Challenging Case Seminar #1 at the Family Systems Institute. – Presented by Linda Mackay PhD.

Blog is written by Aleksandra Trkulja as part of a post-grad learning internship 

Link to Powerpoint slides: 
Intimacy, Sex and Child Abuse

Dr. Linda MacKay presented a case study of how to discuss intimacy with clients who have histories of sexual abuse. The case explored the relationship of a heterosexual couple where the woman had experienced sexual abuse as a child. Her family included her mother, father, and two older siblings, with a ten-year gap between herself and the older brother and sister. The client recalls discloses abuse by her elder brother during a school counselling session. The disclosure leads to the father and son separating away from the mother and youngest daughter.

The aim of this seminar was to develop a familiarity with Bowen’s family systems theory in relation to the complexity of a history of child abuse. The seminar also developed a participant’s ability to conceptualise the family system’s emotional process, chronic anxiety, differentiation of self, and couple dynamics. And finally, the seminar provided the opportunity for the therapist to reflect on the challenges to their own differentiation of self with a challenging case. 

There were many fascinating moments within this seminar, with several take-home ideas for participants. The first was Dr. MacKay’s explanation of how the prefrontal cortex shuts down when anxiety hits, and how this may affect how people respond to emotionally stressful events. The degree to which this mediates our reactions to one another is the degree to which the person is able to then “wake-up” the pre-frontal cortex and think less reactively about the dilemma at hand – this is an essential component of the process of differentiation itself. This process involves resisting the urge to behave out of panic (assuming there is no risk of harm), and to think more clearly when responding to any anxiety expressed within the family system. 

To conceptualise this challenging case study from a Bowen lens, participants discussed the instinctual relational level of sensitivity towards meeting expectations, attention, distress and sense of approval. Questions raised included

• How much are expectations for approval and understanding within the couple relationship modelled on the survivor’s perception to their parents’ reaction (adverse/supportive/dismissive) to the disclosure of abuse.
• How much energy is still going into being “believed”? What capacity does the survivor have to hold onto their own view, in the absence of support?
• How are these patterns of reaction transgenerational?
• What can we hypothesise from this in terms of the emotional process of the whole family?

When exploring the couple’s issues, a therapist can explore the notions of ‘needs’ and ‘adequacy’ in relation to intimacy. These are often gendered assumptions, and according to Bowen these things can be magnified depending on how much the client has grown up accommodating for others. How might patterns within the family system lead to individuals harbouring expectations that they must accommodate to the needs of others over themselves? This pushes the therapeutic focus onto exploring the client’s ‘wants’ versus ‘needs’ within the intimate relationship. 

When exploring ‘wants’ versus ‘needs’ in a romantic relationship, it is important to ask each client to reflect on their ideas as to whose responsibility it is to meet these ‘needs’, and to what degree it is vital they are met. Within the exploration, the couple must consider the difference between intimacy and sexual release when they talk about ‘needs’. Questions the group were encouraged to consider included:

• How much of the clients attending therapy, and healing from sexual abuse, is about becoming the person she wants to be for her partner? 
• Is she doing it for herself? How might she work not to derail efforts to grow a more solid sense of self in her intimate relationship with her partner? 
• If either partner agrees to the other partner’s request for more intimacy,  how can that partner be clearer about what is a thoughtful decision, that is, a move to “warming up the relationship” or when/if this move is operating more out of accommodating reactivity? 
• In cases of sexual abuse, how might this accommodation and potentially painful sex be reminiscent of past sexual abuse for the victim? What/who is responsible for managing this?  

A second take-home idea is that Bowen theory considers symptom development as a response to an overload in the system. This could manifest as the victim of sexual abuse giving up on their sense of self, taking on a submissive role in the intimate relationship, maintaining the expectation that they are defective which stems from their position within the family of origin story, and directly affects the intimacy within the relationship. 

The group explored how discussing sex doesn’t need to always involve discussing the specifics of sex, but rather the interactions that occur within the sexual relationship. Discussing sexual relationships involve discussing desire discrepancy, for example, couples often present with one person who experiences low desire as the ‘problem’. This belief is then challenged, and the therapist can explore how this belief can play into power dynamics, and accommodation of another’s needs. 

A third take-home idea; the dynamics outside of the bedroom affect the events within the bedroom. The participants were coached on how to explore sexual relationships using how, what, when, and where questions to understand the sequences of events leading up to sex and the general emotional process around this. Discussing sex can often be an optimal way to learn about the family system because patterns of behaviour may be more observable.

Dr. MacKay’s challenging case study helped participants conceptualise how family circular processes can impact a client’s intimate life. It educates participants on core Bowen theory concepts, explore symptoms development, discusses the couple’s ‘wants’ versus ‘needs’, and coaches participants on how to discuss sexual intimacy using what, when, where, how questions.