WHEN I WAS A CHILD, I sometimes saw monsters in the dark as I was falling asleep at night. These were of course shadows in shapes that my childish imagination could construe as scary monsters. To feel safe, I would pull the covers over my head and close my eyes. Then I was able to drift off to sleep. In the morning the monsters were gone and I didn’t give them a second thought. It never occurred to me to wonder if they were real or not, any more than a child who has an imaginary friend asks herself if the friend is real. Children believe in many kinds of imaginary beings that they know are not exactly real yet exist for them in some way or other. Unlike adults, children don’t always distinguish sharply between reality and nonreality. And therapists who work with children must keep in mind this difference between adults and children.
One day last autumn, a very worried mother called me about an unusual problem that her daughter was having. “My daughter feels like invisible people are watching her. She’s very frightened,” Alice Farnsworth said in a faltering voice on the phone. She continued, “My sister-in-law is a nurse and she thought that Katelyn might be having delusions or hallucinations. She said Katelyn could have schizophrenia or paranoia. Do you work with this kind of problem in children?”
I tried to be reassuring, as Alice’s high-pitched voice sounded tense and worried. “Yes, I do. I’ve treated children with all kinds of fears,” I told her, sidestepping the diagnostic question of schizophrenia or paranoia. In fact, although I see children with a range of anxieties, the fear of being watched by “invisible people” is something I’d seen only twice before. “How old is Katelyn?” I asked Alice.
“She just turned ten.”
“Why don’t you and your husband bring Katelyn in later this week?” I checked my schedule. “How about Thursday at, say, four o’clock?”
“Thank-you, we’ll be there,” Alice said.
Thursday was a perfect autumn day. The air was crisp and the sky was a deep robin’s egg blue. I was excited about meeting Katelyn and her family. The case was especially intriguing to me, not just because “feeling watched by invisible people” is unusual but also because of the difference between adults and children in regard to this symptom.
If an adult reported that he or she felt watched by invisible people, a therapist might well regard it as a delusion. In psychiatry, a delusion is a fixed belief that is resistant to reason, such as a man’s claim that he is Jesus Christ or the king of England. This would be a sign of a serious disorder for which medication might be a viable option. A hallucination is a perception of something that does not exist outside the mind. The ghost of Hamlet’s father, for example, is sometimes played as a hallucination. The hallucinations associated with schizophrenia, however, are typically auditory—usually described as “hearing voices”—rather than visual.
One must be cautious when thinking about delusions or even hallucinations with children, for children are very different from adults in how they experience the world. Children have a rich fantasy life, where make-believe and everyday reality frequently intersect. The pediatrician and child psychiatrist Donald Winnicott calls the imaginative world of children a “play space.” This is where Santa Claus, Winnie the Pooh, and the tooth fairy exist. Winnicott emphasizes that adults should not challenge a child’s imaginative beliefs in the same way we would challenge adults who held the same beliefs. We wouldn’t think of telling a young boy that the tooth fairy is a figment of his imagination, but we would certainly have concerns if his mother expected a winged creature to bestow a gift on her when she lost a tooth.
I had these ideas in mind as I anticipated the Farnsworth family’s visit. When I walked into the waiting room at 4:00 p.m., Katelyn was reading the latest issue of National Geographic Kids. She was very pretty, with pale skin, high cheekbones, and blond hair pulled back in a ponytail. Her parents, Warren and Alice, were having a quiet conversation in which they seemed to be disagreeing about something. They were both tall with blond hair and blue eyes. Alice wore an elegant white linen dress. I greeted them and shook hands, and we walked into my office.
Alice spoke first. “Katelyn feels like she’s being watched by invisible people.”
“Really?” I asked, turning to Katelyn. “So you don’t actually see them, but you feel like they are there watching you?”
“Yes. And it’s scary.”
“And how often do you feel like the people are watching you? Is it every day, twice a day, or more often?” I wanted to get a baseline for the frequency of Katelyn’s experience, so that I would be able to tell when we were seeing improvement.
“It’s almost all the time,” Katelyn replied. I was surprised that she didn’t have any hesitancy about talking to me. She seemed like an exceptionally verbal and outgoing child, and her vocabulary was sophisticated for a ten-year-old. I thought to myself that her parents probably had conversations with her about a variety of topics, and undoubtedly encouraged her to read books beyond her grade level. “And the invisible people make you feel scared?”
“I feel really scared. Sometimes I get scared at night and then I run into Mommy and Daddy’s room.”
“Katelyn has been sleeping in our bed lately. It seems to comfort her,” Warren said.
“But it’s not a permanent solution,” Alice added. Warren nodded in agreement, frowning as if to say that they had tolerated this behavior long enough.
“What makes you scared at night?” I asked Katelyn.
“I’m afraid that Mommy or Daddy will die. My friend’s mother died in a car accident.”
Alice clarified: “This happened a few months ago. It was really tragic. She had three children.”
“I see. That was very sad.” So Katelyn’s fear was somewhat reality based. I asked her, “Do the invisible people ever talk to you?”
“No!” Katelyn said emphatically, as though my question were silly. “They just watch me.”
Now that I had a better understanding of Katelyn’s experience, I needed to hear a little more about the family. Katelyn was looking hopefully in the direction of the sand tray and miniatures, so I invited her to play while I talked with her parents. I told her that she was welcome to join our conversation at any time. Katelyn didn’t need any more prompting. She went over to the sand tray, sat down next to it, and started picking out tiny figurines and examining them.
“Look, Mom. Here’s Dorothy, and the green witch, and the Munchkins.”
“We took her to see Wicked for her birthday, so she’s really into Wizard of Oz,” Warren explained.
“Is Katelyn having any problems at school?” I asked, shifting the conversation to the matter at hand.
“No, she’s not really having problems as such,” said Alice. “But her teacher told us at the last parent-teacher conference that she wasn’t working up to her full potential. We agree with that.”
Alice and Warren told me they had two boys, ages fourteen and sixteen, Warren’s sons from his first marriage. Warren had full custody and the boys lived with them. “I think it’s hard for her because her brothers are so much older than she is. Sometimes I think she feels left out,” said Alice. I looked over at Katelyn, but she was engrossed in her sand play. I asked about the parents’ jobs. Warren was a high school drama and music teacher, and Alice was a project manager at an electronics company. Our time was almost up. Katelyn, meanwhile, had filled the sand tray with patterns of shells, leaves, and figurines. The arrangements were strikingly colorful and varied. What a rich imagination this girl has, I thought to myself.
I took out one of my little notebooks and said to Katelyn, “I’d like you to write in this notebook every time you feel the invisible people watching you. Write the day and the exact time that it happens. Then write about all the feelings you’re having. Write about everything you’re thinking and whatever you feel. Don’t leave anything out. That’s very important. Write down every detail. Okay?”
“Okay,” Katelyn said, taking the notebook.
“And I’d like to talk with Katelyn alone next week.” We made an appointment, and they left.
As I prepared myself for the session with Katelyn, I had several questions in mind. Who was her symptom protecting—perhaps her mother, or was it someone else? Usually a symptom has a specific function in the family. Was Katelyn drawing attention to herself in a very dramatic way to distract her parents from some problem of their own? What was the metaphorical meaning of the invisible people?
I opted to frame Katelyn’s unusual symptom just as I would approach any other childhood fear. I did not choose to see it as a delusion, any more than I would think that a child who told me that she had an invisible friend or saw monsters in the dark was delusional.
I decided that a strategic dialogue would help Katelyn feel better and help me uncover more about the meaning of the invisible people. This is the technique I used with Elizabeth, in which I asked her a series of carefully designed questions about precisely how she washed her hands—with hot water or cold, with soap or without soap. By using this dialogue, I had let Elizabeth know that I fully accepted her hand washing and wanted to understand more about her experience. With Katelyn, I was hoping to find exceptions or times when she didn’t feel she was being watched or when she felt less scared. Hitting upon these exceptions in the strategic dialogue actually gives the child the feeling of being more in control of her fears or other problem behavior such as hand washing. The strategic dialogue addresses the child at the level of perception and feeling, not merely at the level of thinking.
At our next visit, Katelyn came in willingly and sat down on the couch. We looked through her worry book together. She had dutifully made an entry at least once a day, writing that people were watching her and that she felt scared. She also wrote about a mean girl at school who was trying to take a friend away from her. Katelyn seemed comfortable talking with me, so I decided it was time for my invariant question.
“Are you more worried about your mother or your father?” I asked. She replied right away, “I’m more worried about my mother. When she comes home from work, she screams at everyone because she’s really stressed out.”
“Is she stressed out about her job?”
“Yes, I think mostly it’s her job. But she also fights with my father. He’s not that nice to her. Like once Daddy yelled at Mommy that he was sick and tired of her asking him to fix things around the house. Then Mommy went into the bedroom and slammed the door really hard. That was scary.” For a ten-year-old, Katelyn certainly had more than her share of worries. I would have to talk with her parents about this. I jotted down a few notes and then turned to the strategic dialogue.
“Do you recognize the invisible people, or are they strangers?” I asked. Katelyn thought about this for a few moments. Then she said that the faces of the invisible people seemed to be familiar, like the faces of some of the kids at school. Good, I thought to myself. She was choosing the less scary alternative. My goal was to have her experience the feeling as less frightening.
“Do you feel like the people are going to hurt you, or are they just watching you?”
“No, I don’t feel like they’re going to hurt me. They just watch me.” Again she picked the more benign alternative. Of course, I didn’t pursue this line of questioning because I didn’t want her to think the experience was scarier than it actually was. In the strategic dialogue, the child typically chooses the less frightening of the alternatives, thus moving gently toward a reframing of her experience. So Katelyn’s invisible people turned out to be known to her, not strangers, and harmless instead of harmful.
At each step, Katelyn chose the more benign alternative, so that slowly she began to feel that there was nothing really threatening about the situation. Now it was time to paraphrase what Katelyn had told me. Paraphrasing makes the child feel in charge of the conversation, as though she is leading the way and I am just trying to follow her train of thought. Many children’s symptoms serve the purpose of giving the child a feeling of control in a difficult situation. Having a symptom, especially a worrisome symptom, gets a lot of parental attention that the child might feel she cannot get in any other way. The symptom thus becomes a child’s attempted way of gaining more attention from her parents. But this solution itself becomes a problem in which the child eventually feels trapped. The strategic dialogue offers her a way out. The more sense of control I could give Katelyn, the less trapped she would feel.
“So you feel that the people watching you are familiar people, kind of like the kids at school. And they don’t mean you any harm. Is that right? Do I understand you correctly?” I was putting her in charge by making her the expert on her own problem. And in making her the expert, in a sense I was putting myself “one down.”
“Yes,” said Katelyn. “That’s right.”
“Okay. Good. Do you have this feeling more often when you’re alone or when you’re with other people?” She thought about this for a minute.
“It’s more when I’m alone, like after my dad drops me off at home after school. When I’m on a playdate or at the park with my friends, I don’t feel like the people are watching me.”
I had now found an exception. There was less of a problem when Katelyn was with friends, more so when she was alone—especially when her dad dropped her off. Was she feeling cut off from her father? I was now forming a hunch, a working hypothesis.
I said to Katelyn, “Maybe you’re just feeling lonely.” At these words, Katelyn breathed an audible sigh of relief and sank back into the couch cushions. Her face relaxed. She clearly felt that now I understood her. Katelyn told me that she did feel lonely, especially in the afternoons. Her brothers usually had basketball practice or games, so often there was nobody at home with her. Even if her brothers didn’t have practice, they played basketball in the backyard and ignored her. She felt left out.
I told her that I would speak with her parents about this. Perhaps sometimes they could arrange for her to be at a friend’s house after school. Or maybe her father could spend a little time with her. Katelyn also told me that occasionally she felt pressured by her mother to do things perfectly, especially her schoolwork. She loved to work with her mother on art projects, but her mother was critical—every little thing had to be perfect. Ah, I thought to myself. A critical parent might well make a child feel like she was being watched.
Alice came to the next session without Warren, who had to fly to Sacramento to visit his mother in the hospital. I asked how Katelyn was doing, and Alice told me that her feeling of being watched was “a little bit less often.” I was happy to hear that. I have noticed many times that the strategic dialogue can bring about a change in a child’s feelings and perceptions even after a single session. Also, I was happy that her mother was seeing improvement. This would give her confidence in me and make it more likely that she and her husband would comply with my directives.
I asked Alice if she and Warren had arguments in front of the children. Alice told me that she sometimes felt undermined by Warren when she tried to discipline the children, and his attitude made her angry. She said that he always wanted to be the good guy, a buddy to the kids, which forced her to be the bad guy, the disciplinarian. Alice candidly told me that she felt like their family was split into “two warring tribes.” Warren and his sons were in one tribe, and she and Katelyn were in the other. If she said that one of the boys had to do a chore or walk the dogs, Warren would object that the boy had too much homework. If she asked Warren to fix the garbage disposal, he would think of a million reasons why he couldn’t get to it that day. And then he’d forget about it entirely. Instead of spending time together in the evenings, Warren would retreat to his study and play video games. “I wish that just once he would suggest watching a movie together or going out to dinner. I wish he would come over and hold my hand,” Alice said. “I feel like I’m staying in this marriage only for the children.”
Alice described Katelyn as the “mom defender,” the one who always sided with her. I could well imagine that Katelyn was bearing the brunt of all this family strife. Not surprisingly, the most vulnerable member of the family had become symptomatic of more deep-seated problems between the parents. At first glance, at least, the child who is the most empathic and caring becomes the “identified patient,” the one with the problem. But in truth the family is the patient. Anyone in the family can be the identified patient; it is not always a child. A husband can become depressed. A wife can become agoraphobic or have panic attacks. A young adult can drop out of college and start to use drugs. But in all these situations we must look at the purpose or function that the symptom is serving in the family. Who is becoming more connected by the symptom? For what larger problem is the symptom a distraction?
Alice’s narrative made the source of Katelyn’s problems clearer to me. Instead of the parents maintaining a healthy hierarchy, with clear boundaries around them, Katelyn’s father was allied with his sons and cutting Katelyn’s mother off emotionally. This pushed the mother and daughter toward “enmeshment,” or overcloseness, their mutual loneliness driving them together. I could imagine that Katelyn’s loneliness was a reflection of her mother’s loneliness in her marriage. Warren had distanced himself because of his wife’s demands and expectations of him. Alice and Warren’s situation reminded me of what famed family therapist Salvador Minuchin calls the “signature arrangement of the troubled middle-class family.” A mother’s closeness to one of her children is an emotional substitute for intimacy in her marriage. A father, too, can substitute closeness with a child for closeness with his wife. No wonder Katelyn had become symptomatic.
But Katelyn’s particular symptom was not inevitable. The reason the symptom took the particular form it did might have had something to do with her feeling scrutinized by her mother and held accountable for any little mistake. A family therapist cannot know precisely why a child has one symptom and not another, or why one child in a family takes on the role of the identified patient, leaving the other children to go about their normal lives. And then again, many marriages come to the brink of divorce without a child having symptoms at all. No matter how well family therapists understand family dynamics, some puzzles always remain.
Alice didn’t wear her emotional vulnerability on her sleeve. She had the outward persona of a tough, competent, and intelligent woman who seemed very much in charge of any situation. But beneath her strong outward demeanor I could see that she was also angry—and lonely. An old Irish proverb says “Strife is better than loneliness.” Couples who are lonely in their marriage often fight because the anger gives them at least some trace of connectedness with each other. Fighting may be an attempt to restore their lost connection, and can be a substitute for lost intimacy.
Alice revealed another cross-generational alliance that could possibly spell trouble. Warren’s mother had lived with them for the year following her divorce. This was eight years ago. Alice felt that her mother-in-law had always taken her husband’s side about discipline and was the source of many conflicts between the couple. She ignored Alice’s rule that the boys had to be in their rooms by 9:30 on school nights—sometimes watching television with them until 10:30 or 11:00 p.m. Finally, Alice had insisted to Warren that either her mother-in-law move out or she would move out. Warren eventually did ask his mother to leave. Alice had tears in her eyes as she told me the story. Since this incident, she had built up an emotional wall between herself and her husband. But for all she had been through or perhaps because of it, Alice had remained strong. I admired her devotion to her children and her determination to help her daughter, however painful the journey might be.
Toward the end of the session, I mentioned that Katelyn had told me she felt lonely at home after school. Could Alice pay one of Katelyn’s brothers to babysit for her? Alice thought that was a good idea—the boys always needed money. “But they’d have to play a game with her or take her out somewhere to earn the money,” she said. I thought that would help a lot. Katelyn would love the attention from her brothers. I also asked if Warren could spend a little time with Katelyn after school. A general rule, when trying to strengthen boundaries around parents, is to get the less involved parent more involved with the symptomatic child. Alice questioned this, as I thought she might. But in the end I convinced her, and Warren made time in his day to do this.
I then scheduled an appointment for Katelyn and a separate session for Alice and Warren. And I wrote out a few simple recommendations for the parents—to keep their arguments away from the children, to pay their sons to babysit Katelyn, to go out together on a date once a week, and to avoid putting too much pressure on Katelyn. I suggested that Warren be the one to help Katelyn with her homework. I also suggested that Alice try to go to the gym to relieve her stress. I asked that both parents make a point of reassuring Katelyn that they were taking good care of their health to try to allay her fears about their dying.
Alice asked me, in her typical direct fashion, what all these written recommendations were meant to accomplish. Jay Haley used to say that family therapists should not share their views about the protective function of a child’s symptom with parents. I tend to follow his advice and keep my reasoning to myself. But since Alice did ask, as parents sometimes do, I felt I owed her a straightforward answer. I told her that I thought that Katelyn was protecting her with her symptom by deflecting Alice’s attention from the other stresses in her life and the marital discord. Alice understood this very well. “I was the protector in my own family,” she told me. She said that it would take her and her husband a little time to implement my strategies, but she understood the rationale behind them.
At her session two weeks later, Katelyn told me that her feeling of being watched was “less often.” From feeling it all the time, she said she now felt it “about three times a day,” and the feeling wasn’t as scary.
“It feels more normal now,” she told me. “It almost feels like I’m an actress on a stage and an audience is watching me.”
I thought to myself that her parents must be implementing my directives thoroughly to be seeing this much improvement in so short a time. I asked Katelyn how her parents were, and she told me that her mother wasn’t yelling as much. Katelyn wasn’t worried about her mother anymore and no longer feared her parents dying. Good, I thought. Therapy was helping.
I asked Katelyn if she was still writing about her fears in her worry notebook. She told me that she “was getting lazy” about writing. This is typical. Although the notebook helps at first, when the child starts to feel better she tends to forget to write about her problem. The worry notebook is a strategy that parents can easily use with their children, even without therapy. Journals and diaries have long been a method of externalizing unpleasant feelings and reducing their intensity. Just writing down their concerns often makes children feel better, whether or not they discuss their worries with an adult.
Katelyn told me that her father was spending time at home with her after he picked her up from school. He had started going in to work early so he could stay at home with her after school three days a week. Her brothers seemed to be home more often as well, and they had played Monopoly with her twice. She didn’t have much more to talk about in the session, so we played the game of Othello. Katelyn caught on to the game right away, figuring out that she had to secure the corners and the edges of the board. She had never played Othello before, although her father had showed her how to play Reversi, a similar game, on his computer. Katelyn and I had fun discussing strategies.
Old-fashioned board games are a treat for children these days, as they provide the opportunity for personal interaction that computer games and game machines often do not. Sadly, electronic games and the computer itself have supplanted board games and card playing in many families, taking away the intimate contact with parents that these diversions provide. Game playing is a wonderful way for parents and kids to laugh together, strategize together, and engage in healthy competition.
As we’ve seen, families have a great capacity to heal their members. Katelyn’s fear of being watched by invisible people, although it seemed like a terrible problem—one that some therapists might have diagnosed as paranoia—was overcome mainly through the efforts of her parents. The underinvolved parent, in this case her father, began spending more time with Katelyn. My strategic dialogue helped Katelyn, too, by validating her fears and feelings and leading her to reframe her experience as benevolent instead of frightening. She was able to connect the “invisible people” with her ordinary loneliness, and realize that in situations with other people, she did not feel lonely or feel she was being watched.
As much as the strategic dialogue helped Katelyn, I have found that in order to defeat a problem permanently, change also has to occur within the family. Individual techniques, though they are good supplements, by themselves are not enough. A child may feel better after a session of strategic dialogue, or after a session of play therapy for that matter, but if she returns home to an atmosphere of parental hostility or distance, her good feelings will not last very long.
The fourth session, two weeks after I met with Katelyn, was with Alice and Warren. We still had the problem of improving Katelyn’s school performance. And I needed to strengthen the parents’ marriage so that Katelyn could become a little more disengaged from her mother. At the beginning of the session, Katelyn’s parents told me that she showed significant improvement. She was no longer complaining of being watched by invisible people, and she wasn’t waking up frightened in the middle of the night and coming into their bed.
Warren and Alice admitted that they were not usually on the same page about discipline. Alice tended to lose patience and yell, while Warren was more easygoing and patient. And, like most parents, Warren and Alice hadn’t been aware that their disagreements and negativity might be affecting their child. I suggested some compromises. If Alice backed off on discipline, Warren agreed to take more of a role. He would see to it that the boys did the chores they were supposed to do to earn their allowance.
Then I asked Warren what he needed from Alice. He had plenty of grievances. “No more of your ‘to-do’ lists,” he said. “I have enough on my plate with work and picking up the kids after school. I don’t need to come home to lists of things that I’m supposed to do around the house.”
“So how are they supposed to get done?” Alice asked angrily. “You won’t let me hire a handyman, and you won’t do them yourself. The bathroom faucet has been leaking for a year, and you won’t call a plumber. The garbage disposal doesn’t work. What am I supposed to do?”
“I told you I’ll get to them,” Warren said.
“But you don’t. You never get to them.”
This was a problem I had heard many times before. Fortunately I had a useful strategy.
“Warren, I think it might help if you give Alice a time frame for fixing things. Perhaps you could say, ‘I don’t have time today, but I’ll get it fixed by Sunday at seven. If I don’t get it done by then, I’ll call the plumber on Monday.’”
Warren looked relieved.
“That’s a good idea. I like that. As long as I don’t feel like I have to fix something right away, I don’t mind providing a time frame.”
I turned to Alice and asked if that was acceptable to her. She said it was.
It is the little things that wear down a marriage and form the bricks and mortar of the emotional walls between husbands and wives. It’s the caps on the toothpaste, the honey-do lists, and the retreats into cyberspace to avoid facing what Virginia Woolf famously called the “dailyness of life.” In today’s couples, it is not only the wife who faces the second shift of caring for the children and the house after she comes home from a full day of work. Fathers too—at least those in two-income families—come home to a second shift. They make dinner, pick the kids up from baseball practice, coach their teams, and plan playdates. They also help with homework in a world where, unbelievably, kindergarteners can have an hour of homework each day and middle-school children can have up to three hours. Often, too, both parents turn to their own work after the kids are in bed. It’s no surprise that this high-pressure home life can lead to disappointments and disagreements that quickly morph into an emotional barrier between parents.
Once the wall is up, breaking it down or even finding a chink in it poses a formidable challenge to the therapist. For me, the critical factor is making sure that both spouses feel that each can be influenced by the other’s needs. Husbands and wives must see for themselves that their spouse is willing to modify their own behavior. Even if asking Warren to fix the faucet doesn’t seem like a big deal to Alice, the way she asks him to do it may seem like a big deal to him. Giving her husband a wider time frame, instead of asking him to do a task right away, went a long way toward salvaging Alice’s and Warren’s relationship. Because Warren felt that Alice’s job was superior in status to his own (she earned more money than he did), he was especially sensitive to the way she asked him to do tasks around the house.
I have observed that some men think their wives expect them to do what they ask immediately. All it takes is an idle comment at dinner like “Y’know, those roses need some cutting back” for these men to think that they are supposed to jump up from the dinner table and put on their gardening gloves. Even if their wives didn’t mean they should get to the task anytime soon, the feeling that their wives expect them to do something right away makes these men dig in their heels.
Warren and Alice said that going out alone on a date once a week was also helping them. At least they had time to have a grown-up conversation without the children distracting them every minute. They were hoping to get away by themselves for a week in the summer when the children were at camp. In my experience, a romantic vacation, away from the stresses of work and children, can do wonders to rejuvenate a marriage. It provides an opportunity for intimacy, which is so often lost in a modern marriage because the demands of work, children, and the ever-increasing complexities of modern life seem more pressing than the need for emotional closeness.
Alice admitted that she had probably been putting too much pressure on Katelyn to do well at school. “I’m a perfectionist with myself and everyone around me,” she said. Warren seconded that, and encouraged her to lessen the pressure on Katelyn. Alice assured me she would try to ease up on her expectations. We made up a list of Katelyn’s good qualities—she was intelligent, a good friend, helpful around the house, fun to be with, and creative—and I asked the parents to sprinkle these compliments into their conversations with Katelyn to enhance her self-esteem. They added the list of positive qualities to the other strategies I had given them.
Then I asked if Katelyn had friends at school. “Her teacher says that there are a few nice girls she’s friendly with,” Alice said. “But for some reason Katelyn doesn’t feel like she has friends. She tells me that she feels like she’s left out of the cliques of the popular kids.” Perhaps feeling left out at school was a remnant of Katelyn’s feeling of being left out by her brothers at home. We talked about planning more playdates for Katelyn. Warren and Alice were continuing to implement the recommendations I had written down for them. At least they had to have conversations with each other about dealing with Katelyn, which was better than their fighting.
At the final session, Katelyn no longer had feelings of being watched, and didn’t feel lonely in the afternoons. I told Warren and Alice that Katelyn no longer needed therapy, but I asked for a telephone update in two months. At that time, they reported that Katelyn was doing fine.
When I first learned about the strategic dialogue as a therapy technique, I didn’t feel comfortable with the idea of using it with children. It had been developed for use with adults and has a quasi-hypnotic aspect to it. And, more important, as a family systems therapist, I was accustomed to resolving children’s problems by strategic-systemic techniques. I gave parents directives and reorganized families to put parents in charge of their children. I strengthened parental boundaries and sliced through enmeshed parent-child relationships by prescribing date nights and romantic weekend getaways for parents. I told parents to maintain their privacy by locking their bedroom door. I provided parents with ways to help their children soothe themselves—with music and story CDs or tapes—in order to free the marital bed from children. After abandoning play therapy many years ago and falling in love with systemic thinking, I felt resistant to any method of therapy that addressed the individual child instead of the family system.
But since I found the strategic dialogue so effective with older adolescents who were experiencing fears, anxieties, and compulsive behaviors, I thought that there was good reason to try this technique with younger children as well. I approached it cautiously, writing out scripts ahead of time. Today it is one of my most valuable interventions. It is a very gentle strategy, seemingly simple on the surface but actually complex. The questions are not aimless. As in the ancient Socratic dialogues, or the hypnotic techniques of Milton Erickson, the questioner has a final goal in mind and carefully sculpts her questions to reach that goal. By giving an illusion of alternatives, the questioner creates a new feeling right in the session that will be the beginning of a change in the child’s perceptions of herself and her world. So when I asked Katelyn if she felt like the invisible people just watched her or if they threatened to hurt her, I was hoping she would choose the less threatening alternative and begin to feel less frightened.
Parents who have observed me using the strategic dialogue are impressed with how it seems to help their child feel better, and they have asked me if they can use the technique themselves. After giving this question careful thought, I came to the conclusion that it probably wouldn’t work. The sequence of questions can be difficult to invent and must be tailor-made to the child’s individual problem. Creating the questions and asking them in a way that will bring about change is a subtle and complex art. I had to practice the strategic dialogue for more than a year before I got the hang of it. Of course, parents can take a lesson from the “paraphrasing” part of the strategic dialogue. They can listen carefully to what their child tells them and reflect back the child’s feelings, which in itself can help a child feel heard and understood.
Loneliness was a central theme in Katelyn’s family, and in many ways loneliness is one of the deepest problems of modern life. Mother Teresa once said that loneliness is the greatest impoverishment of a society. Family members are often estranged from one another either by geographical distance or because they cling to old resentments and grudges and don’t create opportunities to talk things over. Parents are busy with work and long commutes and have barely enough time to help their children with homework, let alone spend quality time with each other to keep their relationship alive.
Estrangement and loneliness played a central part in the story of fifteen-year-old Margaret, who had received the terrible diagnosis of paranoid schizophrenia before I met her and her family. This case actually began for me with Margaret’s ten-year-old sister, Susan, whose teacher had suggested family therapy.
Susan’s mother, Josie, called me to make an appointment and asked if she and her husband, Enrique, could come in and meet me first. I told her that would be fine, and I made an appointment for them the following week.
“What can I do for you?” I asked them after we made our introductions. Enrique was a large man, tall and broad shouldered. He worked as a repairman for the telephone company. Enrique’s parents had moved to this country from El Salvador. Josie was petite with pale blue eyes. She worked part-time as a librarian.
Josie began. “Our daughter Susan—she’s ten—has been crying at school every day. Her teacher has tried hugs and encouragement, but nothing seems to help Susan feel better. The teacher is really worried, and that’s why she recommended we see you.”
“When did Susan start crying at school?”
“Her teacher said…” Josie seemed on the verge of tears herself. “She said she’s been crying at school for the past two years. She doesn’t cry all the time, just off and on. All of her teachers have told us about it at parent-teacher conferences. They’ve all been really nice to her, but nothing helps for long.” How unusual, I thought. I wonder what is so terrible in this little girl’s life to make her cry at school. It must be embarrassing for her to cry in front of her friends.
“And do you know why Susan has been crying? What does she say about it?”
“She started crying when her sister, Margaret, hit her and chased her into her room,” said Josie. “It happened a few times. That was about two years ago. Susan told us that Margaret said to her, ‘I’m going to kill you!’ I’m sure Susan was terrified—she was only eight at the time.”
“The teacher told us that when Susan is assigned to write stories in class, she always writes about Margaret,” Enrique said in a somber tone.
Josie continued. “We took Margaret to a psychiatrist. He saw her a few times and diagnosed her with paranoid schizophrenia. He recommended medication and therapy. But we thought that was too strong a diagnosis. I asked my friend who’s a social worker. She knows Margaret well, and she agreed the diagnosis was not right. Margaret was not having delusions or hearing voices. The only symptom she had was that she was angry and hit her sister.”
“So what did you do about the violence?” I asked.
“We never leave the girls alone together in the house,” Enrique said. “And I put a lock on Susan’s door so she would feel safe in her room. Margaret hasn’t hurt Susan again, but she isn’t exactly nice to her either.”
Margaret certainly has gotten her parent’s attention with her violent behavior, I said to myself. Her family seems to be organizing itself around her violence and the need to keep Susan safe.
“So why is Susan still crying at school?” I asked.
“She says she doesn’t know why she’s so sad,” Josie said.
This is an interesting puzzle, I thought. Was Margaret’s violence perhaps a metaphor for anger between Enrique and Josie? Or was there some other volatile situation, maybe in the extended family? Was it just sibling rivalry? In order to make sense of the story of Susan crying at school, I needed more information. I asked Josie and Enrique what else had occurred in the family at around the time Margaret’s violence began.
They thought about my question and quickly realized that just before Margaret threatened Susan, they had moved into a house on the same street as Enrique’s sister and her family. Susan and Margaret affectionately called his sister Auntie Jaycee—her real name was Jocelyn—and the girls were really happy to be living close to their cousins. That first Christmas, Auntie Jaycee invited their family to her house. But instead they had gone to Josie’s parents for the holiday. Auntie Jaycee had taken great offense at this, and Enrique’s father had also felt insulted. Since that Christmas, Enrique’s father had barely spoken to Enrique and had pretty much ignored the girls.
Enrique admitted that he was very hurt that his father ignored his daughters. His father would visit his sister’s children down the block but wouldn’t even stop in at Enrique’s house. And his sister wouldn’t allow her children to see Susan and Margaret.
“Is there anything you can do to reconcile with your father?” I asked. I could imagine how hurtful this situation was to the girls.
“We’ve tried,” said Josie, “but Enrique’s father is a proud and stubborn man. Once he is offended, he doesn’t forget it easily.”
I decided to put aside for the moment the situation with the grandfather and aunt and focus on getting the parents in charge of Margaret’s behavior. Right now, the threat of Margaret’s becoming violent was controlling the family. Josie and Enrique were always on the alert, afraid that the terrible diagnosis Margaret had received was true and that violence could erupt at any time. I decided to frame Margaret’s hitting her sister as a behavior problem instead of viewing it as a frightening psychiatric disorder and gave her parents some strategies.
I told the parents to clearly state to Margaret the rules she had to follow with respect to Susan. She was not to yell at her, hit her, or in any way threaten her. If she did, she would have to do a half-hour “helping chore,” supervised by her father. If she refused to do the chore, she would lose her cell phone and not get her allowance that week. Together, we made a list of chores that Margaret could do around the house. In addition to a chore for being mean to her sister, Margaret would have to buy Susan a gift from her own allowance.
To address Susan’s sadness until I could intervene with the family, I asked the parents to see to it that Susan laughed every day. Josie was to take Susan to the library and check out books of cartoons and humor. They were to read these every evening. In the morning, they should read the comics in the newspaper together. I chose not to label Susan’s crying as depression, reframing it instead as sadness. The simple strategy of bringing laughter into a child’s life can be very effective for the whole family. Laughter, scientists tell us, stimulates endorphins in the brain that produce a feeling of well-being. Of course if a child seems sad for a prolonged length of time and for no apparent reason, parents should consult a family therapist.
I was guessing that Susan’s sadness and her sister’s violence were connected to the situation between her parents and her aunt and grandfather. As we saw with Cindy’s family in Chapter 4, a child’s troubled behavior can stem not only from a conflict between her parents; it can also be rooted in a conflict involving a grandparent. I asked Josie and Enrique to bring the girls to the next session, and we found a time that was convenient for everyone.
When I greeted the family in the waiting room on the day of the appointment, Margaret hung back, thumbing through a magazine and seeming reluctant to come into my office. In a few minutes she joined us. I started out by introducing myself to the girls and telling them that I had met once with their parents. Then I asked Josie and Enrique to explain why they were here.
“We want Susan to be happier,” Josie said.
Margaret started to tap the floor with her toe.
“Could you please ask Margaret to stop the tapping? It’s disruptive,” I said to Enrique.
“Margaret, cut it out,” Enrique said. Margaret glared at me but stopped tapping her foot.
When I raised the subject of Aunt Jaycee and the girl’s grandfather, the girls had a lot to say.
“They are being hateful to us,” Margaret said angrily. “And it’s especially hurtful to my dad.” Turning to her father, she said, “You can’t trust Grandpa. He’s done this before. You get close and then he gets cold and distant. I never want to see him again.”
“She’s right,” Susan said, speaking for the first time. “You can’t trust Grandpa, Dad. It’s not worth trying.” I could see that the girls were being protective of their father. Usually violence in children is a sign of parental discord. But it can also signify discord between parents and grandparents. Was Margaret’s violence a way to focus her father’s attention away from the breach with his own father, and was it at the same time a metaphor for the emotional violence of the rift?
Over the next few weeks, Margaret’s behavior improved. Her father was monitoring her behavior toward her sister, and Margaret had had to do only two chores. Susan was starting to feel better. With her parents’ permission, I spoke to Susan’s teacher, who said that Susan was not crying at school lately and seemed a little more cheerful. The teacher felt that Susan had been crying because she seemed to be carrying the burden of her family’s troubles—and the burden was too much for her. The teacher of course didn’t know all the details, except for scraps of information that Susan had disclosed in her writing assignments. The teacher was pleased to hear that Susan’s family was in counseling.
Somehow the grandfather heard about the girls’ problems, and he had written to Margaret, sending her a gift of money for her sixteenth birthday, which took place a month after the family started therapy. At the next session, Margaret brought me a copy of the letter she had written to her grandfather. She trusted me now, since she saw that I wanted to help her father. In the letter, she wrote that she never thought of him as her grandfather because he didn’t want to have anything to do with her family. She accused him of always giving her cousins gifts and taking them places on their birthday, while ignoring her and Susan. Most of all, she accused him of ignoring her father on his birthday, hurting not only her and her sister but also their father. She ended the letter with the question, “What have we ever done to you to make you treat us so cruelly?”
I sympathized with Margaret. Now I understood that she was protecting her father from her grandfather. This is not as common as a child protecting a parent, but it does occur. I told Margaret that she and Susan should focus on school and their activities, and let me take on the job of healing the rift in their family.
Margaret looked at me skeptically. “Can you do that? Can you talk to my grandfather?”
“Absolutely,” I told her, hoping I sounded confident. The truth was that I had no idea if I would be able to get her grandfather into a session. But I was going to try. If nothing else, I would be able to talk with the grandfather on the phone or write him a letter.
Although Enrique was reluctant to invite his father to a session, I persuaded him that it had to be done for the sake of his daughters. I said that I was sure the girls would continue to have problems if the rift between him and his father was not resolved.
“Why does this have to hurt my kids?” asked Enrique. He had started to cry. “My relationship with my father has nothing to do with them.”
Parents ask me questions like this all the time. Like Enrique, most of us think of emotional pain as an individual feeling, for that is how we are used to experiencing it. But to think of pain in one member of a family as simply an individual feeling is to some extent an illusion. From a family systems perspective, the family is an organic whole, and sorrow in one area can pop up somewhere else in the system.
I tried to explain to Enrique that pain and loneliness in a family overflow the boundaries of the individual and can be felt by other family members, especially children. I assured him that this wasn’t his fault—he had done nothing wrong. Enrique finally agreed, with great reluctance, to have his father come to a session with him and Josie. We decided the girls should not be present; they didn’t need to witness the volatile emotions that were bound to emerge.
Enrique said his father would be more likely to come if I made the call and set up the appointment. But he didn’t think his father would come to see a therapist because he was very traditional, and therapy wasn’t part of his culture. Although it would be unusual for a psychodynamically oriented therapist to make a phone call to a member of a client’s extended family, family therapists do this all the time—especially with families being harmed by long-standing grudges.
In the end, the grandfather did come in. He arrived early for the session. He was a tall, dignified-looking man, with white hair and a white beard. Josie arrived a few minutes later, but there was no sign of Enrique. I was starting to worry that Enrique wasn’t going to show up because it would be too painful to see his father. But finally he arrived, looking nervous.
After I introduced myself and shook hands with Enrique’s father, Albert, I explained that, for the sake of his granddaughters, the differences between him and his son and daughter-in-law had to be resolved. Enrique explained that the favoritism his father showed to his sister’s children was hurtful to his daughters, and he wished his father would treat all the cousins equally. Albert suddenly became furious.
“It’s all your fault,” he said, his voice rising to a shout as he pointed at Josie. “You kept me from seeing my granddaughters at Christmas two years ago. We were all supposed to be together for Christmas at Jocelyn’s house, right after you moved into the neighborhood. You just decided everything and Enrique went along with it.”
When Josie tried to defend herself, reminding him that her mother had gotten out of the hospital after her hip replacement just before Christmas, Albert became so angry that his tanned face turned bright red. Abruptly, he got to his feet and walked out of the office, leaving us all shocked. Enrique shook his head, saying that it was useless to try to talk about feelings with his father. Josie turned to me and apologized.
“I was afraid something like this might happen if Albert came. I hope you’re not offended.”
“Oh, no, of course I’m not offended,” I told her. “It’s not the first time that someone has stormed out of my office.” Hearing the way others feel about you can be painful, and walking away is the ultimate way of defending against the pain. The three of us sat there in silence for two long minutes. Josie started to cry softly. I handed her a box of tissues.
And then, while I was wondering what to do next, an astonishing thing happened. Albert came back into the office, sat down, and apologized to me. Turning to his son and daughter-in-law, he said, “When I die, I will not be able to leave buildings or monuments with my name on them. All I have to leave behind is my grandchildren. So now I’m going to do what I can to help them lead happy lives. The past is the past.”
During the rest of the session, I suggested to Albert that he spend roughly equal time between his daughter’s children and his son’s. I recommended that he try to treat the cousins as equally as possible. I also suggested that Albert ask his daughter, Jocelyn, to become friendlier with Enrique’s family. “Your granddaughters really miss their aunt and their cousins,” I told him.
After this dramatic session, things began to change. Albert sent Susan a belated birthday present with a friendly note. Enrique visited his father and started calling him once a week. Josie invited Albert for Sunday dinner at their house, and he brought gifts for the girls. Auntie Jaycee was back in their lives again, and the girls visited her house and played with their cousins.
Over the next few years, Margaret did not hit her sister again. Their relationship became much better, and she would occasionally invite Susan to go to a movie with her. I continued to see the family periodically for three years. One crisis erupted when Enrique injured his head in a fall, suffered a concussion, and had to take disability leave from work. Margaret came to see me, complaining of headaches; her symptom once again was a metaphor for her father’s pain. The strategy that helped her was for Enrique to reassure Margaret that his head was healing well and he would soon be back to work. He told her that physical therapy was helping him regain balance and strength. He invited her to come to a physical therapy session with him to see how much progress he was making.
I coached the parents to be positive and hopeful with Margaret, and not to let her overhear any of their financial or other worries. They saw me for several sessions of marriage counseling. Margaret graduated high school with her class, getting an award in English literature. She went on to community college and did well. After the first few weeks of family therapy, Susan did not cry at school anymore.
Grudges and resentments can wreak dreadful damage in families, as they did in Enrique’s. And they challenge the family therapist to come up with creative interventions. I framed Susan’s crying at school as a metaphor for her family’s pain at being cut off from their grandfather, aunt, and cousins. And I saw Margaret’s violence not as psychotic behavior but as an effort to protect her father from the pain of his rift with her grandfather and from the grandfather’s anger at her mother.
In a fascinating case described by Salvador Minuchin, the repercussions from resentment played a powerful role in creating a girl’s symptoms. Eleven-year-old Jill could not move her left leg or arm. Medical tests showed no physiological cause for her paralysis, and Dr. Minuchin decided to treat it as a problem of relationships in the girl’s family. Jill’s grandfather initiated the therapy, calling Dr. Minuchin at the Philadelphia Child Guidance Clinic.
In the first session, attended by Jill, her mother, and her mother’s parents (Jill’s father, Richard, was out of town on business), Jill entered the room leaning on her mother and dragging her leg. Minuchin soon uncovered an underground resentment in Jill’s parents’ marriage. Jill’s father was an engineer for an international oil company; a few years earlier, he had been assigned to Caracas, Venezuela, and had moved his family there. Jill’s mother, Janet, fiercely resented the move. She had been happy with her career, her friends, and her house in Houston. She had sacrificed all of these for her husband’s career.
During the year in Venezuela, Janet’s love for her husband drained away bit by bit, poisoned by her anger and resentment at leaving the life she loved for what she felt was a bleak existence in a city she hated. Before long, Janet’s reluctance about moving emerged as a symptom in her daughter. At least this was the hypothesis that Minuchin formed while talking with the family during the first session.
Salvador Minuchin was trained as a psychiatrist. But he approached Jill’s problem—which Freud would have called “hysterical paralysis”—from an interpersonal perspective. He treated the paralysis not simply by exploring Jill’s psychological state but by focusing on the relationships, alliances, and boundaries in her family.
Janet’s resentment toward her husband resulted in her withdrawing emotionally from him and becoming closer to her own parents. Just as Janet leaned on her parents, using them as a crutch to move away from her husband, her daughter was using her as a crutch, leaning on her in order to walk. The daughter’s symptom was a metaphor both for her mother’s reluctance to move to Caracas and her increasing emotional dependence on her own parents. Like Katelyn, Jill became overly allied with her mother in the silent war that her mother was waging against her father.
Minuchin decided to use a three-step plan to guide Jill to autonomy. Step one was to hook up the disengaged parent, Jill’s father, with his daughter to help her move away from her mother. The second step was to move Janet closer to her husband: to address the conflicts in their marriage and draw a firmer boundary between Janet and her daughter. The third step was to intervene directly with Jill to explore the meaning of her symptom and challenge her paralysis. A final intervention would be to address Janet’s enmeshment with her own parents—who supported her in disengaging from her husband. Minuchin knew that a daughter’s enmeshment with her mother usually mirrored the mother’s enmeshment with her own mother. Wise parents, who look to the well-being of their grandchildren, respect the boundaries of their son’s or daughter’s marriage. Janet was not as self-reliant as she might have been, which meant that it was easy for her to drift back toward her own parents when she was unhappy with her husband. And Janet’s parents were more than pleased to become overly close with their daughter to fill the void in their own lives.
Minuchin worked on all these levels to help Jill walk again. Not only did he have to restore and rearrange boundaries in her mother’s marriage and extended family, he also worked one-on-one with Jill. He sent her to a practitioner who used the Alexander technique—a bodywork system of improving physical and psychological awareness—which helped her release stress and regain movement in her muscles. Another important strategy—one that I use frequently with parents—was to get Jill’s parents to go on a three-day trip together, with instructions to Richard to be especially solicitous to his wife. This would help strengthen the boundary around the parents as a couple. Because Janet loved New England, they stayed in a romantic country inn in Vermont, in a room with a fireplace and canopy bed. And they discovered that they liked being alone together. Janet returned from the trip feeling much better about their relationship. She thought she could finally forgive her husband for disrupting her life.
At the end of the month, the family had to return to Caracas. Although there had been progress, Jill was still using a cane to walk.
In a final session with Minuchin, which occurred six months later—with the family flying to Philadelphia from Caracas to see him—Minuchin asked Jill if she was sometimes afraid that her parents would separate, and Jill admitted that she was. She was worried because they were still arguing and because some of her parents’ friends had divorced. Minuchin, an incomparable showman, drew out the hidden meanings of her cane. One minute it was like a security blanket, something on which Jill was dependent. The next minute, Minuchin used the cane to hook Richard’s leg and then Janet’s, pulling Janet closer to her husband. “It’s a parent catcher,” announced Minuchin. Having established the metaphor, Minuchin asked Jill if she felt like she needed to “hook” her parents together. After a silence, Jill answered “yes.”
Once Jill’s fear of her parents divorcing was out in the open, Richard reassured her that their arguing was just a way of discussing issues, which was better than keeping things inside where they could fester and become worse. He told her that their arguments were not a sign that they were going to divorce. Jill pointed out that her parents sometimes called each other mean names. They admitted this but told her it was not a cause for her to worry. Sometimes parents could be childish.
At this point, Minuchin, in his inimitable theatrical way, held up the cane and told Jill’s parents that it was also a symbol of Jill’s feeling that they needed her—and her symptom. Then he had them tell Jill that they didn’t need her to have a symptom in order for them to stay together. They had no intention of separating. In a final move, Minuchin declared that he would keep the cane and Jill would have to lean on her parents if she needed support. Jill looked at him very seriously but said nothing.
A few weeks later, after the family returned to Caracas, Jill wrote Minuchin a letter. “I’m finally walking without a cane,” she told him. Minuchin was thrilled.
In this exceptionally challenging case, Minuchin had to move back and forth among many levels—the individual, her parents, and the extended family—many times over. He used metaphor to understand the meaning of the symptom and the role it played in Jill’s family. He thought in terms of metaphor to arrive at the meaning of the cane as a parent hook. He also used the idea of the protective function of Jill’s strange symptom—to keep her parents from separating. Only by fully involving the members of Jill’s family and rearranging alliances was Minuchin able to help her walk normally again.
Up to now, most of the parents I have been talking about have been cooperative in therapy, following my recommendations because they trusted that I knew how to help their child. These compliant parents are a joy to work with. But what of those parents who can’t—or won’t—follow a therapist’s recommendations, even to help their children? In these situations, family therapists have to use indirect techniques, which are usually paradoxical. They are paradoxical because the therapist prescribes more of the very behavior that the family has come to therapy to change. I’ve already described a few paradoxical interventions—prescribing Joey’s resistance at bedtime and prescribing more hand washing for Elizabeth. In the next chapter I have more to say about this fascinating and surprisingly effective type of intervention.