Family Dysfunction: How Therapists Get the Whole Story

Shame, guilt, and protecting reputations stop people from opening up.

Posted Mar 21, 2017

..she tells you she's an orphan

after you meet her family

                 ~ The Black Crowes

 Flicker, Columbo by James Whatley, CC by 2.0
Source: Source: Flicker, Columbo by James Whatley, CC by 2.0

Whenever you hear a story about someone’s family problems in a news story, in a letter to an advice columnist, or directly from friends and acquaintances, the story will quite often be, shall we say, incomplete. The story as told may be true as far as it goes, but it often leaves out details and information about the context in which the events occurred.

These details can drastically change any impression about what had happened that a listener might have formed from hearing the initial account.

The same can be said for stories told by new patients in psychotherapy. This post will describe some helpful therapist techniques for eliciting a more complete description of what is really happening. Some of these techniques can also be employed by readers who attempt to metacommunicate with their own family members - that is, discuss family patterns with the purpose of putting a stop to repetitive problematic interactions.

Whenever I bring up the fact that people are frequently not completely honest about dysfunctional family patterns, not to mention about themselves, I get accused of assuming that people are all lying. Actually, I do not assume anything. I investigate all possibilities. It seems to me that my critics are the ones who are assuming that they are getting the whole truth and nothing but the truth. As advice columnist Carolyn Hax once wrote back to a letter writer, what was said in the original letter was clearly "the tip of the storyberg."

 Flicker, Danmark O Fohn Fjord Renodde by Rita Wallaert, CC by 2.0
Source: Source: Flicker, Danmark O Fohn Fjord Renodde by Rita Wallaert, CC by 2.0

To think that patients do not hide things due to their shame, guilt, denial, and/or protection of family members is to live in an alternate universe. For example, I had one patient who admitted in her initial evaluation that her father was an alcoholic, but then denied it vehemently when I brought it up a few sessions later. It turned out that he was not an alcoholic after all. He was a heroin addict!

In therapy, as the therapist gets to know the patient, listens carefully, and employs certain techniques to help get passed the patient's defenses, the plot almost invariably thickens, and the whole story gradually emerges. The added information puts everything the patient had told the therapist before in a whole new light. 

One commonly-used psychotherapy technique for getting patients to open up is facetiously called the Columbo style of questioning, named after a famous TV detective played by the actor Peter Falk. He would often get suspects to incriminate themselves by, in a sense, playing stupid.  He would point out discrepancies in the suspect’s story and kind of scratch his head, acting if he were the one who was just not bright enough to figure out how to explain them. 

He would never actually say that he thought that the suspect was purposely misleading him, although he obviously knew that was really the case. The suspect would then try to “help out” the hapless cop by clarifying the apparent discrepancy, much to his own detriment.

In therapy, the object of this strategy is of course not to make the other person incriminate himself or herself, but to get the patient to open up about the whole picture. When patients contradict themselves or employ specious logic, the therapist (or a metacommunicator) can tactfully expresses confusion about what the person is trying to say, or point out seeming contradictions. This is done in an almost apologetic fashion, and with a matter-of-fact tone of voice. Rather than accusing the other of purposely being misleading or confusing, therapists try to indicate that they themselves are taking responsibility for any lack of interpersonal understanding.

With this strategy the patient (or family member) often feels obliged to clear up the confusion. In order to do so, he or she often must drop the logical fallacy and/or reveal new information. When this happens, it is important that the therarpist seems grateful for the new clarity, and not have a kind of “I told you that you were irrational” attitude.

For metacommunicators, maintaining this bemused, self-effacing sort of style is often particularly difficult to do if there is component to the family member's irrational argument that sounds like a personal attack. In that case, the metacommunicator will be the one who usually becomes defensive, and who therefore derails his or her own effort to solve ongoing problems. If you are being accused of being overly sensitive, stupid, or irrational yourself, the best response is to not argue about whether or not that is true, lecture or scold the family member, or become defensive. You can instead say, "Well, maybe so, but I still want to understand some of the things that you say and do."

In therapy, patients often contradict what they have said earlier many sessions or many months after an initial assertion is made, so it is important that the therapist remember all along things the patient has said in the past. My memory is unfortunately not that good, so I take extensive notes after every session. Just prior to the following session, I do a quick overview of all of my previous notes to refresh my memory.

As patients talk about what’s on their mind concerning ongoing issues, they will often say something that contradicts something they said earlier casually and almost in passing. This can therefore be easy to miss. Sometimes this even happens while patients are discussing matters that seem to be totally unrelated.  I just happen to be paying closer attention to what they said than most people. When a contradiction happens more than once, it becomes even easier to address.

I politely ask them to clarify for me how seemingly contradictory statements they have made fit together. I do this without accusing them of trying to obfuscate issues or to confuse me. Again, I ask them to help me understand this from a position of my being confused, and perhaps just too thick to understand it.

Another technique therapists use for expanding the scope of an inquiry is called pattern matching. The patient's story may remind an experienced therapist of common dysfunctional family patterns that may (or may not) apply to the patient’s situation, and about which the patient would have no way of knowing. The therapist mentions to the patient that in other similar cases, such and such explained similar family behavior. The therapist then inquires as to whether or not this may be possibly be what is going on in the patient's family. The way the question is framed allows patients to disagree with the hypothesis if they so choose, which tends to decrease their defensiveness.

A big clue that a therapist may or may not be barking up the wrong tree is the patient's response to any hypothesis the therapist may offer to explain what causes patients and family members to act the way they do. Back in the day when psychoanalytic therapies were king, we were taught that there were four possible patient responses to any observation or interpretation a therapist makes. Their ideas about this are still valid today.

First, the patient agrees with the therapist, and then a bunch of brand new information begins to come out. That’s obviously the best outcome.

The second best outcome is that the patient disagrees with the therapist, but a whole bunch of brand new information still comes out. This usually means one of two things: 1. That the therapist is partially correct, but is missing something important. 2. That the therapist is bringing up something prematurely, before the patient is quite ready to admit to certain things for any of a variety of reasons.

The second-to-worst outcome is when the patient agrees with the therapist, but then gets quiet, with no additional information coming forth. This usually means that the patient is agreeing with therapists only for the purpose of placating them - telling them what the they seem to want to hear. 

The worst outcome is when the patient disagrees with the therapist and then gets quiet. That usually means the therapist is way off. When this happens, it is time for the therapist to ask for the patient's thoughts, and then shut up and just listen.