Marriage and Family Capstone

Diffused Boundaries and Intergenerational Triangles

Master’s Program for Marriage and Family Therapy

Katherine Ziskind, Central Connecticut State University, 2017

Legal Notes: All rights reserved. This publication is designed to provide accurate, expert, and authoritative information regarding marriage and family therapy and positive outcomes. This is based on a true story. However, to protect HIPPA, names have been changed and multiple client stories have been complied together to illustrate important family therapy themes. In regard to the subject matter, it is provided with the understanding that the author and publisher are not engaged in rendering legal, accounting, mental health advice, or other professional services. This is not intended to cure a disease. When professional advice is needed, seek out a competent professional person. Please show respect and do not plagiarize or copy any text illegally.

1. Introduction

The purpose of this paper is to introduce Nicole (33) and her husband, Alan (50). They have daughter named Lily (27) and son, Forrest (4). You will see various patterns, triangulations, and visible in the three generational genogram. I used structural and narrative therapy and interventions to bring light to and remove these constraints. I am presenting the case focusing mostly on the Sequences and IFS metaframeworks domains. In addition to addition to the case, you will also learn about me as a therapist, hear about my growth, and challenges I faced including being aware of my tone of voice and cultivating patience.

1. Conceptual/Perceptual
2. Systemic orientation

Nicole’s mom was sexually abused by her own brother at a young age. She never did her self-work to heal taking that trauma into her marriage.

Nicole’s parents had diffuse, disconnected boundaries and conflict was covert. As a child, she was pulled into the triangulation. Her mother cheated on her alcoholic dad forcing Nicole to keep this secret from her dad. Nicole was forced to listen to her mom have sex with other men. As she allied with her mom, she betrayed her dad, until he eventually found out, and he continued to pretend that nothing was going on, taking a submissive role of low self-worth. Her mom was critical and had rigid boundaries in the relationship with Nicole.

Seeking freedom, Nicole jumps into relationships like her mom. At 21, after cheating on her boyfriend with Alan, Nicole learned she was pregnant. The constant uprooting and instability of moving also continued.

When Nicole was a young mom, age 22, she was raped by her best friend’s boyfriend. She explained the rape to her friend. To Nicole’s surprise, her friend believed her lying boyfriend. Since Nicole did not say “No! Stop!” the police could not press charges. This experience perpetuated shame from her FOO, that her voice was insignificant, forced into a submissive role, and reinforced her fear of commitment and that betrayal is inevitable.

Like her parents, in Nicole’s marriage with Alan, they have diffuse, disconnected boundaries, covert conflict, and do not directly talk about issues. She emotionally cheats on him with other men, a pattern picked up from her mom. Alan takes a submissive role, showing low self-worth marrying a man like her father. When he does speak up, Nicole justifies her actions and disregards his feelings, pushing him out of the parental hierarchy. Similar to Nicole’s FOO, a triangle is seen with her youngest, Forrest, who is brought to one parent’s side and then the other in fights. Nicole is very critical of him.

Now, Lily, Nicole’s oldest, a young adult, has diffuse boundaries with her critical boyfriend, covert conflict, and puts up with him cheating on her with other women. She takes submissive role and pretends that it is not happening perpetuating low self-worth like Alan showed her.

Alan’s parents are married. His mother, Sandra, has little praise for her son. His dad, Ronald, is passive. Alan had a previous relationship with Mary (never married) before Nicole. Mary and Alan have their son Ryan. Alan’s mom purposefully invites Mary to family functions to make Nicole feel like sloppy seconds and forced into a submissive role. Nicole also helped raise Ryan.

A pattern of employment is seen systemically, relationally, and intergenerationally. Nicole’s Dad worked to distract from his low self-worth and lack of commitment from his wife. Even though he knew she was cheating, he held his emotions inside and drank. Now, Nicole does the same in terms of her job.

Nicole works long hours while Alan is unemployed. Alan has lost jobs due to his mood outbursts and medical issues. In an effort to avoid the shame of having to move back in with her parents as an adult with a family, which has happened multiple times, she works to prove herself to them. Also, since Alan does not work, Nicole sees him as inferior, treats him as a child talking down to him, and pushes him from the parental hierarchy subsystem into a powerless child.

Nicole’s daughter, Lily, lives with Alan’s parents, also continues this pattern and works to distract herself from her low self-worth and lack of commitment from her boyfriend, who lives with his parents. She pays for everything for her boyfriend.

Assessment data

1. Individuals (including any relevant DSM dx)

Nicole is a 42-year-old Caucasian female, married, with PTSD. She had gastric bypass, but has regained the weight she lost. Both pregnancies were a surprise as Nicole was told she would never bear children. Her husband, Alan, has a diagnosis of bi-polar disorder, asthma, and other health conditions. He recently had two heart attacks due to smoking for many years. He quit smoking 20 years ago. Their son, Forrest, is sweet natured, has an established sense emotional-regulation, is curious, and playful. Lily, 20 years old, had a large abdominal tumor when she was in her early teens. She had it removed and it has not returned.

Family/Relational System Dynamics

Nicole shows strengths including organization and friendliness. She is sweet, easy to make laugh, kind, and a caretaker. She mothered Ryan, Lily, and Forrest as well as Alan. However, these also constrain her ability to reach her full potential and see beyond her role as caretaker. Nicole came into therapy seeking help for irritability, which is a trauma response. She started talking about her history and it became clear that she was giving tremendously to others in an effort to hold her family together, protect herself, and avoid focusing on her trauma.

1. Extra-familial Systems, if relevant none relevant

1. Genogram see attached
2. DSM diagnosis-

F 43.10 Z 309.81 PTSD

As a child, Nicole was exposed to trauma of listening to her mom have sex with other men and her father’s drunken violence. She was raped later in life. Similarly to her dad, Alan is submissive which does not threaten Nicole. However, she avoids being intimate with her husband for periods of time and cheats on him. She plans ahead and controls her environment to ensure nothing related to her traumatic past happens again. When Nicole cannot sleep, she has memories of her trauma. Due to her mother’s and father’s verbal and emotional abuse, Nicole has low self-worth, shame, guilt, and is promiscuous. Nicole is triggered around people (Sandra unparticular), places, conversations, activities, objects or situations that remind her of her trauma and feels intense anger, guilt, and shame. Likewise, Nicole has overwhelming negative self-talk, persistent and distorted phrases- “I am bad. I am ugly,” and “World is dangerous. There is no reason to make friends. They will always betray me.” She estranges herself from others. Irritability and self-destructive behaviors are also present. Hypervigilance, eating issues, startled stress response, and sleep disturbance are all present.

1. Analysis of the case through the six Metaframeworks domains

Organization: Nicole and Alan have diffuse boundaries, she seeks attention of male friends, goes to movies with them and lets them sleep on her couch without regard for Alan’s feelings. These men have sent Valentine’s cards to her home address that she hangs on the fridge. The boundaries are too open. Nicole and Alan create a triangle with Forrest. Due to the distance in the marriage, Alan has developed an alliance and over enmeshment with Forrest, which irritates Nicole. In terms of hierarchy, balance, and structure, Nicole controls the entire house rigidly like her mom in her FOO. She then complains that Alan acts like a child.

Sequences- S1)

Nicole’s thoughts feel overwhelming because she is always planning and trying to keep order. She is flooded by negative thoughts every moment. Similarly, to her mom’s cheating and her dad’s alcoholism, she is uncomfortable with her feelings. She is driven by her aversion of her undesirable emotions and constantly searches for an escape outside of herself to ease her emotional pain.

Sequences- S2)

Nicole criticizes Alan, she slams her bedroom door, and comes out later. She and Alan then watch TV together, never really dealing with the issues. Then, she binges on large amounts of food or texts other men, betraying, cheating, and showing her fear of commitment and protective parts. “When people relate to one another, they engage in a recursive process, whereby they attribute certain meanings to their interactions” (Breunlin, Schwartz, & Kune-Karrer, 1992, p. 53). Nicole projects intense anger towards Alan who she believes is not committed to their relationship, however she is the one who is not committed and outwardly disregards his feelings. From the conflict, Alan blows up at work, gets fired, and comes up with a medical issue to step out of his own financial commitments in the marriage. The patterns create financial instability forcing Nicole to pick up the slack at her job, coming home irritable. They get evicted very few months. Nicole wants a mature husband for a partner, but she shames him in a demeaning tone. Consequently, when Alan is sick, the only way he cooperates is if Nicole babies him to eat and take his medicine.

Sequences- S3)

Alan’s job instability is a stressor to the family system. She says “no” to time with her cousins and aunts, so she can take extra shifts for the money. Alan blew up at work and got fired in the past, whereas Nicole weights the responsibilities, bills, and livelihoods of her children, and resents Alan for losing control of himself. “Equality is only possible if both partners have this attitude… Each feels that he is worthwhile; each feels that he is needed” (Carson & Casado-Kehoe, 2011, 42). When cheating on Alan, Nicole makes sure he knows she does not “need” him as she invites them over in his presence.

Sequences- S4)

Nicole’s current interactions where impacted by her childhood. As a child, Nicole’s mom and one of her sisters were sexually molested by their brother. Her mom never built a healthy relationship with men and cheated on Nicole’s dad, repeatedly. When Nicole was eight, she remembers meeting her mom’s boyfriend while her dad was at work, hearing her mom having sex, cheating on her father, from her bedroom, and being forced to keep the secret from her dad, showing a triangulation. Nicole is replicating the story of her mother being quick to jump into relationships and using cheating as an escape.

Nicole also continues her dad’s pattern of “keeping the peace” and stuffing her uncomfortable feelings through work.

Lily, continues this pattern by paying for dates when she goes out with her boyfriend and continues to take him back after he cheats on her repeatedly.

Development- Nicole developed anger and resentment early on in because she allied with her mom and betrayed her dad. The guilt holds her back from growing. At nineteen, she was forced into a role as submissive, caregiver role forced to take on responsibilities of someone even ten years older. She never had the experiences as a young adult that she needed to feel independent, empowered, or respected as a woman. In comparison with Erickson’s stages of psychosocial development, in order to move past the crisis of individual identity verses role confusion, she needed to have the opportunity to experiment with different roles and to formulate her view of herself in society in a social way. Nicole never had time on their own to develop a sense of autonomy before developing an identity with Alan or Lily. (Newman & Newman, 2015). After fleeing the nest, the young adult challenges beliefs created by their FOO. Nicole oscillates around age nineteen, trying on different men.

Internal Family Systems: Nicole’s identified parts including the keeper of secrets (keeping the secret of her mom’s cheating), guilt (from betraying her dad), evil alien (dislike of her own body), the destroyer of relationships (fear of commitment and intimacy and sabotaging her marriage), and girl Nicole. Nicole has parts that try to keep her functional and safe, but desperately maintain control of their inner and outer environments.

Managers: Nicole is organized and a caretaker such as when she was pregnant and trying to find suitable housing without the stability of a home or relationship. The parts keep her job as her husband is unemployed. Her managers helped her daughter, Lily, deal with her tumor, numerous surgeries, and be successful every time they moved. Her parts provided Ryan, her starving young step-son, a place to eat as much as he wanted and feel safe. Nicole is focused on taking care of others’ rather than her own needs.

Firefighters: When her managers could not keep up anymore, her exiles started to surface and the firefighters took over. Her firefighters are in extreme roles in an effort to protect her exiles and are blended with herself. Her anger, criticism, and sharp tone pushes others away. Forrest prefers the comfort of Alan over Nicole when he is sad. Her yelling built a barrier of distance, a diffused boundary them.

Nicole impulsively buys items she does not need including a multitude of pets, books, shoes, and overeats junk food in an effort to push aside feelings of worthlessness and shame. She also works long hours and cheats on her husband to numb out her feelings of betrayal, guilt, shame, loss, pain, and low self-worth.

Exiles: As a child, she was triangulated, forced to keep the secret of her mom cheating on her dad left her feeling like she betrayed her dad and guilty. She refers to him as such a good person and father. She has resentment towards her mom forcing her into a small, submissive role as a child. In addition to her mom, Alan’s mom triggers Nicole into feeling substandard. Without closure from one relationship to the next or time alone for self-inquiry, she filled the void of shame and inferiority with Alan and now with other men perpetuating her fear of commitment. When Nicole was 22, she was raped by her friend’s boyfriend and her friend did not believe her. She developed exiles of shame, loss, and distrust in the world due to her horrific, sexually abusive experience. She fears being unable to sleep with racing thoughts as if her brain will not turn off as well as the fear of being alone, again, and the doom of that loneliness. She has never had a chance to get to know herself intimately.

Gender/Culture:

Part of being an American woman means, “women were expected to be independent, strong, and able to make it alone…self-control is highly valued, suffering was to be borne in silence, and conflicts were covered over” (McGoldrick, Giordano, & Garcia-Preto, 2005, p. 515). Constraints include being an American, white woman without a college education with a history of sexual trauma. Her mom showed her that cheating was an outlet rather than talking and to “keep the peace.” Being a teen mom was a struggle because she had unstable living arrangements, was not in a committed relationship, and dropped out of college instead of graduating. She has to hold it together for her family. Since her culture teaches her to be independent, every time she and her husband cannot provide financially and are evicted, Nicole, Alan, Lily, and Forrest move back in with her parents, which accumulate exiles: inadequacies, failures, and shame of not keeping it together.

Another constraint is that in Nicole’s FOO she was raised more traditionally. She was told she needed a man to depend on finically. Her dad showed a traditional gender role as he supported her family while her mom stayed at home. Her mom’s role was to make sure the children were bathed, fed, well behaved, and everyone had clean clothes, just to name a few. Moving outside the expected gender roles creates conflict with her parents who do not like Alan because they believe she deserves a man who will financially support her. He is unemployed and has been on and off for their entire marriage, so she is not only the breadwinner, but also the main caretaker. Since Nicole is challenging gender roles of how she was raised, she faces more criticism from her mom, increasing her criticism and irritability for Alan, and pushes him away. This creates a triangulation with Forrest and enmeshment.

Nicole also shames herself for feeling emotionally disturbed, stressed, and pushes forward. She constantly wants to increase her medication, plus adding additional ones, with her psychiatrist, which only distracts her form working on herself.

Nicole grew up in a culture when oversexualized at a young age creating an intergenerational pattern where Nicole jumps man to man. Her American background told her to “keep the peace” even if there were problems. Her mom cheated repetitively on her dad, but he submissively kept the peace despite the adultery. Nicole continues to play into the culture of work ethic like her dad supported her mom. There is a culture of “putting up with it” and “keeping the peace,” without directly talking about feelings or the real issue as well as the recursive pattern. She treats Alan like her mom and dad treated her, taking power by making Alan feel inferior and shamed. Now, her daughter, Lily, takes a submissive role and puts up with her boyfriend who cheats on her perpetuating low self-worth buying him whatever he wants.

• Executive
  1. Individualized treatment summary and plan

Narrative and Structural Therapy Treatment Plan- Initial Phase of Treatment- Initial Phase Therapeutic Tasks

1. Develop working therapeutic relationship. Respect and warmth.

Relationship-building approach/intervention: A) Use curious stance and everyday language to create partnership with each member; allow all voices and perspectives to be heard; move slow enough for Nicole to feel safe.

1. Assess the individual, family, and cultural dynamics.

Assessment strategies: A) Map the roots of anger, see what is beneath including the need trauma responses. B) Use enactments to map structure to identify potential cross-generational patterns and coalitions, effectiveness of parental hierarchy, and quality of parent/couple relationships. C) Assess Nicole’s full history.

1. Define and obtain client agreement treatment goals. A) Inquire about preferred way of meeting (individually vs. family) and identify areas deemed most critical.
2. Identify needed referrals, crisis issues, collateral contacts, and needs. A) Referrals/resources/contacts: Discuss potential of medication: discuss pros, cons, and perspective’s and values.

Initial Phase Client Goals

1. Increase Nicole’s sense of having agency in relation to trauma responses. A) Use IFS C’s and increase her ability to understand her mind through psychoeducation about trauma and her nervous system. B) Simultaneously increase Nicole’s awareness for her choices and actions to reduce her need to distract from and intimate relationship and the family issues she is avoiding.

Working Phase of Treatment- Working Phase Therapeutic Tasks

1. Monitor progress towards goals. Assess each person’s view of the problem including Nicole’s alone. A) Monitor sessions for evidence of Nicole implementing self-care practices and generating new meanings that translate to new actions positively impacting her family. B) Administer PHQ9.
2. Monitor quality of therapeutic alliance at therapy proceeds. Begin to challenge Nicole’s habits of PTSD and diffused boundaries in the couple.

Working Phase Client Goals

1. Balance Nicole and Alan boundaries. Use IFS to help Nicole get to know her parts. Clarify parental hierarchy and unity in fights.

Measure: Able to directly and assertively ask Alan for support when needed, speaking calmly and kindly instead of accusatorily, and communicate her feelings thus reducing outbursts for a period of a month with no more than two mild episodes of arguing in a week period.

1. A) Use enactments that reduce aggressive communication, reinforce parental hierarchy, and teach healthy communication- improve communication and clarify boundaries. B) Invite Nicole to understand inter-generational patters through her genogram.

Measure: Able to speak with mindfulness with an appropriate tone and to sustain aggression for a period of a month with no more than two mild episodes of failing to support the other.

1. Reframe irritability as a trauma response. B) Encourage Nicole to build positive self-talk and internal dialogue.

Closing Phase of Treatment- Closing Phase Therapeutic Tasks

1. Develop aftercare plan and maintain gains. A) Create long-term self-care, identify early “warning signs” of a big blow up, and how to manage. B) Shape competencies by having Nicole and Alan take a proactive role in identifying potential future problems and solutions. C) Letter from therapist to document Nicole’s progress and solidify narrative of be-friending all her parts.

Closing Phase Client Goals

1. Increase and thicken positive self-talk, well-being, and ability to turn inward instead of outward for solstice.

Measure: Able to sustain positive interactions in the marriage with no major damages for a period of a two weeks with no more than two mild episodes.

1. Increase external relationships that support Nicole’s positive sense of self. A) Therapeutic letter from therapist to document journey of Nicole and family healing.

Systemic treatment planning

1. Hypothesizing:

I hypothesize that Nicole is presenting with impulsive anger outbursts because she has a protective part that is reacting from childhood trauma. She was subjected to listening to her mom have sex with other men and keeping the secret from her dad. She had no voice. Being raped as a young adult was difficult enough, but again her experience told her she had no voice and people were no to be trusted. No one, but Alan believed her about being raped.

1. Planning and c) Conversing

When speaking with Nicole, she connects that she is resentful and it pushes her and Alan further apart. During one couple session, I had Nicole and Alan enact their typical fight. Systemic therapists, “may be clearly detached from family interactions so that they can clarify boundaries or prescribe a specific intervention, maintain a moderate level of connection to coach the family in new interactions…” (Gehart, 2010, p. 130). Nicole does not know how to fill her need for love and get support in an adult way because she never received it or saw it in her FOO. I saw the way their patterns perpetuate homeostasis. In a later couple’s session, I did an enactment that unbalanced the system and challenged Nicole to restructure her language.

1. Reading Feedback

When reading feedback, I always made sure to watch both the facial expression and body language during session. I would ask Nicole and Alan how they felt therapy was going every few weeks. I noticed in sessions Nicole looked over at Alan often when I ask her a question showing insecurity in her own sense of self. They held hands showing affection and that they were comfortable being themselves around each other. When she talks to Alan, her tone changes to sharp and critical, or especially child-like.

1. JARRS/bowtie

When joining and accommodating with Nicole, I listened empathetically without giving advice or cutting her off. I used narrative therapy, “this process is a gradual shift from ‘I want to make this problem go away” to “I want to create something beautiful and meaningful with my life” (Gehart, 2010, p. 404). I built the therapeutic bond and Nicole began to understand how her past traumas have influenced the way in which she perceives the world, relationships, and intimacies now.

Her mental landscape was a negative tape recorder on repeat. We worked with the “destroyer of relationships” to offer love to herself. We worked to strengthen positive, core beliefs about herself to remember she is a powerful, capable person. When restructuring and unburdening the system, I did enactments that help Nicole open up and be softer when interacting with Alan.

Execution of interventions

1. Timing and pacing of interventions

I wanted to meet and join with Alan, but right away, perhaps due to the trust and rapport Nicole and I had already build, she explained right way the most recent argument and her frustration with Alan. I took this as an opportunity to do an enactment rather than let Alan sit there being blamed. I wanted to see enough of an argument to understand how the system worked, but I did not want to let it continue to the point where triggered parts would be creating verbal wounds and regrettable things would be said. “Communication…is one means for achieving a sense of intimacy and closeness” (Karpel, 1994, p. 41). The enactment’s purpose was to assess and restructure the balance in the relationship through communication.

1. Accurate application of techniques

Enactments allowed me to observe how Nicole and Alan, “mutually regulate their behaviors, and to determine the place of the problem behavior within the sequence of transactions. Enactment is also the vehicle through which the therapist introduces disruption in the existent patterns…” (Minuchin & Lappin, 2011, p. 11) From the fist enactment, I had more knowledge about Nicole and Alan and cataloged important therapeutic information, that Nicole was critical and dominant and Alan was submissive.

In the second exercise, I repositioned chairs and moved the room around. I had Alan put this back to Nicole in a chair with wheels. Nicole was facing his back in a chair. I prefaced by saying I hear that Nicole is coming from a place of love, worry, and care with what she ways, but that what I heard in the previous session came off aggressive. I had Nicole imagine she was coming into the room and yelling how she usually would, but Alan could say “redo.” When the tone felt warm and caring, he could turn his chair. Nicole changed her rate of speech and her words seeing her impact on Alan.

1. Demonstrated responsiveness to feedback…

We had a short discussion about fluxuations in tone of voice and how it conveys emotion. Nicole had difficulty seeing eye to eye with Alan, saying she always talks in the same tone no matter what she says or how she says it. Nicole expressed how hard it was and how she really had to think to finally change her tone to have Alan turn his chair around.

In sessions before this enactment, Alan would say to her, “I don’t need an another mom” and “You’re worse than my mother,” indirectly trying to explain how he felt. Nicole would simply laugh to avoid the issue showing how she disregards Alan’s feelings like her parent did to her.

Case management

1. Administrative procedures

I did Nicole’s intake, explained confidentiality, and the 24 hour no show policy. I scheduled and saw her for all sessions. At UCFS, we use an electronic system, so every time we met, I typed her progress notes in the greenway computer system and they were sent to my supervisor Ashley Webb. After a month of seeing me, Nicole requested medication and after talking how it is only one piece of the pie, how internal trauma work, exercise, meditation/mindfulness, nutrition, consistency in therapy all play a role in mental health, I sent a psychiatrist evaluation over electronically.

1. Clinical/referral context of treatment

In terms of larger systems, constraints, and resources, I gave Nicole information about groups including DBT group to help her meet her treatment plan goals. I emailed the lead clinician of the group to speak about Nicole. I referred Nicole to the UCFS food pantry and gave her a list of Norwich services. I looked up free yoga classes and nutrition/binge eating support groups and give her the printed list.

1. Description of handling termination

When it comes time for termination, I will talk to Nicole about her treatment plan objectives, her progress, and evaluate her results from therapy. I will ask Nicole how she feels about her goals and treatment plan. We will also discuss coping skills and relaxation strategies to reduce PTSD symptoms and address IFS parts when they come up. I will have Nicole write a letter nurturing herself with love, care, intention, so she can read it when she is struggling. We will recap our journey through therapy, highlight strengths, review coping tools, self-care strategies, lessons learned, and express my thoughts about termination. We will talk about therapy as a revolving door, that they are always welcome back.

1. Identification and description of potential ethical issues

I explained in our first couple session that I want to create an open and honest space for the both of them, that I would not keep secrets. If I met with one of them and he or she disclosed an affair, drug use, or STD, I would be obligated to share that with the other person. None of these came up, but I wanted to protect myself and the therapeutic-alliance beforehand.

1. Therapist Factors
   1. Therapist stance
2. Self-disclosure of the therapist

Even though I am of a different age and walk of life, I find connections. For instance, when she talked about being the oldest and having less freedom and more rules than her younger sister, I said “I know what you mean, I am the oldest too and I felt the same way.” My intention was to help validate her feelings and remind her she was not alone. Hanson (2005) explained that when therapists disclosed personal information, it improved the therapeutic alliance, fostered more egalitarian relationships, exhibited coping skills, and normalized and validated the client’s experiences. When I see that there is an opportunity to uplift Nicole, I share something short, simple, and to-the-point about my life.

Hierarchical stance of therapist

Madanes (1990) explains the importance of empathy in the therapeutic bond and how modeling it means helping the client feel like an equal. Therapists in the past were trained much differently than we are now defining, “‘the therapeutic posture’: a certain sense of superiority, distance, and arrogance toward the client” (Madanes, 1990, p.11). Egotism and grandiosity are the exact opposites of what I want to evoke, so I choose to work at the same level as Nicole. I see that she was made to feel small and insignificant as a child and as an adult by Sandra, so it is more therapeutically appropriate to work from a humble approach.

In narrative therapy, stepping down from the position of a fully educated graduate student is helpful because Nicole only completed some college and I want her to feel comfortable, like we are simply having a flowing, intimate conversation about her deepest pain, trauma, life stories, and feelings. This would not happen if she felt weary of trusting me.

1. Awareness of and attitude toward difference between therapist and family

Nicole and I are both white women. This may be an influence as to her explaining important details about her life. Both Nicole and I come from a large extended family, which is a great resource. I was able to relate when she said, “Cousins are built-in best friends.” I can understand the benefits of the love, the friendship, the enjoyment, and am very comfortable in my large network. Nicole loves horses and her parents have her horse on their property. My sister loved riding horses also and I have a sense of the terminology and love that comes from an equine hobby.

Ability to demonstrate qualities of leadership

Calmness Being calm when Nicole starts retelling a story allows her to see that I feel safe, am holding a peaceful space, and that all feelings are welcome. My calmness also shows her I am listening and understanding her feeling deep beneath the story. Being around a calm person may not be something she has at home. Being calm shows her my okay-ness with what she is sharing.

Curiosity When I find a self-critical or triggering part pop up, I become curious about myself and remember that this part prevents me from seeing true beauty, that beauty that comes from inside the heart out. I am curious about Nicole s life in the way that I ask intricate questions about her emotions that only a therapist would ask showing her I am genuinely interested in her. When I ask about her history, I show calm, curiosity and let her know it is okay if she does nto want to share.

Clarity From being clear-minded, having good nutrition so my mind can think, and leaving my home-life at the office door, I can see her life more distinctly- dysfunctional boundaries, analyze family systems, and hold the space for all of Nicole’s emotions, irritableness, sufferings, and life story. Being clear helps me see which intervention would be most appropriate for the given moment.

Compassion By offering courage and compassion to my IFS parts, I do the same for Nicole. By staying present, I compassionately thank the part for helping keep me safe, but I am okay and can take it from there. With compassion, I shift my mental landscape. I feel for Nicole’s pain and send her loving kindness. I can sense when Nicole’s pain, loneliness, and vulnerability lay underneath her anger, and I use compassion to reach those parts and coax them out.

Confidence My ability of confident, self-correction when I find myself in a path of negative thinking takes practice and self-awareness, but it leaves me feeling sure of myself, calm and centered. I help Nicole improve her confidence and self-worth with positive self-talk, compassionate inner dialogue, statements of self-worth, and courage. When I do this for myself, I own another level of authority in my own life and am filled with loving kindness and give that to my clients.

Creativity I reconnected to my creativity to challenge myself to be wise in how I worded myself and the tone of voice I used as not to offend or hurt Nicole’s feelings. I used creativity to give Alan value and feel like his voice had power in our couple’s sessions, while also helping Nicole take his feedback without immediately disregarding his feelings or seeing him as inferior. I use my creativity to guide visualization and meditations for Nicole.

Courage I feel courage from self-awareness. I am reminded of a Buddha quote, “You yourself, as much as anybody in the entire universe deserve your love and affection.” Being self-led and offering care to others begins with the way I treat myself. I remind Nicole it is very courageous that she made it to session. I encourage her to step outside her comfort zone.

Connectedness: In order to be self-led, I go inside, step into my authentic self, and become present. I use the vehicle of my breath to connect my mind, body, and spirit. When my mind and body are connected, I am in the here and now, and I offer an uplifting presence to Nicole. I connect inside my heart. When I am self-led, I can help discern, see patterns, and speak in a way that effectively allows Nicole to unveil the shadows that prevent her from taking radical action.

Patience I use patience when working with Nicole because she will go at her own pace and that is okay. I use patience when listening to her talk and when gathering information about her life. I noticed Nicole fixated on blaming others and regressed to pointing her finger at Alan. I used patience to help her refocus on her contributions to her marriage and how cheating betrayed him. I am also patient with myself when it comes to challenges, such as have two clients in one couple’s session, which are part of the growing process. When I started to work with Nicole and Alan, I used patience to slow down my rate of speech, so I did not get overwhelmed.

Presence I meditate and do yoga to be present for myself and my clients. Doing one meditation practice will in no way bring enlightenment, but a short daily practice over time may allow me to cultivate patience, presence, humility, and compassion with myself by sitting with both the comfortable and uncomfortable sensations. I practice and feel it inside myself in order to be a therapist.

Playfulness I use playfulness in action methods including talking in jbberish as well as laughter yoga. Playfulness helps Nicole laugh through some really tough stories and the use of humor is very beneficial. My self-care mediations help me have a new mind for each client who enters the room.

Perspective I use perspective when working with Nicole, if the balance in the equation were to favor persistence, then I could become aggressive, forceful, and injure the therapeutic bond. I need to be present to notice.  “I have moved from being an active challenger… to a softer style, in which I use humor, acceptance, support, suggestion, and seduction on behalf of the same goals” (Minuchin, Nichols & Lee, 2007, p. 6). Through my breath, I connect to the perspectives of the different members of the family in the room knowing that everyone has a different memory of the same experience.

Persistence Every time I work with Nicole, I use slow persistence to unfold the new layer and look deeper. Likewise, meditation and yoga, my preferred methods for working persistently on myself-work, provide me with a perspective shift. Sometimes I find myself holding onto more than I realized once I sit and breathe. From being persistent with self-aware, I can relax the areas of tension, look into their source, and gain a sense of playfulness with myself as the cycle continues back to persistence.

Demonstrated cultural competence

Nicole’s mom was sexually abused by her brother, leading to a mistrust in the world and fear of commitment, which was passed down to her. Nicole’s mom never did her own self-work, developed closeness, and had a fear of vulnerability, so she never nurtured Nicole or taught her empathy. By not getting the love and praise Nicole deeply needed as a child, she developed barriers to being able to give and receive love in her spousal relationship as an adult. Nicole’s mom had sex with many men and Nicole was triangulated into keeping this secret. Her dad felt betrayed from his cheating wife, so he turned to the bottle, something that would always be there for him, just like Nicole turns to cheating on her husband and caretaking. To this day, she feels like she has betrayed her dad, even though he eventually found out. Rumi once said, “Your task is not to seek for love, but merely to seek and find all the barriers within yourself that you have built against it.” Culturally, without role models who communicated in healthy ways, Nicole learned to “keep the peace” and “hold it inside.”

Description of any personal challenges or areas of growth-

As a result of working with Nicole and her family, I have been challenged in new ways. In my practicum and internship, I had seen a handful of couples, but none had the substantial amount of time spent together, the 21 years Nicole and Alan have, which provides a stabile foundation for therapeutic work. Nicole and Alan also were not newly into sobriety which posed as issues with other couples. I learned how to confidently instruct the enactments and understand the meaning of non-verbal feedback.

Description of intern’s utilization of supervision/consultation or pursued extra training or research-

To evolve and better myself as a therapist, I took Dr. Melendez-Rhodes’s feedback, suggestions, and tips from her years of experience about how to weave interventions into the therapy sessions. She helped me see how Nicole and Alan had difficulty listening to each other and the main message of what they were yelling at each other was that they wanted to be heard and feel heard. “Each one wants to be heard by the other but feels attacked. In defending him- or herself, he or she shuts out the other’s message, thus reinforcing the other’s sense of being unheard” (Karpel, 1994, p. 42). Dr. Melendez-Rhodes also helped me understand how Nicole was talking to Alan as if he was a child, which emasculated him individually and in their marriage.

Dr. Melendez-Rhodes taught me how to be assertive and challenge Nicole in a caring way. “Challenging the family’s worldview and unproductive assumptions typically involves verbally questioning operational assumptions in the family system… It’s better to keep the peace than start conflict; It’s easier to sacrifice my needs than ask for what I want; It’s better for the kids for us to stay in this unhappy marriage” (Gehart, 2010, p. 134).

In order to strengthen my clarity in developing and using a systematic approach to the case, in November of 2016, I attended the Renfrew conference in Pennsylvania. The Graduate Student Association Scholarship helped a lot. At the Renfrew conference, I learned about specific types of eating disorders, took workshops, heard keynote presentations on femininity, ethnicity, gender, and learned about diverse populations such as the LGBTQ community.

Also on the note of LGBTQ, in June of 2016, I attended Transgender Culture 101 for three hours in Manchester, CT with my supervisor, Ashley Webb. I learned politically correct terminology when it comes to the transition process of my transgender clients. I directly implemented what I learned when I co-facilitated both teen and adult GLBTQ groups weekly during my internship.

Closing statement

Nicole’s mom never dealt with being sexually abused by her brother, which perpetuated dysfunction for Nicole. Unable to feel safe, Nicole’s mom cheated on her dad, controlled and criticized her daughters, making many household rules. Nicole was pulled into a triangulation, allied with her mom, and betrayed her dad, to this day which he still has guilt. Nicole’s dad financially supported her family taking a submissive role while being cheated on. Nicole’s parents had diffused boundaries, covert communication, and passed down the themes: “keeping the peace” and “do not talk about conflict.” In her marriage, Nicole has become her mom, speaking critically with Alan, exemplifying diffused, disengaged boundaries, and betraying and cheating on him instead of dealing with issues. She married a man like her father who is submissive despite knowing she is actively dating other men. She takes after her dad because she works long hours. Her oldest daughter, Lily, takes on these same patterns in her relationship with her boyfriend. She has become like her father, Alan, with low self-worth. She thinks diffused boundaries, the way her boyfriend cheats on her repeatedly, and putting up with it are normal.

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