Figure 10.1 Initial Geneogram of the Keats Family
Family therapy is popularly known as an intervention defined by the inclusion of children and parents in conjoint family sessions. Many professionals and most laymen use family therapy and conjoint family therapy synonymously. In fact, limiting family therapy to conjoint sessions can be as restricting and stultifying as any other therapeutic method. The intervention used should ideally flow from the family's needs rather than from the therapist's prejudice.
The nuclear family is most often the correct unit of therapeutic intervention when young, dependent children are referred as identified patients. The parents and siblings of a young child are inextricably involved in the child's daily life. They will have immediate and overpowering influences on any individual therapy attempted. Since these influences are omnipresent and the child cannot gain complete independence from his family, involvement of the nuclear family in the treatment process is a logical step. But conjoint therapy can begin with any family member as the identified patient.
Many family therapists work with various subsystems of the family at different times during therapy. SkynnerNote 1, in his treatment of a fourteen year old boy referred for behaviour problems, moved from a predominantly child-centred therapy to a marital therapy with the child's parents. In his discussion Skynner clarified his reasons for this necessary shift in emphasis. He found that work with the marital subsystem was required in order to resolve the presenting problem. MinuchinNote 2 emphasises the usefulness of varying the subsystems upon which the therapists acts. He adds a further twist by allowing family members excluded from a family session to watch the session behind a one-way screen in the company of another therapist. In one family study, AckermanNote 3 treats an eight-year-
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old boy referred for childhood phobias in conjoint family sessions, individual sessions, and in many different combinations of family members involved in the sessions.
In the following clinical case study, therapy progressed from an individual adult referral to marital sessions, to conjoint family sessions, to involvement of extended family members. During the sessions, I used many of the techniques previously described in Chapter 7.
Mrs Felicia Keats was referred to the clinic for guidance by her general practitioner. I received the following referral letter:-
Dear Doctor
I shall be glad if you will send this patient an appointment to attend your Sexual Dysfunction Clinic if you might be able to help.
She formed a recent lesbian relationship which has since ended. The is married with two children and is quite sure that if she were to tell her husband her marriage would end.
She has been depressed and is in need of guidance and she is upset and worried over her lesbian tendencies. Hoping you can help her.
There was no further information forthcoming. I agreed to see Mrs Keats and sent her an appointment.
I wondered if this woman would require a family-oriented approach for what had been presented as a problem of sexual identity. She may just require individual therapy aimed towards adjusting her self-image to her lesbian tendencies. But there was an immediate, potential family and marital crisis. She had fears about informing her husband. The effects of her affair on the marriage indicated at least one area in which family therapy might help. The referral did not mention the quality of her relationship with her husband or children. Nor was there any hint of the extent of the sexual satisfaction in either of her physical relationships. Guilt and secrecy figured prominently. I wondered if she possessed an underlying tendency to deal with emotional matters through secrecy and guilt. I was curious about Mrs Keats and wondered where her problems might lead.
Mrs Keats was a tall, well-dressed blond woman with a masculine face.
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She was visibly anxious and drawn. I allowed her to talk freely to me about her anxieties and feelings of guilt. She gave a detailed account of her relationship with an older woman who had befriended her. Their sexual relationship began when the woman had tried to comfort her during one of her bouts of depression. She found the physical side more exciting than her dull sexual relationship with her husband. She had been treated for over five years by her general practitioner for a mixture of anxiety and depression and was taking various antidepressants and tranquillisers. She unconsciously connected her current crisis with longstanding problems. I wondered what had started her original symptoms. Attempts to reduce her medications by her doctor resulted in 'withdrawal' symptoms including gastrointestinal upset and insomnia. Nevertheless, the medications had not controller her panic attacks or crying spells. Nor had they helped her to deal with the intense guilt generated by her sexual liaison. She felt that she was losing her mind and was fearful of becoming a lesbian.
I asked about her background and upbringing. Her mother had had many affairs and four divorces. She said that she had been sexually assaulted by one of her mother's lovers. She was especially bitter about her mother's sexual promiscuity. Mrs Keats feared that her mother might find out about her relationship and use it against her. Her relationship with her mother and stepfather was not a very close one. The family transgenerational influences could reveal a great deal if I pursued them. But I filed away this information for the future. It was too early to introduce a geneogram or family-oriented work. I felt I must first help with the crisis, then engage her husband in the therapy. I listened as she described her husband to me. He was a grocer who was kindly and inoffensive. She was frightened that she had ruined her married life. He was not sophisticated and she feared his reaction if he found out about the affair. He accepted her current 'illness' but had no idea of the cause. Her immediate major fear was that he might discover her indiscretion. I had sufficient engagement to begin working on her problem but a family quandary was looming in the background. At the moment she was desperately worried and willing to depend on anyone who might help her survive the present crisis. The rest of the session was devoted to plans of further action.
Her most pressing fear related to her guilt and the underlying need for punishment from her husband to ease that guilt. Since her husband was described as such a kind person I explained that I might be able to help her in discussing the issue with him. The next session would be a joint marital session. The immediate cause of her illness would be dis-
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cussed if I thought it would not end their marriage. She was visibly relieved when I proposed this. She wanted to work on the sexual side of her relationship with her husband, confessing that the lesbian affair had awakened her to new possibilities of sexual satisfaction. She also wanted freedom from her panic attacks. Finally, she wanted to end her dependence on medications if possible. I planned a schedule to reduce her medications and asked that she contact me by phone if any symptoms returned. I cautioned that she might face a few difficult weeks while her body readjusted. She seemed to welcome this. Receive punishment from me as penance for her misconduct? I arranged to see her and her husband in two weeks.
While considering her problems in isolation, I was already mapping out in my mind a progression of therapy from her to the marital subsystem, possibly also including her mother. Her husband needed to learn to satisfy his wife's sexual needs. He may also need to learn how to confront his wife. Their two children were not mentioned in the session. I wondered what effect their mother's problems had on them. A transgenerational pattern was evident in her description of her mother. Two generations with sexual problems might be significant. Her attitude towards her mother was rooted in the sexual pattern. I felt it was right to work with her on her immediate crisis while tying in other issues as therapy proceeded. A great deal remained to discover before I could be certain about the causes of this quandary and its solution. I was confident that Mrs Keats would return and hoped that the next session would increase my understanding of the quandary.
Mr and Mrs Keats arrived together. Mr Keats looked much younger than his age. They both looked nervous and the initial minutes were awkward ones, taken up by my introduction to Mr Keats. Felicia launched into a description of her physical symptoms since stopping her medication. Finally she admitted that she had told her husband about her lesbian affair. He had responded with reassurance and support as well as puzzlement. Mr Keats was surprised about the severity of his wife's reaction. I felt that Mrs Keats wanted her husband to react with anger or resentment; he seemed too passive and accepting. I asked Mrs Keats if her fears had decreased but she admitted that she felt increasing anxiety. I asked Mr Keats about his family of origin. He was the youngest of four boys and his parents were advanced in age when he was born. His family had never discussed sexual matters and he had not been able to talk to
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his brothers about sex. He said that he was very naive about sexual matters and would value help in this area. Mrs Keat's had been working on her husband at home. He admitted that his wife had suggested that they could both benefit from sexual therapy. I tried to explore his feelings about his wife's lesbian relationship, but his responses were muted and embarrassed. He was afraid of his wife and her reactions. He started to explain that his two daughters knew nothing about the cause of their mother's upset, but I returned to his feelings about his wife's affair. He finally admitted that he might be angry; he was afraid to show his feelings in case his wife reacted badly. Here Felicia interrupted. She returned to the issue of sexual therapy and asked if I could help them with it. I must stick to their immediate felt needs, specifically in regard to sexuality. Only through their struggles with these needs would they accept that other issues were involved. I discussed the possibilities of sexual therapy with them and introduced the idea of sensate focus. They were both enthusiastic to try this technique. They agreed to practise sensate focus according to a programme given them as written instructionsNote 4. Other tasks were set. Mr Keats was asked to express his feelings to his wife more clearly. Mrs Keats was to continue to refrain from taking her medications. Before they left the office I briefly explored the beginnings of her depressive illness. Although her youngest daughter had started school five years ago, no loss or other precipitating cause for her illness was uncovered. There might still be some unacknowledged or secret precipitant five years ago, but I decided not to pursue it. They were to return in two weeks.
I felt more puzzled at the end of this session than I had after the first. Mr Keats had been drawn into therapy easily. He saw the need for his inclusion in a sexual therapy dictated by his wife, but I was startled by the ease with which she informed her husband of her affair.
Other matters were clearer to me. I expected Mr Keats to take my permission to express his feelings to his wife seriously. They would probably have a row which would relieve some of Felicia's guilt. She would feel that he had punished her and shown his love for her at the same time.
The geneogram that I drew for myself (see Figure 10.1) revealed that Harry Keats, the youngest sone of four sons, had married the oldest daughter of three children. He had little knowledge of the opposite sex and no premarital sexual experience, while she was the eldest child with two brothers and a mother whose sexual promiscuity was an open lesson
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in her family. Mr Keats was surrounded by women in his present family since both the children were girls.
I wondered about Mrs Keat's choice of a lesbian affair rather than a heterosexual one - perhaps an unconscious attempt to 'love' the mother she despised? It certainly signified a breakdown of sexual control in a way similar to her mother. The effects of this quandary must influence the children in ways unexplained yet.
Mrs Keats had complied with all my suggestions and instructions. I was certain that the couple would return but I remained uncertain as to the final nature of real work in therapy. I planned at the next session to explore both of their backgrounds in greater detail.
Both Felicia and Harry seemed pleased to see me. They were anxious to related the events of the previous two weeks. They had returned home and experienced several of the most intensely pleasurable lovemaking sessions of their married life. These interludes had occurred shortly after Harry had an angry argument with his wife about her affair. Two days later, Felicia lost all sexual feeling for her husband. They attempted
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sensate focus but Felicia experienced no response from the stimulation. They both felt that something was interfering with their sexual relations. I guessed that Harry's ability to argue with and confront Felicia signified that he cared. He relieved her guilt long enough for her to respond to his lovemaking with abandon. She was then frightened by her responsiveness and lack of control.
I explained that I felt she had great fears of her own sexuality and that he had been unable to confront her for many years. I asked if they knew the origins of these traits and at this point
introduced the geneogram to them (see Figure 10.2). In drawing the geneogram I discovered that Harry's father died shortly before his wife had begun to experience anxiety and depression. He had turned inwards at the time and withdrawn from her. She became anxious and upset by his withdrawal; the lack of physical contact led to an increase in her sexual needs which were not met by him. His withdrawal was coupled with her change in role from a mother with toddlers to one with schoolchildren. Increased time on her hands made her feel unwanted. She might also have been mourning her father-in-law's death. Her increased sexual desire led to a fear of promiscuity that was intense. Her husband drew my attention to one of Felicia's guiding principles in life which was to avoid being in any way like her mother. Her fear led her to withdraw from her children so as to avoid contaminating them as her mother had contaminated her. She reached an unstable equilibrium in which her tension built up until the affair occurred. During this period she increasingly abandoned her children to her husband's care until she was an outsider in the family.
Felicia was attracted to her husband's naivety and boyishness when they met; she felt safe with him. She was able to draw emotional and physical comfort from him while remaining in control of the relationship. His withdrawal had threatened her control. When his normal mourning process receded she was entrenched in her pathological state and he was too weak to confront her enough to draw her out.
Neither Harry nor Felicia had much contact with their families of origin. Every Christmas Felicia's mother and stepfather would impose themselves by staying at their house. She had never been able to tell them not to make the journey from Exeter. Harry's brothers had moved away over the years and he had lost contact with them.
A pattern of sexual difficulties and conflicts over sexuality existed in Mrs Keat's family back to her maternal grandmother. Her maternal uncle and aunt had both found sexual relationships and marriage difficult. Her uncle had divorced and remarried, while her aunt confided to Felicia that she was frigid with both her husbands. Her maternal grand-
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<Page 200 entirely taken up with Figure 10.2 Final Geneogram of the Keats family landscape>
I ended the session by explaining to the Keats that I would like to see them with their children so that I could assess the involvement that might be required of them in the therapy. I drew attention to the fear that Felicia had about passing on the family taint. With little further explanation they both agreed to a full conjoint session. I hoped that a series of family tasks would grow from the session to initiate a process of change. They left the office with no further tasks, to return with their children in four weeks.
I believed that the lesbian affair had several meanings. It was a symbol of the loss of Mrs Keats control of her sexuality. Poor control of sexuality was a family pattern, directly traced to her grandmother's disease, death and its aftermath. Sexuality, death and secrecy were intermingled in a family pattern. The affair was also a symbol of the similarity between Mrs Keats and her openly despised and resented mother. Finally, in her lovemaking with an older woman, she symbolically revealed her love for the mother who raised and moulded her. Her fears about the effects of her behaviour on the children were related to a fear of continuing the family pattern. Her husband's passivity and naivety were a result of his experience as the baby of his family of origin.
The family quandary was a serious one. In order to change, Mrs Keats must break a pre-existing family pattern. This would require her to establish a new position within her family of origin. She must also stop withdrawing from her family and her husband must learn to confront Felicia with greater authority. The tasks and techniques required to bring about these changes involved the entire nuclear family unity. They were living together and would be affected. I needed to see the family as a working unit.
Session Four
The children appeared at the interview with their parents. They were restrained at first with outbursts of occasional nervous giggling. I en-
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couraged the children to discuss problems which they saw in their family. They both mentioned mother nagging too much and not playing with them. Later a review of the family history was done in their presence. I wondered why Mrs Keats was so reluctant to talk about her youngest brother, but I decided to ask about it later. There was no information that the children hadn't known before.
Family role-playing was then attempted. The children played their parents' roles while Harry and Felicia acted as their children. Both daughters assumed the guise of a distant and hostile woman when asked to be their mother. The children were intensely aware of Felicia's withdrawal but did not know its cause. The children expressed the feeling that their mother must dislike them since she so often ignored them. Felicia played a very active role as one of her children. She proved that she could step out of her usual role and enter into a play situation with the children.
After the role-playing, we took stock of the tasks set previously. Felicia informed me that she was off her medications entirely. Harry complained that their relationship had not improved greatly over the past weeks. The children agreed that their parents weren't getting on with each other very well. I emphasised that the children were not in any way responsible for their parent's unhappiness. Children often blame themselves for their parents' discomfort. The session ended with two separate appointments being made. Mr and Mrs Keats were to return in two weeks while the entire family was to return for a videotaped session in four weeks.
I felt that I could now plan family tasks for changing reactions and relationships in the family. Mrs Keats reacted to her children by isolating herself. I mapped out several possible exercises for the conjoint session which could be elaborated upon outside of the session and whose emotional impact might alter the present situation. But I needed concomitantly to deal with the marital relationship. Mr Keats still allowed his wife to dictate to her family and I felt he needed more support to assert himself. Mrs Keats needed guidance in order to alter her relationship with her mother. I hoped that if she succeeded, the resultant reaction would relieve her feelings about damaging the children and alter her feelings about her own sexuality. She might even come to accept her mother rather than avoid and fear her.
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After a brief catalogue of the current unchanging state of affairs in the family, a long discussion ensued about the last session. During the reflection and analysis which followed, Felicia spontaneously connected her self-imposed exclusion of her children with her feelings about her mother. A flash of insight which I felt would make the solution to the family quandary easier. She spoke heatedly and angrily about the tense and unhappy relationship with her mother and burst into tears. I asked if her mother knew of her inner feelings but she recoiled from any suggestion of revealing them. She remarked that her family was not an open one. Here I remembered the hesitancy about her brother.
I asked her whether her youngest brother was involved in the family secrecy and she revealed that her younger brother was the cause of her mother's divorce from her father. Her mother had had an affair with her uncle, her father's brother, and had become pregnant. She wept again and said that she was afraid that she was going to ruin her marriage as her mother had. Harry sat by helplessly, unable to comfort his wife. I challenged his passivity and asked him to make some positive effort to comfort her and I left the room. When I returned Felicia was being warmly and firmly embraced by Harry. This instinctive move on my part grew out of my desire for Harry to take charge of his wife.
I set Felicia a definite task to involve her mother in the therapy. She agreed reluctantly to consider inviting her mother to the sessions but only as a last resort. Instead she offered to write to her mother and express her inner feelings. I pressed her to make this letter a firm commitment. I explained that it was necessary for her to change her feelings about and her relationship with her mother, in order to change her relationships with her children and ensure that her relationship with Harry improved.
I set Harry the task of asserting himself in an argument with his wife before the next session.
My feelings at the end of this session were mixed. Despite their reported lack of progress I detected that their relationship was improved and their marital bond strengthened. The lesbian affair and Felicia's fears about becoming a lesbian had receded into insignificance. I had weaned Felicia off medications unsuccessfully used for five years. I was especially pleased by Harry's ability to take charge in the session after my prodding in the office. I hoped it would generalise in thbe home environment. Despite her flash of insight, however, Mrs Keats had not yet effectively
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managed to change her underlying fears or alter her behaviour. I hoped that I had the right exercises planned for the next session and that my assumptions about her need to change her relationship with her mother were correct.
This was a conjoint videotaped session. The family seemed relaxed despite the presence of the equipment. The first game which I had devised for the family was one in which Felicia was to be held forcibly within a circle created by Harry and the children. She relaxed and was held by the family at first. She felt that this was a supportive, comfortable and happy position. She was asked to break out of the circle and did so with some difficulty. The next exercise involved her in an attempt to break into the circle. She immediately removed her watch and glasses; she became aggressive, hostile and angry as she tried to break into the tightly knit grouping that her husband and children had constructed against her. She only succeeded by injuring her oldest daughter. I felt worried by this. I had planned to follow a progression with these exercises but felt that I must now deal with the feelings aroused. Up to the injury things had gone as I expected. The second exercise revealed the way in which the family had closed ranks against Felicia. I asked Felicia to comfort Eileen as she did at home. She took her daughter on her knee and hugged her and patted her rump. The effect was to calm Eileen immediately and induce an intense rapport between them. I thought there was an intense identification based on sibling position and personality traits. Felicia completely 'took over' her daughter at one point. I asked Eileen to change places with her father. Felicia strenuously objected at first, saying that it was a ridiculous suggestion. I pointed out that there was no real difference. This was a paradoxical statement intended to highlight the sexual differences. My statement broke the tension and the family roared with laughter as Harry sat on Felicia's lap. I told her to pat his rump and the laughter redoubled. With no explanation, I felt that the message got across; they would thereafter always know the difference between physical comforting and sexual relations. There followed several attempts by Harry and Felicia to find a more comfortable way to cuddle each other. The children looked on with avid interest making suggestions as they watched. When a comfortable arrangement was found, I ended the games.
I asked them to tell me about their home work. Harry revealed that he had been very angry at Felicia one week previously, and the argument which followed ended when he threw Felicia out of the house. He still
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felt guilty about his behaviour and thought, at the time, she would ask him to leave the house. She related her version of the argument with a twinkle in her eye and seemed proud of Harry even while she related the details of his abuse of her. Harry had accomplished his tasks. I hoped he would maintain his new position. Felicia had not written to her mother yet and I asked her to bring a copy of the letter to her mother to the next session.
In order for the new experiences of the exercises to take root I set Felicia the task of going out with Eileen and Lesley to museums, beaches and other places. She was also to take part in activities with the children at home. I connected the feeling of being in the family circle with the task in contrast to trying to break into it. I asked the parents to return for the next session in one month.
The activity session graphically portrayed a progression from family quandary to sexual problems. Resolution exercises helped prepare the way for homework tasks. One interesting transgenerational influence was uncovered when Felicia remarked that her aunt used to fondle her bottom when comforting her as a child. The children served as consultants during the session, apprising the parents of their needs and suggesting ways in which these needs could be fulfilled.
Harry had achieved all that I expected of him in his handling of the row with his wife. She was proud of his new ability to assert himself. I believed that he would maintain this new behaviour since no transgenerational influences directly opposed this new style. The following session was to be in one month. We might return to the sexual work, if Felicia succeeded in writing to her mother. I felt that if she did, there would be no more resistance to work on their sexual relationship. The transgenerational influences and passage of sexual anxieties would have been compartmentalised; the past separated from the present.
Felicia had written a letter to her mother. She showed it to me and the following is an excerpt from it:-
Dear Mum
I have never been able to tell you about the way I feel about you. It has always been difficult for me. I am now seeing a psychiatrist who feels that my problems are partly due to my early life and all the things that happened at home. I always feel that you put me down
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and take advantage of me. You may not know that when I was twelve I used to be so frightened when you and Uncle John used my bed.I have tried to live my life differently from you and I still want to do that. Now that I've told you I don't expect you'll ever speak to me again but I had to write to you and it's no use hiding what I feel any more. I still love you as a mother and can't blame you for everything. I hope we will be able to get along better in the future now that it's out.
Her mother quickly returned a short note.
Dear Felicia,
I hope to see you at Christmas as per our usual arrangements. I never treated you any different than your brothers. I'm sorry you hold a grudge against me. I enclose the children's presents.
Felicia wrote back to her mother and cancelled their normal arrangements. She asked her brother to house her mother and stepfather for the holiday period. When they arrived, Felicia spoke to her mother alone for a long time. She bared her more negative feelings and as a result of their talk she felt that her mother would never be able to frighten her or push her around as she had previously.. Paradoxically, she felt an increased warmth towards her mother. The concentration on Felicia's relationship with her mother had borne fruit. Felicia reported an increase in communication and sharing between herself and Harry. Their sexual relationship had improved slightly as well. Felicia had no difficulty in carrying out her tasks with the children. The family outings to parks, museums and the beach had been enjoyed by her. She lost her fear of contaminating them. The exercises had shown her that the children valued her. Harry maintained his strength and had been able to take a more active role in controlling Felicia during her flareups.
Both Harry and Felicia felt that they were ready to work on the sexual side of their relationship. Felicia still had no orgasmic response to her husband. She found it difficult to find anything which would turn on her sexual feelings. Harry required specific education for his ignorance of sexual technique and female anatomy. They were both prescribed sex manuals and asked to resume their sensate focus exercises. The following session was scheduled as one devoted to sexual exploration.
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Several structural changes had occurred between the last session and this one. The relationship between Felicia and her mother altered; Harry took a more authoritative role with Felicia and the children; Felicia was more closely linked to her children; and the children had matured a bit by providing help for their parents. The children were now in a better balanced position between a relatively more distant father and closer mother. The balance between family members had been achieved but I was worried that it had been at the expense of Felicia's mother. I did not expect a total break in that relationship since nothing in the family history indicated that parents completely and irrevocably severed links with their children. I imagined that Felicia's mother was strong and would weather the storm. But I would dearly have liked to see her for my own peace of mind.
The sexual problem remained awaiting a solution. I hoped that a sexual exploration session would break through their naive fantasies about their bodies while their reading might increase the range of their sexual fantasies.
Mr and Mrs Keats were apprehensive and embarrassed. They were both asked to remove their clothes. An examination room of the conventional sort was used. I began by connecting Harry's genitals with the various words used for them in their assigned reading. Felicia was asked to examine Harry and touch his various private parts while she used these words. She blushed with embarrassment but she also became aroused. Here was evidence that there was a sexually arousing stimulus for her. Felicia was then asked to lie on the examination couch and a similar procedure was followed. I pointed out her anatomy and then asking Harry to do so. Both Felicia and Harry were surprised that they had been wrong about their assumptions of the position of the clitoris. Felicia found her husband's examination intensely stimulating.
The examination ended and after dressing we returned to my office. They both seemed flushed; the examination had actually provided Felicia with an experience which she could use in her fantasies. We first spoke about their reactions to the examination. Felicia had not found the reading material useful at all. They both seemed reluctant to discuss other aspects of their life although they admitted to a generally improved home life. They wanted to return home to continue their work on the sexual relationship. The examination session had a profound emotional effect on them. They needed time to assimilate their new
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feelings. For the first time, I felt that they were reluctant to share their fantasies with me. I asked them to continue practising their sensate focus exercises. They were reluctant but finally agreed. I asked them to phone me when they require further help on their sexual relationship.
I felt that most of the therapeutic work had been done. Their responsiveness in this session showed that they were able to enjoy a sexual relationship. But when they realised their reawakened feelings in the session they began to exclude me. There was a great deal of follow-up data that I wanted, but the session had plucked such deep personal chords that there was no room to talk about it.
They contacted me three weeks later; they reported that their sexual relationship had improved considerably. They both felt little need to continue treatment sessions. I suggested that they bring their children to watch their videotape sessions in two months. They could contact me if further problems developed. I was apprehensive because of the sudden cessation of treatment. My worry related to fears of unfinished business. I also experienced feelings of loss related to the effort I had put into the therapy sessions. I hoped for reassurance about the outcome of our work together.
The family which arrived for this session seemed a much more self-satisfied and complacent one than I had been expecting. My fears were unfounded. Their assurance and poise told me that their family life was settled and improved. After I greeted them, I asked them to watch the videotapes of their sessions on their own and left them in my office. I wanted them to experience themselves as a family without the need for an expert to interpret what they saw. I was not confident that they would see the change in their behaviour since the earlier sessions.
On my return the family had just finished drying tears of laughter. They expressed some disbelief that they had ever reacted as their images revealed. Eileen and Lesley felt older than their images. Felicia noted that she had been blaming everyone in her family for her behaviour in the videotape. She now realised that much of her behaviour was of her own doing. Harry was most aware of the passive way in which he acted and spoke. He felt that he had changed; he still avoided conflicts with his wife but not to an extreme. The parents admitted to a better relationship together, including their sexual relations. Felicia and her mother had been much closer since her letter and their talk. Her youngest
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brother recently took her to one side and praised her. He felt that she should have confronted their mother years ago.
I discussed with them my own feelings about the course of their treatment. The family had been in therapy for just under one year. I asked that they return for a follow-up session in one year or get in touch sooner if they needed further help. I discharged them to their general practitioner with the following letter:-
Dear Doctor,
I am writing to tell you that Mr and Mrs Keats, who have been seeing me over the past year, have been discharged from treatment. Although Mrs Keats was originally referred to the Sexual Dysfunction Clinic, I have been seeing them and their children in family therapy. I feel at present that they have established a better relationship. Their sexual relations are improved. Mrs Keats requires no medications, and their children report a happier home atmosphere.
Faced with the end of a difficult and complicated therapy I felt pleased at the final outcome and saddened at my loss of a good working relationship. I was surprised at the number of different techniques I had used. I believed that the effects of treatment would last despite the approaching adolescence of the children which must raise anxieties in the family.
The lesbian affair which had caused the referral had led us on to a tortuous pathway. It started with Mrs Keats and her feeling of anxiety, depression, guilt and disgust. MrKeats was included when I understood how his inexperience with women and sexuality collided with Felicia's needs. The transgenerational passage of sexually-based conflicts were traced to Felicia's grandmother's disease, death and its aftermath. The children were included in the sessions when Felicia's fear of contaminating them with a family taint became clear. Finally, her mother was indirectly involved in the therapy when her continuing influence became apparent. The effect of the accomplishment of the various tasks was a removal of symptoms, an end to medications and a strengthening of the marital bond.
A two-year follow-up of this case revealed that the youngest daughter had become a school refuser briefly six months after the end of the therapy. Mr Keats had dealt with this firmly without the need for outside intervention. No other unusual family or individual problems developed. The
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final outcome was a successful adjustment at this stage of the family's development.
Conjoint family therapy sessions do not automatically provide solutions and favourable outcomes to family quandaries. Janet Clergy was referred as a fourteen year old school truant. Her mother attended with her at the first session. The problem was explored in relation to the other family members. Two years prior to referral, Mr and Mrs Clergy had lost their two year old foster child when his parents abducted him one weekend. MrClergy became depressed and simultaneously developed a morbid jealousy of his wife. Their relationship deteriorated after he struck her several times. She became pregnant and he denied paternity. He required his wife to pay for the private abortion and subsequent sterilisation, but his jealously continued unabated. Finally his wife began fighting back, and Janet began staying home from school.
Her truanting was a minor problem, easily dealt with between her and the school, but the conjoint sessions which followed were difficult. MrClergy dated his jealousy to the loss of his foster son. He had also become depressed shortly afterwards when he had to clear the remains of a man from the railway tracks as part of his job. Several conjoint
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marital and family sessions failed to increase communications or improve relations between the parents. MrClergy was admitted to hospital following an overdose. When his wife found out about the admission she appeared at the hospital and signed him out against medical advice. Further treatment was offered but refused. He was much improved when taken off all of his medications. Home life seemed to have settled down. Six months later his wife went to live with her secret lover of two years' duration. MrClergy was seen by his general practitioner for help with his nerves, heavily in debt and facing eviction.
In this case family therapy seemed the appropriate form of intervention but Mrs Clergy had consistently been deceitful in her dealings with the rest of the family and the therapist. The original symptoms of truanting was easily resolved so that therapy may have been considered a success. But the family quandary was rooted in the loss of the foster child which destroyed the relationship between the parents. My failure to realise that the husband's jealousy was well-founded (accepting the wife's story without challenge) led to a poor outcome.
Conjoint family sessions were based on a false assumption and failed utterly to resolve the quandary.
1. R. Skynner, One Flesh, Separate Persons (Constable, London 1978), pp. 339-60.
2. S. Minuchin and B. Montalvo, 'Techniques for Working with Disorganised Low Socioeconomic Families', American Journal of Orthopsychiatry, vol.37 (1967) pp. 880-7
3. N. Ackerman, The Psychodynamics of Family Life (Basic Books, New York, 1958), pp. 308-15.
4. M. Crowe and P. Gillan, Training Programme for Sexual Inadequacy, privately published monograph, 1974.
