a commitment to work. He had also given me an opening for his first tasks. I instructed him to sit down with his father and discuss his father's past with him. I asked him to seek out those sensitive and secret areas of the family past which might be present as barriers between him and his father. The areas included the courtship between Glen's parents, the deaths of his paternal grandparents and their effect on his father, and some information regarding his father's sister, especially her relationship with his father in their childhood. I suggested that he could write to his aunt requesting information about his father's early years from her memory. Finally I instructed him to challenge his father to a game of chess. I gave him this instruction as an intuitive response to his previous disclosure. I felt it was a self-generated task from him. We both laughed about this instruction and broke through his reservations. The session ended after one hour and he was given an appointment to return in one month. I expected that it would take one month to complete the tasks and realise some of the emotional impact which would result.
I recognised a feeling of indefinite boundaries common to adults in an arrested adolescence. I was alert to issues of identify, maturity, and the growth of adult relationships. I wondered as the session proceeded how well I had explained a family oriented view of his problems. I avoided pressing him to involve himself with his mother and her side of the family. I sensed his reluctance. His view of her was of a perfect but unapproachable person. I mentioned that she would have to be involved in the future and noted his coolness to this prospect.
The tasks were intended to catalyse an adult relationship with his father by exposing secrets. I also wished him to develop a peer relationship with his father's sister. I hoped that this step in altering relationship bonds would prepare him for work with his mother. I recognised afterwards that playing chess with his father was a task set by Glen. It was his declaration of motivation and a test of my willingness to treat him as an
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equal participant in the therapeutic situation.
His family's background was a mystery but I speculated that Glen's father identified him with his eccentric older sister. His brother was identified with his father my similar names and sibling positions in their families. Glen was an eccentric without knowing why, and his relationship with his father had turned sour at an early age without logical reason. This would partially explain his difficulty with his own identity.
I felt that Glen was loosely engaged in therapy and that the tasks assigned him would be carried out eventually. I was aware that neither he nor I knew the source of his problems. The family quandary involved an arrested transition from adolescence to adulthood in at least one child, the eldest child in the family.
Glen returned and appeared more relaxed. He was early for his session and was enthusiastic in his greeting. He immediately launched into a description of his session with his father. He found that his father was surprisingly willing to talk about his family. Glen had used his request for a return chess match as an entry into a discussion with his father about is father's family. They spoke hesitantly about his family until the game ended. Glen won the game and his father asked for a return match. I felt that this was a signal of the altered reaction between him and his father. To his amazement his father then took a monograph from his bookcase and showed Glen a complete family geneology which his father had researched long before marrying. His father informed him that Cedric had seen it. He had wondered whether Glen would ever become interested. Glen was given a copy which he proudly displayed to me in the session. We were side-tracked into a discussion of his family's remote past. I felt that the family geneology was an important document for Glen but that it ignored the more immediate, recent emotional issues. I asked Glen what secrets he had learned about his father or his father's family. His father had revealed that he had been married twice. The first marriage ended tragically when his wife had died on their honeymoon. Glen was emotionally involved as he spoke. His father had remarried late in life. He had met Glen's mother while she was nursing him in hospital. I noted that the courtship was mentioned perfunctorily. Anything relating to his mother was avoided. He learned that he was named after his father's father. His father felt that his sister had drifted throughout her life and noted some similarities between Glen and this sister. Glen believed his relationship with his father was better. They would have more contact although the relationship was still
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cooler than he would have liked. He was more relaxed in his father's presence and they had been phoning each other more often since his visit. I felt that the bond between them was reactivated but changed from a child-parent bond to one between peers. He had written to his aunt three days before the session but had not yet received a reply.
When asked how he felt in himself, he was still confused. Glen felt no better about his work or his ability to develop lasting relationships with women. He was less unhappy and despondent but such temporary improvements had occurred in the past. It was time to turn to his relationship with women, leading to a discussion of their links with his mother. His statement about temporary improvement reawakened my fear that he would drift in the therapy.
In the remainder of the one-hour session we discussed heterosexual relationships and bonds. He described an intense ambivalence towards his girl-friends. If they became attached to him or interested in him he was repelled. Women who were uninterested in him proved a challenge. As soon as he had gained their attention and interest he left them. With one girl-friend who argued with him over trivialities he unemotionally disagreed with every third remark she made. This confrontation satisfied his girl-friend and she stopped arguing, but he lost interest in her. A conflict was moulded into him from some transgenerational influence. There was a heterosexual bonding quandary. His father had a traumatic first marriage, his aunt only married later in life, and his symptoms began when his brother married. Perhaps he can't contemplate marriage while he remains in a child-parent bond with his mother? A comparison of the similarities between his mother's relationship with him and his relationship with other women was made. His mother's contact with other family members was fraught. His brother argued often with her and his father did the same. Glen was the only immediate family member who did not argue with her. He often sided with her in her arguments with the others. He felt that he kept a distance from her which enabled him to keep his independence without arguing. He felt his mother would be easy to talk to and more understanding than his father. Yet, he shrank from engaging in close conversation with her. He revealed that his middle name, 'Stone', was his mother's maiden name. He must have been named for some reason. Replacement? Some secret on his mother's side of the family? He mentioned his annoyance at his mother's continued use of an infant nickname, Pooba. This fleeting comment was quickly covered over with further accounts of his mother's kindness to him. I felt he had given me the clue to another task.
I explained that naming him after his grandfather might mean that he
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replaced some aspect of his grandfather in his father's eyes. I asked him to continue exploring his father's family of origin. I explained that this task should keep him in some contact with his father and help establish a new affinity with him. I asked him to request that his mother stop using his baby name. His adult name was Glen and she should call him that. I asked him to talk to his mother about her family of origin and her past. He was unsettled by both suggestions despite a full explanation of the reasons and the connection between her and his problems with girl-friends. I felt that he might fail in these tasks with his mother but hoped that he would make the attempt. He was asked to return in four weeks.
I was pleased with the work that Glen had done with his father. He had taken steps to balance their relationship and in the process had learned more about his own roots. I had hoped that work would increase his motivation more than it had. The intensity of his avoidance of tasks relating to his mother puzzled me. Either there were some family secrets around which his mother held a boundary, or my initial formulation was in error. I hoped it was the former. His ambivalence towards women certainly included his mother. Since my own family had included an analogous problem I hoped the similarities hadn't affected my ability to judge the tasks necessary for him to change. I wondered if he would return for the next session and I worried that I had rushed him into tasks for which he was ill-prepared. I hoped he would accomplish the tasks he had suggested, that of being addressed by his adult name.
Glen arrived late to the session. He looked unhappy; his clothes were scruffy and his beard and long hair were dishevelled. He had dark circles under his eyes. He started by explaining that he had had several severe crying spells since our last session. He was feeling more troubled and unhappy than he had for several months. He had been home to see his father and mother and had asked his mother to stop calling him Pooba. He felt that he had hurt her by his request but that she reluctantly agreed to honour his wishes. She said little during the remainder of his visit. He did not feel able to approach her about personal matters after he had just injured her. He spoke at length with his father but despite the increasing intensity and interest generated within this new relationship he ended his visit home feeling increasingly despondent and lonely. One week later his mother phoned him on his birthday and used his
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baby name while wishing him a happy birthday. He was intensely annoyed but unable to correct her on the phone. Since then he wondered whether it was wise to delve into these matters since they only seemed to make him more miserable. He had become increasingly aware of the anger he felt towards his mother but felt extremely guilty about it. We had come to the turning point of the therapy. If I could explain the task more clearly and motivate him sufficiently, I felt that he could break through the barriers erected between himself and his mother. I was pleased that he had realised some of the negative aspects of that relationship.
I spent most of the remainder of that session confronting Glen with the task that faced him. I pointed out my own speculations about the cause of the secrecy which existed between him and his mother. I explained that he must be a replacement for someone in her family but that there was no proof yet because of the lack of information. I pointed out the similarities in her relationships with each of the men in her family. She was attracted to her husband when he needed nursing and protected him still. Her relationship with Glen and his brother was over-protective. Because of the collision of the two family cultures, Glen was less able to break away from the over-protection. I redrew his family geneogram on the blackboard to enforce an objective view of his family on him. I explained that the task facing his must be done. His main problem was fear of his mother and of the effect a change in that relationship might have on him. He responded by admitting that his relationship with his mother needed changing. But his first attempt had failed and he felt much worse since the effort had been made. I pointed out that it was the failure of the task which had made him despair. He finally realised that his failure had deeply affected him. His motivation was stimulated by this obvious connection between the task with his mother and his emotional state.
We had been involved in a therapeutic relationship for three months. The remainder of the therapy was clear to us both. He fatalistically agreed that he would return home and ask his mother about her past and her family background. He more firmly resolved not to allow his mother to call him Pooba. This resolve seemed the start of an inner change from adolescence to adult. He departed admitting that he was frightened of what might happen over the next four weeks but his strength of purpose had asserted itself. He seemed more agitated but less depressed than when he had entered the office.
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By the end of the session I felt considerably relieved. I was certain that the session marked a turning point, not only in the therapy, but in the life of Glen Tucker. In order to change a relationship, one of the two people involved must take the first step. I felt that Glen had done that during the session. The task assigned would lead him to a confrontation with his mother which would alter their relationship. I was not certain that the task I had chosen for him was a correct one. I hoped that he would learn the reasons for his mother's over-protective concern, but the boundary between himself and his mother would shift and change. I was sure that he would return. On his return he would undertake and complete any further work required. I felt the entire family would ultimately benefit from the shift in relationship. His next session might be the last one required.
Glen arrived early, appearing relaxed and happy. He moved with an assurance and confidence which I had not seen in him before. He started the session by informing me that the weekend after his session with me he had returned home for a visit and spoken to both his parents. He related with pride that he had firmly told his mother that he did not want to be called Pooba any more because it was degrading. He asked his mother to spend some time going through old photo albums with him. Although she was startled at the strength and forcefulness of his request, his persistence was rewarded. While looking through old photographs she described the story of her life and that of her family (see Figure 8.2).
Glen told his story with a depth of feeling which he had previously rarely shown. His maternal grandfather was born out of wedlock. He was the bastard son of English nobility. Throughout his grandfather's childhood he had been an embarrassment and a well-kept secret to the family which helped support and educate him. When he married he was encouraged to emigrate to Ghana. There his first-born son died after contracting malaria at seven years of age. He had also had two daughters; the younger was Glen's mother. The loss of their eldest and only son was a tragedy which hung like a pall over the household for many years. Glen's mother recalled that her father blamed himself and was a broken man thereafter. They returned to England shortly after their son's death. They refused to contact their noble relatives and secrecy enshrouded the connections with the extended family. Now it was clear to me; Glen was the first-born son who had taken the place of his dead uncle, the dead older brother of his mother. She had become over-protective of her
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son, following an unconscious moulded concern about ensuring the survival of her son. The avoidance of discussion was moulded into Glen's mother from the secrecy which his maternal grandfather possessed within him. Glen was surprised to discover that his younger brother had already known most of these details about his mother's past. Cedric had questioned her about it in his early teens. She hadn't wanted to worry Glen with the details of her life and so had never volunteered the information. He spent over two hours in conversation with his mother, during which he felt emotionally strained. By the end of their talk he was exhausted. He reported that when he took leave of his parents at the end of the weekend he had felt alive and at peace with himself.
During the following weeks he felt a new sense of freedom and responsibility. His mother contacted him several times and was careful not to call him by his childhood name (a name which had also been his dead uncle's). Concomitantly he noted an alteration in his relationships with women at work and on dates. As a result of his discussions with his mother he found that he was much less worried when getting into intimate situations with women. He found that he was more direct in dealing with his photographic models and colleagues. He had no recurrence of the feelings of despair or lack of drive which had plagued him
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previously. I felt that he was almost euphoric in his sense of accomplishment. He was perhaps floating at an unrealistic level.
The remainder of the session I explored the impact of his new growth on the rest of his life. Since only three weeks had elapsed, he was too close to the alteration in dynamics within his family. I felt that a follow-up period would be necessary. He incidently reported that the arguments between his parents had decreased and that he was in closer contact with his brother than he had been previously. The only task which had failed to develop was that of involving Glen with his father's sister. She had failed to reply to his letter.
The session ended with a discussion of the need for further work. He felt that he had no further need to continue. After some discussion I agreed with him and asked that he return in six months for a follow-up appointment. I felt that he was asked for necessary time to consolidate his feelings and the alteration in the family relationships which had resulted from his work. He thanked me for my help and left the office.
My immediate thought after this session was that it all seemed too good to be true. I was suspicious of this 'instant relief'. From his account, the transgenerational analysis had become clear. His mother had singled him out as the especially vulnerable child who must be protected from any form of physical or emotional harm. She was unable to prepare him for separation from the family by taking the initiative. In the collision of family cultures, his father had identified him with his older sister, an eccentric and uncommunicative sibling. He had cut Glen off emotionally at an early age and was unable to provide the help Glen might have valued in his adolescence. Secrecy was a strong and common feature on both sides of the family, which created difficult boundaries for Glen to cross because of his vulnerable position. His therapeutic work involved uncovering the secrets, forging a new relationship with his parents and integrating himself within his nuclear family as an adult instead of a child. As a result of this alteration he gained a stronger sense of identify, increased confidence and supportive adult relationships with his parents. Nevertheless I felt uneasy when he left the office. I hoped that he would return for follow-up if only to confirm that his new-found status was not temporary.
Mr.Tucker did not return after six months for his follow-up appointment. Neither did he answer written requests suggesting that he attend
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at an alternate date and time. Attempts to contact him by phone and letter were to no avail. I wondered what the ultimate result of my interventions in his family were to be. Although vaguely disquieted I was reasonably confident that none of the work we had done together would have damaged Glen or his family members. As time went by with no word from him I gave little extra thought to this family therapy which I had provisionally classified as successfully concluded.
Two years following the completion of the therapy, I began a pilot study on the outcome of my patients. With help and some detective work I managed to trace Glen. He apologised to me for having missed his final appointment. He had felt that the last session was sufficient for him and events in his life overtook his resolve to keep the follow-up appointment. He had moved from his original flat several times during the six-month period and as a result both his address and telephone number had changed. His relationship with his parents and brother had blossomed, and he was now married and expecting the arrival of his first child. He had received several promotions in his work since the therapy sessions and he was very happy and content with his life. I was satisfied that the family therapy sessions had been instrumental in the change in his life.
In this chapter and the succeeding two chapters I intend to provide synopses of cases using similar transgenerational practices and techniques to those used in successful cases in order to illustrate the failures of this approach. In this way I hope to provide a balanced picture of my work. I believe that no one theory or method of therapy can provide a universal method of dealing with family quandaries.
The following case report briefly describes the unsuccessful use of transgenerational family therapy methods with an individual family member.
A 26-year-old writer was referred to me by his general psychiatrist. He had requested the referral because the patient wished a psychotherapeutic approach to his problems which included an obsessive preoccupation with sexual matters, free-floating anxiety and guilt.
In our first interview I established that he had a mild obsessional neurosis characterised by ruminations. He also suffered from multiple discrete phobias, including a public-speaking phobia and a telephone phobia. His original referral coincided with the exacerbation of symptoms while preoccupied with his feelings about a new girl-friend of whom he was unsure. She had recently emigrated abroad. His family
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background was remarkable for its paucity of married siblings or uncles on both his father's and mother's side of the family (Figure 8.3).
Neither of his uncles had married nor had any of his four older siblings. His parents came from widely divergent religious backgrounds and religion played a major role in the patient's development until the age of eighteen when he rejected the teachings of the church and became an atheist. Despite this break with his parents' orthodoxy, his parents continued to accept him and welcome him into their home. His mother was his major confidant to whom he would detail his every problem.
My analysis of the transgenerational influences led me to conclude that he was unable to become an adult member of the family without a major battle with his parents. Since his parents were so accepting they could not be induced to fight with him. This situation may have been similar to that which had prevented his older siblings or his uncles from separating from their respective parents. As the youngest son, he was the most over-protected by his family and he reacted to it by over-compensating. His attempt to stir up conflict by rejection of his parents' beliefs had failed to free him from their influence. His obsessional symptoms had been present since his early teenage years but were increased in severity when his girl-friend left and he realised that he was in love with her. Since the only model of marriage he had was that of his parents he had rejected marriage as an institution. Because of that model, he had become paralysed by indecision. A part of him wanted to follow his inclinations to propose and marry.
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The therapy involved this patient in several weekend sessions with his parents, attempting to confront them with his inner feelings and needs. Further transgenerational information was obtained and finally a confrontation that was engineered between himself and his father occurred. The resulting conflict split the family and the patient became totally estranged from his parents for six months while his siblings polarised and wrote letters to him taking sides. He proposed to his girl-friend and married her without inviting any of the family to attend. An uneasy rapprochement occurred between himself and the family. His problems at work and his phobias had disappeared as the result of some behavioural work.
At two-year follow-up he had begun to attend a private therapist for guidance and help with his obsessive ruminations and marital difficulties. His relationship with his parents remained strained but cordial.
1. M. Bowen, 'Family Therapy after Twenty Years', in Handbook of Psychiatry, unedited draft.
2. E. Carter and M. Orfandis, 'Family Therapy with one Person and the Family Therapist's Own Family', in P.Guerin (ed). Family Therapy (Gardner Press, New York, 1976), pp. 193-219.
