Case Example

The following is a brief history and a diagram for Gabriella. She is a 13 year old young lady of White British / Caribbean ancestry presenting with self-harm, on and off, since the age of 12, daily cannabis use and concerns that she was a member of a gang. Her parents have been having significant marital problems. Her father, a strict disciplinarian, was expecting Gabriella to obey his instructions at all times, not to use any substances, to be at home by 7 pm every day and to stop seeing all of her current friends as they were a negative influence on her. He was also insisting on going through Gabriella's belongings and mobile phone address book and insisting on checking if she had her periods for fears of her becoming pregnant. Gabriella's mother was suffering from depression and had little input into Gabriella's upbringing during periods of illness, although when she was well she was much more involved. She generally sided with Gabriella, perceiving the father's strict parenting style as the root of the problem but also felt unable to care for Gabriella at various points in her life. The immediate precipitant to the presentation was a break up with a boyfriend and an increase in self-harming behaviour.

The target problem here was designated as the difficult relationship between Gabriella and her parents, especially the father. When asked how the family would know if this was a worthwhile session, father immediately stated that the only way forward is for Gabriella to do as she is told and that he will not compromise under any circumstances. Gabriella and her mother said that they would value an opportunity to have their views heard. After some debate (and compromise) the current relationship between parents and Gabriella was rated as 1 out of 10. Each member of the family was asked how they would know that things have moved up one point to 2 out of ten. When mutual demands and accusations surfaced, the question was re-phrased to what each family member would do to contribute to this. The main agent of change (somewhat surprisingly) appeared to be the father. When asked what the family would do instead of engaging in power struggles he offered a variety of activities that all family members would enjoy. Gabriella then suggested that she would aim to stay at home more often (mother encouraged her with a surprised/happy remark) and listed several other things she could do, before saying, hang on this wouldn't be 2 out of 10, this would be 7 out of 10 already (everyone laughed). She also made it very clear that her father would spend more time with the family in her ideal future. In some ways the father already offered the same in his opening remarks. Mother was saying very little and the therapist was worried about her role in the process. Towards the end of the session she said she would know that things were better if she kissed Gabriella good night. Going back to the rating of 1 out of 10, the therapist explored what factors were responsible for the relationship not being 0. The following contributions were made: the fact that they all talk to each other and that they all sit together now. When asked to produce an example that would show the relationship was not 0, Gabriella described the family trip to a large out-of-town supermarket when she walked alongside her parents and shared a joke with her father - this was of course also an exception. The session was concluded with a plan derived from the family members' ideas and an offer to notice the elements of the preferred future until the follow up session.

Hi Gabby,

First of all I wanted to thank you for sharing so much of your life story with me and also to thank your parents for being open about the family difficulties. I enclose the diagram that we made. It mainly describes your relationship with your parents and I'm sure there are many other things that could be in the diagram but are not - as you know we could change it and re-think it as we continue to work. In this letter I thought I should briefly re-cap the main ideas that you and your parents discussed - would you feel comfortable sharing this letter with your parents? If not, I could write a separate letter to them or we could even write one together. As you may remember, the relationship between the family members was rated as 1 out of 10. I was wondering if this rating was still true at the end of the session but forgot to ask you. What did you think? I wanted to check with you if I forgot anything important that all of you mentioned about how you would know things were getting better. Your father thought of loads of things that you have enjoyed in the past, like going to the Tate Modern, going on a cycling trip in Norfolk and going to visit his brother who is a musician and whom I thought you liked very much. It seems you were particularly keen on the visit to your uncle Barry. I wonder what uncle Barry would have said had he been sitting in the session. You thought that if you stayed at home more often and did your school work, and did your bed in the morning, then this would contribute to a better relationship in the family, although that would definitely be more than 2 out of 10. You also thought that sharing jokes, having a meal together and spending time together would be part of this future change. I was very impressed with your observation that you and your parents were together at the assessment and that you did make an effort to do your homework and how that made a difference at school. The shopping trip to Bluewater particularly impressed me. You mentioned that you joked about your father being a shopaholic and how you even held hands there briefly. I thought it was important that you and your parents felt comfortable talking about your feelings of warmth towards each other. Your mum then also mentioned that she would know things were getting better if you had a good night kiss - this used to happen a lot in the past and used to make her feel good.

Gabby, as you know, I will see you next week and if you have an opportunity I would be interested to know if you (or your parents) can notice any more examples of an improving relationship over the next few days.

With best regards
Dennis