Challenging a Singular ‘Inside’ Perspective

Fourteen-year-old Lizzie had a number of symptoms and came to therapy with a diagnosis of anxiety and depression. She attended the first visit with her parents who were separated and clearly conflictual with each other. They explained to the practitioner that Lizzie had an eating disorder, was rude and disrespectful to her mother and had ‘no friends’. They had sought help from several practitioners throughout Lizzie’s life who had worked with her individually and while the immediate symptom which had motivated them to seek therapy would resolve, something new would soon take its place. During the first session the practitioner noticed that Lizzie appeared to be powerfully engaged in her parent’s relationship and her difficulties were a battleground over who had caused to problem and how it could be resolved. She began to think that Lizzie’s difficulties would most effectively resolve by addressing the interactional patterns between all three family members that included the symptoms. However, when she attempted to explore these both parents joined to inform her that the problems were within their daughter with the express expectation that this is how therapy would proceed. How could the therapist proceed?

The supervisor made two suggestions:

The first was to praise the family and Lizzie for all the work that they had done on Lizzie’s personal ’inside’ world. However, in noting this she should also mention that this no longer seemed to be helping and that it was time to turn attention to the outside relational world. This could be tied to the ‘inside’ through adopting a developmental framework that located Lizzie’s struggles within her individual life stage, as a ‘growing up’ problem. However, in doing this she would note the importance of key relationships that needed to be conducted in a way that supported rather than undermined her capacity to differentiate.

The approach allowed the practitioner to take both a complementary stance in relation to the parents while simultaneously moving symmetrically to their rigid and unhelpful definition of the problem. This protected the therapeutic relationship from fracture while allowing the practitioner to work in a way she believed would be most helpful to the client.