Combining psychoanalytic and systemic approaches in
family therapy
Half-day teaching at Prudence Skynner Family Therapy Clinic, 21st June 05
David Pocock, Head of Family Therapy, Swindon CAMHS, Psychoanalytic Psychotherapist in independent practice
Some
basic ideas on my position.
Apologies in advance that this is rather dense. I am
interested in pragmatism (what works) but I think, as a theory of knowledge,
pragmatism is too vague. Ideas have use if they speak to the reality of
people’s lives. Pragmatism needs to be tempered with a form of realism.
I think the
mainstream of family has yet to achieve an adequate epistemology. Social
constructionism contains a number of positions (see Vivien Burr’s Introduction
to Social Constructionism) some which are highly relativist (no knowable
reality which helps to anchor constructions) and others which accept that
reality exists - the fact we have bodies, and there is something real to bump
into (the “death and furniture” argument.)
Social constructionism
that has no relationship with realism (there is a real world that we can come
to know better) leads to the idealisation of not knowing. (Not-knowing is
better seen as avoiding the seduction of certainty – Mason’s “safe
uncertainty”) I like the idea of constraining social constructionism by linking
it to another epistemology; that of the self-psychologist Donna Orange who
talks about perspectival realism: there is a reality
– something always going on – but which cannot be understood directly (that would
be naive realism) but only from a perspective (hermenutics).
From social
constructionism and postmodernism generally we have come to understand how our
perspectives are formed through language, culture, discourse. So this is my
hybrid – which I now call (and it’s a bit of a mouthful) social perspectival realism. Close to Bebe
Speed “co-constructivism”, Glen Larner’s “knowing not
to know” on this.
There is much
written from a theoretical standpoint about integrating psychoanalytic and
systemic ideas. My personal take on this is that there is not much to be gained
from a wholesale integration – trying to fit the ideas into a super-model that
covers everything.
If you have one
model in your head e.g. CBT, or Kleinian, or structural family therapy or narrative
therapy then it is possible to begin to think that the ideas you have really
correspond to the reality in front of you. You might begin to think there are
actual things such as cognitive schemas, or objects, or cross-generational
coalitions or subjugated narratives. When you have two models in your head that
don’t fit together, but both of which seem oddly useful, you realise that what
you are really interested in is the stuff which always lies somewhere beyond
the theory. Reality is never fully captured by theories or words. Language can
be powerful in creating perceptions but it can so frequently fall short of what
really matters. (This is Stephen Frosh’s essential
critique on the partial way that postmodernism has been taken up in family
therapy – it is about the limitations of all forms of representation.)
So no need to try to
join them all up – instead these socially constructed perspectives can be slid
over the top of each other. Each way of seeing illuminates some of the
complexity in front of you but when you are looking through one theoretical
lens you aren’t looking through the others so I would say that each way of
seeing both reveals and conceals. For me the way forward is multiple lenses or
what is often referred to as eclecticism or pluralism (but moderated through
that other, sometimes useful, way of checking out the constraints that reality
imposes which is science). And of course that is only one activity of the
therapist and the therapist is only one participant in the purposeful play of
the family session.
The Sheila McNamee
paper on promiscuity seems to be popular given the frequency with which it is
quoted. And I agree with quite a lot in it. However, I have some doubts about
trying to learn an eclectic approach to family therapy. Most therapists who end
up as eclectic have arrived through a personal journey of serial monogamy;
becoming passionate about one way of thinking at a time.
I also think that
ideas are best understood in practice so this is what I am going to concentrate
on for the remained of this presentation.
1.0
–
“Who the fuck are
you to tell me what to do?”: Omnipotent states of mind
and their relational systems.
“Inscribing
the hurt”: A systemic-analytic approach to self-harm.
Break
3.45 – 5.00
Case discussion and
then wherever else our discussion takes us.
Optional fillers:
Idealising-denigrating
systems: understanding mother-son relationships in the aftermath of domestic
violence.
"Who the fuck are you to
tell me what to do?": omnipotent states of
mind and their relational systems.
Introduction to this topic:
At the moment I am
interested in the emotional adaptations people make to each other. In the
Systems of the Heart paper I put on the web I talked about the way children
lose something of their emotional selves in the interests of fitting in to
achieve a manageable adaptation. I’m going to talk about this in the section on
self-harm. A key parental and therapeutic task in self harm is attunement and
working to increase the range of emotional acceptability. Emotional attunement
so frequently goes wrong in early relationships that re-attuning sometimes feels like
it is the only parental or therapeutic task.
But
in this part of our afternoon. I want to talk about another fundamental aspect of development in
which the key parental and therapeutic task is the containment and survival of
rage when omnipotent states of mind are encountered.
I’ve chosen this
since I think there is an epidemic of uncontained omnipotence in the childhood
population. This may, of course, just be a side effect of getting older– but I
think on the whole there is some real and worrying shift in the handling of
omnipotence.
The first part of
the title of this section was offered to me by a nine year old boy shortly
before ripping my UKCP certificate from the wall, screwing it up and throwing
it at me. This was shortly followed by his chair and anything else he could lay
his hands on.
But it was a good
question. Who is entitled to tell him what to do (or to stop him doing what he
wishes)? And who are they to him when they do so?
I will begin with some
brief description of omnipotence as a state of mind but, as with all states of
mind, it is best understood within the context of a system of relationships and
requires not just new ways of thinking but also some active challenge. I want,
therefore, to outline a combined psychoanalytic-systemic-behavioural approach.
OHP1
How I am using the term
encompasses other terms in the left column
Narcissism Whole
object relating
Parent/child
enmeshment Clear
parent/child boundary
Attachment
insecurity Attachment
security
Paranoid schizoid Depressive
position
Exploitative use of
other Recognition of
the other as an equivalent subject
Can only manage one
to one Can manage to be one
of three or more
IWWIWWIWI Can bear frustration
In
your face. Under your
skin Comfortable to be with
OHP2
Understanding omnipotence
Origins
Part of the human
condition – Winnicott writes about the infant instinctively knowing what is
wanted – imagining the breast first before it appears. If the omnipotent wish
is repeatedly met well enough this leads to security in one’s object
(attachment figure). However, he says more than this – that ordinary good
enough “mothering” includes frustration – there needs to be some mismatch
between what is desired and the reality of what is on offer. If the mismatch is
too big there is great frustration leading to what we would now call attachment
insecurity.
Most people would
now consider the focus on the breast (and solely on the mother) to be too
narrow. The wider issue is one of attunement - the provision of safety,
empathic handling, stimulation, cherishing etc. Too attuned a response may
however lead to the infant being unable to give up the fantasy that their own
wish runs their world. Sooner or later (better sooner) some misattunement
between what is wanted and what is available and a capacity in the other to
contain the emotional fallout from misattunement is
necessary.
Mark Twain’s two
disasters
Mark Twain wrote
that there are two great disasters in life. The first is not having your dreams
come true. The second is having them come true. This sums up what I want to say
about omnipotence.
The third position
is that one’s dreams become modified along the way to something more realistic.
Having or not having the grand wish fulfilled is replaced by something smaller
and more often achievable – leading to relative contentment.
Not having your dream come true
In this first
disaster the child or adult patient in moments of frustration cannot bear the
reality of what is not available in the present. The frustration may become
particularly intense and turn to rage either because the deprivations in the
past have been too big and insufficiently worked through or, more rarely, there
has been too much ideal parenting (see below) and insufficient challenge to
omnipotence. In the usual range of development
this parental challenge and containment has been more or less achieved by the
age of three or four (terrible twos). The growing capacity for independence of
the toddler who now can act on his wishes comes into conflict with the reality
of what is good for him as perceived by the parents and others. Extreme
behaviour is, therefore, (in this way of thinking) an enactment of the rage at
not having the omnipotent wish fulfilled and is also used to attempt to bring
about the omnipotent fantasy.
In these situations
the child lives the dream but at great and miserable cost to themselves and/or
others. Carers or others may be captured by the child through over-investment
in the child, attention grabbing behaviour, childhood illness or other symptoms
that enrage or anxiously preoccupy parents or parent figures. Such children
often present as tyrannical with the captured parent but excessively anxious
away from that parent. The ordinary development of separation/individuation has
become compromised by the uncontained omnipotence.
Or the
child/adolescent/adult may find behaviours that substitute for the ideal as in
the excessive use of alcohol, food, drugs, masturbation, cutting, in which long
term well-being is sacrificed for the relief of feeling good in the short term
and the secondary gain of capturing intense adult concern.
Relational systems that support
omnipotent states of mind
A
shift in western cultural values now that much of the first world is richly
resourced. The Project of
the Self, self-actualisation, consumerism. How cruel
it now feels to give children a good diet rather than omnipotent baby foods
from MacDonalds or to place any limit on childhood
consumption or consumerism.
Cultural
denigration of authority.
To hold a benign position of authority is essential in the containment of
omnipotence. But to do so in our present western culture is to constantly
invite attack. E.g. children’s TV programmes.
An emotionally
cut-off or (avoidantly attached child) may become
locked into a system in which ordinary relating to carers is replaced by
mutually retaliatory interaction either directly (as in continuous argument) or
indirectly such as displacement onto teacher or more indirectly when the
child/adolescent internally regulates their rage into self-attack or various
kinds.
Parental
over-investment in the omnipotence of a child is often an unconscious
corrective script in response to childhood deprivation in the parents. Such
parents will have consciously or unconsciously experienced their parents as
un-giving or cruel. They may feel they are very much not in favour of the
omnipotent behaviour in their child but are unable to challenge it since to do
so feels confusingly similar to their own experiences
of being deprived.
In one recent case
the parents, in total exasperation, criticised and shamed their children, and
told them how much they disliked them in a way that was very difficult to hear.
Home life was dominated by shouting, cruel threats, despair, shame, rejection
and mutual disrespect. In tracking their interaction over one small incident I
raised the question of what would have happened if the parents had early on
imposed a sanction (of taking away for a short period a toy that was being used
as a weapon). The reply was “I could never do that – it would be so cruel.”
This is very common – that underlying abusive behaviour is an original (and
sometimes ongoing attempt) to never deny the child.
And/or there may be
an over-compensation in response to guilt e.g. Mother’s working long hours or
to compensate for an earlier perceived failure (brief case example later).
In parents who have
experienced serious emotional deprivation there is often a split along gender
lines. For women there can be a denial of the needy self and this is cared for
in the infant by way of projective identification. To say “no” to the child is
for the parent to deprive the child and herself. In families where there is
extreme neglect it is not uncommon to find large numbers of children all of who
become dropped when they stop being lovely and therefore no longer available
for the parent to project their own need for love.
For seriously
deprived men the denial of neediness can take the form of omnipotent tyrannical
behaviour – avowing that they need no-one but actually controlling and
exploiting all around the without any recognition of the needs of others.
4. Splits between
love and control
In a persistent
omnipotent state of mind the child has been able to sustain a split in the mind
between those who give him or her what is wanted and
those who cruelly deprive by saying no. There is always an actually split or
conflicted relational system that supports this state of mind – this is the
main focus of brief therapy.
Often there are
several such splits operating simultaneously.
Negotiating the paradox of care
and control
This I think is the
heart of the problem. To give a child what is needed requires a capacity in the
parent to, at times, deprive the child of what he or
she wants. There is a paradox - to give requires the capacity to deprive. This
paradox is hardly noticed by parents who have internalised sufficient care in
their lives but experienced as deeply confusing by those who have not. This is
revealed in the cliché
“You have to be cruel to be kind.” (Which itself can be an
indicator of some history of neglect in the parent).
In fact this is not
a helpful saying since considerably deprived adults can easily identify with a
cruel aspect of themselves. The key task in brief therapy is to bring out the
confusion, understand it as far as possible and to work to reframe the parental
behaviour needed to challenge omnipotence as “caring”. Since challenge and
containment to omnipotent states of mind is what is needed then it is deeply
caring to provide these.
q The task in brief work is to give
responsibility entirely to the parents for giving the child a new experience.
q In mutual retaliatory systems some regular
good experience needs to be introduced alongside limit setting. In
relationships in which love has become absent any limit setting will feel cruel
and will therefore be resisted.
q To work with the internal splits (indulgence
that suddenly switches to retaliation or collapse of parenting). Here it is
necessary to help the parent to bear being hated and rejected and to avoid
being caught up in the rage. The more the child is needed as a source of love
(to make up for earlier deprivation) the greater the difficulty at being hated
or rejected by the child.
q To work with splits between carers to avoid
the separation of the idealised caring role vs. the remote authority role. The
emphasis is on how to create and sustain this new experience and why this is
necessary including taking an understanding view of past parental difficulties.
I give this a higher priority than introducing new behavioural methods or
structural family therapy ideas although these are also extremely useful. If
the paradox can be managed then carers may be able to take in these useful
ideas but, if not, any amount of parent training will drop away.
q Splits between carers need to be managed by a
new coalition in which the child cannot capture a parent in a secret
parent/child coalition that undermines the co-parenting. For the enmeshed
parent this will mean tolerating considerable rage and will require some
understanding of what this means to the parent to be on the receiving end. For
the carer carrying authority split from love there needs to be some commitment
to forge a closer relationship with the child. With such a clear split a
classic task from the Milan Associates can be useful. Odd days, even days task.
This is never actually done – what it does do is to provide a focus for
thinking which can help to hold the new structure.
Further techniques
Use of
the time limited context:
Using the reality of
the time limited nature of the work to intensify the challenge to omnipotence.
This is our first of
three meetings, this is our second of three meetings.
Use of the setting:
Being inside vs.
outside of the room, the distinction between what can be played with in my room
and what cannot are boundary issues around which omnipotence and containment
can be enacted.
Looking for neglected exceptions
Moving to the level of dyads – i.e. not whole
family therapy
Clinical presentations
Cases
– RW – mother’s guilt about termination. Urgency assessment
Rabbit case – mother
couldn’t bear to be unpopular since her mother and grandmother had died. His
response was to demand more (rather than grieve) her’s
was to give in since she could not bear him or her to feel unloved.
Case
example of mother with eight year old – very tyrannical. “He is my baby”.
Inscribing the Hurt: A
Systemic-Psychoanalytic Theory of Self Harm
Brunner-Routledge:
Examples:
Amy – in Systems of the
Heart – parentified, in relation to both parents, loss of grandparent, older
sister moving in with new baby, mother siding with new stepfather. Interactive
regulation unavailable – shift to self-regulation through cutting, and reliance
on transference to teachers of rage displaced from her parents.
Stephanie – “fits”,
suicidal ideas, cutting. Mother insisting she has ADHD or aspergers.
Doesn’t talk to mother. (Mother with
a son with autism). At some point in the session she put her head back
as if straining to hold back feelings. I saw her alone and she was very different
did not feel close to mother. Was instead close to father.
He had an affair and she felt very betrayed. Now her
mother had taken him back. No-where to put her feelings.
Very loyal to mother – impossible to mobilise any anger all turned against
herself. Then revealed another secret family with a mother.
If she sees her every week she feels better.
David Pocock 21.6.05