SSW at the Bouverie Centre: Case Examples
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How clients and workers benefit from a SSW approach
Chris and Molly
The following are excerpts from a taped interview conducted with a mother who had presented with concerns about her adolescent daughter. They had attended a single session together some months before, and in this interview Chris, the mother, gave feedback about her experience of SST.
Initially, Chris describes what led to the referral to Bouverie - her concerns for her daughter. "I wanted someone to help me but not take control of my life. Ongoing anything would have been a problem '¦You don't just send us out the door '¦ you do your follow-ups '¦ It's hard to remember everything '¦ but Colin and Nella were '¦ different '¦ Colin was challenging Molly '¦ it was good for her '¦ but then Nella was tuning in to how I was feeling '¦ I think it's an advantage having two different therapists."
I asked about previous therapy, and Chris told me about having been to a major hospital's psychology department. She said that they had a long "intrusive" questionnaire given to Molly's teachers '¦ "how intrusive is that?" "A one-off was fine"'¦ (She says again that she didn't want ongoing therapy and didn't want to wait).
I asked about whether she was aware of the choices she had at follow-up time. "Yes'¦.I've just forgotten now. She thinks she may have opted to go on the waiting list then: "I may be on the waiting list now".
I question her about changes. "Some things have changed, some haven't. She still wants to be independent '¦ but she's not damaging herself like she was. She's going to school, but often gets there late. (She then speaks to her dilemma around how much to try and assert her authority with Molly and how much to just let her go).
Regarding to what/whom she attributes change '¦ "Molly had given herself a fright and had pulled herself up before we came here '¦ it was good being seen sooner rather than waiting because of this '¦ I mean Molly's readiness".
Regarding her expectations '¦ "That someone would look at my daughter '¦ help me know whether what she was going through was normal '¦ talk to her '¦ help her directly."
If we hadn't offered SST? "I would have kept searching for somewhere '¦ but I had tried a few '¦ didn't like the places that were 'over the top' (that is, lots of questionnaires) '¦ I guess we would have got through it '¦ toughed it out. But with the single session '¦ I was reassured that she wasn't going to come to harm '¦ it was nice to have someone else say things to her (that I was struggling to say) '¦ You know it won't happen overnight, but '¦ I had a feeling with someone else saying it, not just me, she thought there must be something in it".
Now? "I'm trying to toss round whether she needs to go '¦ that would break my heart but maybe she needs to '¦ I don't know. She was really distressed at that time '¦" (Chris then talked again of Molly's furious independence, and acknowledges that this probably comes from her).
The 'J' family's experience of SSW
The 'J' Family genogram: Joan, Barry, Alice, Mary and Tim
Family history and presenting problems
Barry drove the referral for family therapy because he was angry that Tim was not responding responsibly to the opportunity to work in Barry's floor sanding business. Tim and Barry's conflict had increased at work to the point of physical violence. During the session Barry realised the he put pressure on Tim because he did not want him to make the same mistake Barry had made early in his adulthood. Barry had lived on the streets after his Mother attacked him at age 14. Barry had spent some time in jail. Tim was young and did not see the floor sanding job as the great opportunity Barry did. The session conducted by Jeff Young and was video taped
Letter from the family following SSW, written by Barry
To whom it may concern (Bouverie Family Clinic),
In answer to your request for feedback letter on our family session at The Bouverie Family Clinic on Monday 5th August 1996 '¦ On the Wednesday after the meeting we had our own family meeting to view the video followed by a discussion. I have personally watched the video about 10 times and will be watching it more. It is a fund of information and I still see new things each viewing and also change my perspective.
Barry - My commitments from the session
The relationship I want with Tim is -
'I am there for him, he is there for me, 5 days a week'. Tim agreed with this.
'It is OK if it doesn't work, you can go your way and I'll still be there'.
'It is OK for Joan to trust me'.
My result (Barry)
I regard the session as the gate to my life and have embarked on a course to discover my thinking - resentments, fantasies, perfectionism, worries, unattainable goals, hurting ego and internal loneliness. This means much work for me to which I am committed. I have support form Joan and others. It feels for me, that what I have been looking for, I have finally found. The key is identification and I am comfortable with this. I am turning by business slump around having only one debtor to pay off and have an amicable arrangement in this matter. Things are looking great and feeling much better.
Joan - 'what she got out of it,' as per Barry
All the family was interested in keeping the family together - solidarity. Nothing has changed as adirect result of the session, but the following have been acknowledged:
Changes in our relationship eg. helping with the book keeping is now a request from me, not an order.
Less intimidation by me, and we both acknowledge we require work in this area, ie. of kerbing the attitudes of 'Barry is the Boss'.
More time to herself, with me away for over 2 hours each night, with work commitments.
She loves me not drinking.
She loves Tim no longer working for me, with the exception that Tim is now out of work.
We have made a commitment to spend a minimum of one entire, whole day with each other 'doing something'.
Tim - commitments from the session
'All communication channels open'.
'I choose to be a floor sander and like it'.
Tim committed to doing an apprenticeship.
When Mary was acknowledging Joan and there was a bit of a pick session on Dad, Tim said,'Has anyone here acknowledged Barry, for what he does?'.
Tim said 'I found the session enjoyable'.
'If we go back for another session, I want Alice and Mary to be there'.
Tim - results, as per Barry
Nothing was done about the apprenticeship.
Much tension at work - not motivated
No sight of a bigger picture.
It is all my fault; he has nothing to do with any of the problems.
He complained about the hours be worked - so there have been a few 50 hour weeks! But over the two years, he has averaged under a 30 hour week and worked one weekend a month.
I needed someone to help me finish a reasonable week's work. After so many let downs, I decided 'words are cheap'. We agreed to part amicably. On the surface all appears well, I am saying nothing, and hope for his growth.
Alice and Mary, as per Barry
Alice and Mary seemed to have no issues in regard to the session. From time to time they do have issues with Tim, and they deal with these and any of their other issues as they see fit. They are there for support.
The video
We wish to keep the video and have no copies of it, but would feel OK if there was a need for it to be viewed, on arrangement. Basically, we would feel very uncomfortable not having control of this video.
Summary
We wanted help and received it. Words are not enough to express our thanks, but thank you, to each and every one of you from the receptionist to the therapists and all other people behind the scenes. I look at our world and its peace, or lack of it, beginning at the dinner table, or in other words, with the family. Healthier families make happier people. The service you are providing is great and I personally have thought for many years the profile of Family Therapy needs to be much bolder in the Health Services. Keep up the good work. Once again, many thanks and if I can help you please contact me on pager or phone home after hours on......
A Worker Consultation and a Supervision Analogy
A Case example: counsellor consultation
During a consultation, Marcia, a counsellor working at a Family Support Agency, asked one of the authors for ideas on how to engage Doug, a homeless adolescent whom she had seen on several occasions. Doug had a range of difficulties including mild drug abuse and self damaging behaviours. Doug would only attend when he wanted and would not attend for regular counselling. Marcia had referred Doug to a more experienced therapist, but he had refused to attend. Further inquiry discovered that Marcia was providing an extremely valuable service for Doug, sometimes offering a supportive ear, sometimes basic food and shelter. Marcia also reported that half of each meeting was dedicated to engaging Doug and trying to ensure he returned the following week for a planned appointment, which he seldom kept. Suggesting Marcia had already engaged Doug and that Marcia adopt a single session approach - achieving as much as possible in each session - helped Marcia spend much more time responding to what Doug wanted, ironically engaging him further (Young & Rycroft, 1997).
A Supervision Analogy Helps Make Sense of SSW
The apparent fact that approximately 50% of random clients report being satisfied with one 90- minute therapeutic session (and accompanying telephone contact) has threatened our belief that significant client change usually requires longer and intensive therapeutic effort. Given that we have trained for many years guided by this belief, we have not taken this challenge lightly. At the same time, this same apparent fact has confronted us with the currently unpopular view that the therapist, or more accurately, the therapeutic context, can be very influential (i.e. powerful) in clients' lives. We have begun to consider the analogy of clinical supervision to help us understand and reconcile these observations.
Therapists working in a range of models and with various degrees of ability find value in supervision. Typically, a supervisee will approach a more experienced clinician (*) to act as a supervisor, and presents his/her most difficult cases or at least ones in which the supervisee feels most stuck. Because supervision usually only occurs once a week or once a fortnight, considerable prioritising regarding which case to present is usually involved. The supervisor may spend between 30-60 minutes helping the supervisee, utilising many therapeutic skills including curiosity, questioning, some education and advice giving. Often this one-off session is sufficient to enable the supervisee to complete even the most difficult of cases. Maybe a further session will be required down-the-track when the supervisee again feels stuck. Seldom however, does the supervisor insist on a block of supervision sessions for one case.
The supervisor and supervisee may meet regularly but will usually discuss a range of cases. If the supervisee has good general skills, the supervisor's minimal input can be profoundly helpful and is often sufficient to allow the supervisee to complete the case, as well as providing some skills which the supervisee can use with other cases. The parallel to Single Session Therapy is unsettling. Supervisees are seldom considered failures for needing supervision; in fact, it is often seen as good practice to seek supervision; whereas, clients often feel like failures and are implicitly seen as failures for needing to attend therapy. If therapy were seen more like supervision - a place to gain some assistance when stuck with what life throws us - therapy may be less stigmatising. Maybe if we considered our clients as being more like ourselves than different, it would be easier to have greater faith in our clients' ability to change with minimal external input.
Harville Hendrix (1996: viii) makes an important distinction between the time it takes clients to change and the time required in formal therapy, "Therapy is a healing process that requires a long time, but not necessarily a long time in formal therapy sessions". We are not convinced that significant change always takes a long time. In a workshop at a recent family therapy conference, we asked therapists what events and experiences had precipitated the significant changes in their lives. To our surprise, roughly half of those people described single external events (eg. an embarrassing event, a film) that either led to immediate significant change or precipitated a personal process of growth and change, as suggested by Hendrix. The beliefs that "deep" or significant change can only occur from longer-term therapy seems to emerge more from our view of therapy and our clinical theories than from our personal experience (Young & Rycroft, 1997).
(*) Whilst it works best when the supervisor is seen as more experienced, it is not necessary if the supervisor acknowledges he/she is not more experienced and relies on process strategies such as reflection.
