The assessment and formulation process with parents

Examples of embedded problems

Examples of embedded problems in the adolescent and young person may take a number of different forms. For example, they may have a fear that despite being academically competent or even gifted, that they will fail at school and in life unless they work all hours. Some obsessive behaviours may take the form of the young person being preoccupied with a part of their body, usually their face, nose or hairline. Often these behaviours and fears are accompanied by particular rituals in which the young person tries to involve their parents and becomes furious if they refuse.

When parents first arrive to meet the therapist to discuss the embedded problem of their son or daughter, we can assume that they have inevitably become caught up and encapsulated in the problem themselves. It is understandable that their first request is to focus on the problem as though it stands alone or can be separately identified and therefore separately treated. By taking a meaning making stance and one that considers a broader formulation, we already introduce a different dimension into the therapeutic process. We understand that the rigidity and insistence of the young person about their perspective of themselves and the problem, has already pervaded the parents’ thinking, and it is difficult for them to take distance from it. It is not unusual for parents to present in these situations as having to walk on eggshells around their son or daughter. They will also describe scenes at home of the young person crying and becoming hysterical if challenged about how they see themselves and the problem, and even threatening to end their lives. The primary task then in this initial session is to provide containment for the parents and for their justifiable anxiety. Whilst not excluding medical and organic factors in the course of the assessment process, if we solely resort to an illness model we will foreclose on the meaning of the behaviour however complicated and threatening it appears to be. The Division of Clinical Psychology Guidelines refer to this as a potentially false assumption that the primary causal factor in the presentation of some mental disturbances is biological dysfunction, rather than understanding the behaviour as a response to complex life circumstances that need to be explored.

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