Kelly, Jason and Sam

I have been interested in Kelly's Construct Theory since reading it about eighteen years ago. Sometime after, I became interested in computers and in many ways learning about computer programming prepared me for some of the ideas that were around in early family therapy. After listening to a recent lecture by Tom Andersen, I started reading more about this particular subject in terms of co-constructing, the use of therapeutic letters and rewriting life stories etc. I also became interested in particle physics and how this has impacted on our understanding of reality and how New Age thinkers have incorporated these ideas.

Many of these ideas were new to me and caused me to consider how we are as much a part of the universe as we are ourselves. By this, I mean we are as much physical constructions (bones, hair, blood, molecules, atoms etc.) as psychological ones (intellect, thoughts, emotions) and both physical and psychological processes are linked inextricably, as our body is to our environment, as the environment is to the planet and the planet is to the universe. In this sense, our identity lies as much outside us in our social relationships and experiences of the world, as it does inside us in terms of our mental processing and learning. I became increasingly interested in patterns and connections (on a cosmic, personal relationship and atomic level) and how we develop ideas (constructs), beliefs (collections of constructs) and how these things are connected to the physical and relationship world. Being a systemic therapist, I am interested in how patterns (physical and psychological) change and develop (restructure) and what effects that change.

Family therapists are interested in communication (in its widest sense) as a means of change. Human communication is fraught with difficulties because we each experience the world differently. The mental constructions around words, which lie uniquely within each one of us, and that give us our meaning system (our mental construction of who we are and how we make sense of the world) can be difficult to grasp and understand. Maybe, this is why listening skills are so highly valued in many societies.

I would like to share how I have applied some of my own developing ideas and those of others I have read, to a couple of cases I have worked on recently. The first is a boy with encopresis, and the second is a boy with separation anxiety. Although the therapeutic style is different in each of these cases (to suit the child and problem), I have used the same underlying ideas in both. The first case examines the methodology in more detail.

With encopresis, I begin by taking a full social history. Cases referred for family therapy have usually been cleared of any medical cause or complications. However, it is important to check to see whether the parents are convinced of this. I also check to see whether the parents believe the child could control the problem, if they wanted to. The subject of encopresis is dealt with in a matter of fact way, finding out what words the family use to describe faeces and relevant body parts. I have found that most families are happy with "poo" and "bottom" and phrases such as "the hole where the poo comes out". I usually check with the child whether they can feel the "urge" to defecate. If the child does not feel the urge, I focus on when they defecate - what time, place, event etc.

This particular child, Sam, was aged six and a half and was soon moving up to junior school from the infants. He had an eight year old sister who was intelligent and bright and presented the family with no problems.

When I work with children, I mostly do it in the presence of their parent(s) because the process of change in the child (in terms of new or strengthened mental constructs) is helped by change in their parents perceptions too. Learning how their children view the world can help parents to reframe their child’s behaviour. Reframing requires an ability to reorganise previously held beliefs.

I spend a lot of time talking with the child. This has to be done sensitively, and it can be hard to engage some children. It is important to gain some insight into their feelings and beliefs. Sometimes, I use drawing to help facilitate conversation and communication.

After talking to Sam, some developmental issues became apparent. Sam thought soiling was OK when you were a baby and that older children should learn to put poo in the toilet. He told me he would still like to be a baby in many ways. In this sense his soiling was congruent with his feelings. He and his mother mentioned the move from infant to junior school coming up in September.

Sam's mother wondered if his poor concentration was part of the problem. Maybe he couldn’t concentrate long enough to put his poo in the toilet? This led us to discuss issues around the concept of self-control and how his expectations and responsibilities might change as he got older.

I was attempting to construct a map of some of the areas of mental tension in Sam’s life between opposing and developing constructs he held about himself. Diagram 1, will hopefully aid your understanding of what I am trying to say.

There was a tension between his wanting to be both a baby and a grown-up child, a tension between his construct of what being an infant is and what a junior is expected to be like. When we discussed self-control, it became apparent that Sam could do lots of things he wanted to (for instance a jigsaw in the therapy room) and could concentrate if he was interested. He was more likely to be interested if he felt good about himself, he said. He told me he could control his poos if he wanted to and knew when he needed to defecate. At this point we discussed his soiling in terms of sneaky poos that cheated him out of being in control. He would have to pay attention if they were not to sneak out. This was a long period of discussion. I try to match how much time we spend talking to the child's and parents concentration levels. I find that parents are pleased to have their children spoken with (they feel that they and their child are being taken seriously). Most parents are very interested in hearing what their children have to say. The manner of my discussions are not blaming, but gently exploring in nature for the child and the parent.

Sam felt he could control his poos better if he tried, but wanted some help from his mother. His mother devised a contract with Sam. They agreed he should go to the toilet after every meal and that he should tell her if he defecated. She could remind him if he forgot to go. They both signed it. A target was agreed that he should have control of the problem by the time he was seven. This target was made some time ahead so as not to create too much pressure on Sam and his mother but was not made so far ahead that it could be easily forgotten.

In examining Sam’s established mental constructs before moving on to the newer ideas and thoughts about his future, I was hoping to excite the connections between them. At a molecular level, this would involve changing the links between constructs in his mind (brain). At the molecular level, all communication involves the use and direction of energy. Thus the therapeutic conversation becomes an energy focused tool.

What interests me therapeutically, is the area between constructs. These are what I refer to as the "areas of transformation". This is where the potential for change lies. By discussing opposing but developmentally related ideas, the tension (dissonance) increases between them and can cause a flip into more developmentally appropriate positions. This process can be conscious or unconscious. In Sam’s case, it was mostly unconscious. Apart from the contract Sam agreed with his mother, we did not devise a toileting programme.

This approach which focuses on ideas and change within a social and family context, a developmental framework and psychological model of mental constructs, has produced some very rapid results. Sam who had a four year history of soiling and constipation suddenly stopped. Within two weeks his mother felt safe enough to send him on a residential school holiday (she had been very protective) and he had no accidents there. In the first three weeks he only had one accident and since then (3 months) has been completely clean.

Sam stated in his follow-up session that he wanted to be a junior, a grown-up, and although he still liked the idea of being a baby, wasn’t one. However, he still wanted his mother to remind him about going to the toilet and she agreed to do this. I didn’t discuss sneaky poos again, but emphasised that he had acted much more like a seven year old and that it appeared he was more in charge of his life. He felt his mother was less angry and more loving towards him.

I am not presenting this as a rigorous scientific study, but as an article to generate some thinking. Qualitatively, this approach does seem to be as successful and faster acting than other behaviour and cognitive therapies alone. I often find angry and upset relationships associated with soiling and smearing. These relationships are characterised by symmetrical (escalating) relationships and are stuck in repetitive patterns of behaviour and response. Any positive change can significantly improve relationships and reduce risk. I don’t know what the long-term result will be for this boy, but in my work I rarely find children returning to full-blown encopresis unless there are serious factors around such as abuse.

The second case was with a ten year old boy Jason, who had separation anxiety. Jason’s mother had recently managed to get Jason to stay in school. He was still very distressed when leaving his house to go to school in the car and again when his mother left him there. She found this very upsetting too. His mother was concerned that if Jason did not learn to control his feelings that he would be ridiculed when he moved up to secondary school in the following year.

I took all the normal history about school, home, peer relationships, bullying etc. After a long discussion with Jason and his mother, we set a target for change which was Christmas (six months away). The goal we agreed on was for his mother to be able to leave him to walk into school on his own from the car. We discussed the differences between being a junior and secondary school pupil and what changes people might expect in terms of his behaviour. We discussed some of the worries around that transition. We discussed other worrying situations in his life that he had managed to overcome. Again the idea was to find some developmental milestones and points of change to use as a lever towards more appropriate behaviour. His mother felt that if she could leave him a little further away from his classroom each day that he might get used to being more independent about going into school. Jason, though not terribly keen, agreed with his mother that they could make a contract around this. I emphasised that there was plenty of time to achieve our goal but Jason could do it faster if he wanted to. His mother said she would be delighted if this problem were to go by Christmas.

I saw Jason for three individual sessions (this was partly in order to enact a separation) but we discussed his drawings and thoughts with his mother at the end of them. In the individual sessions I asked Jason to draw a worry map of his route to school in the mornings. He drew this on a large piece of paper. It was quite detailed and he marked the major sights along the way. His mother took him in the car along with his younger brother. He marked their house and the playground where he liked to meet with his friends, the dark road up to the park that made him feel scared, the shops he liked to visit etc. As he drew, we discussed his feelings along the route. The beginning of his journey to school was an upsetting point for Jason. On school mornings he was often slow to dress and was generally difficult about getting ready and getting into the car. After the car started he would calm down but at a certain point on his journey there was bridge across a river. The bridge had taken on an enormous significance for Jason. It was very scary and his difficult behaviour and fear became most severe when he got to it. It was a symbol of the point of no return. He knew once he crossed the river he would not be going back home. The other place of upset was when his mother actually left him at school. At this point she was having to take him into the classroom and stay with him for some time before leaving him crying and pleading for her to take him home.

We explored what this bridge meant to Jason. I asked him, if it were a monster, what would it be? He thought it would have Godzilla (a fierce movie dinosaur) on it. He drew Godzilla on the bridge and added his mum’s small car. Godzilla was breathing flames out all over the car. I asked him how he could protect the people in the car. He said they’d need a force-field to do that. We agreed to look into what might energise such a force-field.

I asked Jason how Godzilla had got there on the bridge. He thought about this for a long time and replied that he had put him there out of his head. I asked him whether he thought he could take him off the bridge in the same way. He didn’t see why not.

At this point I taught Jason a little about progressive relaxation. I wanted him to get relaxed in order to introduce some ideas. When he felt quite relaxed, I asked him to think of Godzilla on the bridge in all his fierceness. We talked about how Godzilla got in the way, stopping Jason from doing what he felt he should be doing. I asked him to think about his scary feelings and to take a mental photograph of Godzilla and the feelings associated with him. These were special photographs that included pictures and feelings. He created a box in his head and put the photograph into it. I asked him to think of another image, but he told me to wait because he had not put the lid on yet! The next image was of something that would produce good feelings in him. He thought of a huge piece of chocolate fudge cake with lashings of chocolate sauce. Again I asked him to imagine the feelings associated with the cake and to take a special photograph of it. Next I asked him to think of a time when he knew his parents had been really pleased with him. He thought of a time the week before when both his parents had expressed pleasure because of a fine piece of artwork he had produced. It made him feel very good to know that they were pleased with him, he said. He packaged this image and feelings into another special photograph and put it in his box. I asked him to keep this box in his head. That was not a problem he said, and I asked him to practice taking them out to see what they felt like. Before he went home, we practised changing the way he felt by taking out the pictures. We experimented by having two out at a time. Even with one good one and one bad one out, the good feelings always overcame the bad ones.

Later, he redrew the bridge with a huge piece of chocolate cake on it. The monster had been replaced with the chocolate cake. The river was a thick, chocolate sauce. I asked him how he did this and he told me that he had simply replaced one picture with another from out of his box. He told me he could change things by thinking about replacing them with others. We discussed how he could add or take away pictures from his box. I was pleased to hear this and hoped he was learning to control some of his fears by using these new mental constructs. What interests me as a therapist, is how these changes in mental agility can generalise into other constructs for instance about confidence and self-esteem (going into school on his own, facing high school).

After two sessions, Jason had stopped being difficult about leaving his house and was having no disturbed behaviour on the way to school. Over a period of two weeks his mother was able to leave him first at the classroom door, then at the school entrance and then at the school gate. I congratulated them on their good effort and Jason told me he did not think it would be long before he could be left at the car to walk into school on his own. He felt confident he would solve this problem before Christmas and that by the time he was at secondary school he would have been going into his school on his own for a long time. His mother was very pleased with him too and their relationship has improved as a result. She feels he is acting in a much more grown-up way now and he takes the credit for this with some pride. The sense of pride in being regarded as a more grown-up person may also have helped him to compete with his younger, less troublesome brother.

I hope the work we did together helped Jason deal with his fears and anxieties. He was propelled along by making more appropriate choices based on the development imperatives we had discussed. This was aided by new ideas he held about controlling fears, mastered by using mental images and by the different and improved relationship he was able to enjoy with his parents. The new way his parents viewed his coping behaviour reinforced his own belief that he could cope. This helped him believe that he was changing from a junior to secondary school child. It is as if once a change is considered, that a new space appears in which change becomes possible.

It is hard to know exactly what is happening inside another persons mind, and what changes are taking place as a result of our therapeutic conversations and expressed ideas, but I find the construct model useful and it has certainly resulted in change with my clients. I hope these case examples will help you to experiment in this area too.

 

~

Dennis Neill

Family Therapist

Family Therapy UK

1st May 2008