# 07 Feb 2022 Systemic Group Supervision #systemic #ambivalence J A PS Pt J --- Pattrick presented a case. ## About the family and case - 20 year old Chinese female. Year 1 business diploma at NYP - Living with father, 60+ Security Guard, mother 60+ homemaker - No Fam history. (Mother from malaysia). - AMK follow up . Low mood. - Patient slap mother. - (why now?) - Disorganised? - Long DUP, graduate decline, since Secondary School. - Fairly well in PSLE. Sleeping at home. Rude to teachers and peers. - (Any family violence?) ## Presented Issues 1. two weeks acute behavior change at home 2. Bizarre speech and behavior, prominent thought disorder 3. ?Long DUP - academic 4. went to MI. 2 years, did not do well 5. Mother PPO against father. 6. Family Violence between father, Client and brother. Easily triggered by mother, and slap and kick mother. - ==Presenter said that he feel the case is #chaotic chaotic case, and experience counter transference. Wanting input from team, and how to work the case. == ## Key Issues - Family Violence - Complex family dynamic - Primarily between parents - aggressive communication - Triangulation of children and CM - Nil trust, incongruent treatment goals - Mother's dilemma as victim of violence and mother to C ## Challenges 1. Mother is victim of trauma - (need her own support) #Trauma 2. Stuckness 3. Triangulation ## What concept? 1. Family Violence 1. Trauma ^e29576 2. Highly anxious. 3. Insecure attachment 4. Loss of trust 5. Gaslighting. 6. Why Now? 1. What changed since patient admitted, function of illness? [[Function of illness]] 1. Mother moved out with the son. So daughter aligned with father. Cross alliance. Collusion . Cross gender alliance. 7. What maintain violence in family? 1. Patient against mother. ## Relation to self - Hearing about this case, i feel tired, because there is so much going on.. i am drained already. --- ## What is being recycled here when CM work with this case? - Communication - Not clear communication is confusing. Past experience of being caught in emotional ambivalence? - evernote:///view/463671/s5/13453fb3-429f-4958-b60a-e08e0514443f/c24bc1f0-1ab8-482a-b3ed-5d0ab50ef081 Schizophrenia as a Disorder of Communication The father got no capacity to empathise, to put other being well being ahead of him. - I wonder if he was abused before in his FOO. #safety ## How would this be helpful for you? to the CM. - How to better understand the mother? How to be more present for mother? - Assumption: Because mother need space to unload. She need to be attended. But she already got two workers outside. CareCorner and AMKFSC. - How to work with the father? - Who is your client? ---- ## Opening up to the group - [[Function of illness]] - Collusion - Functioning level of the patient - - Minimising, being guarded. - Limited insight and views of problem. Father does not see this as a psychiatric issues. - PMP, relationship, can connect with others. We don't know the nature of that relationship. - Prior to admission, got a boyfriend... for two months. - My view : it just doesn't make sense... - Any history of Triangle when we become rescuer role -- we also persecutor and victim.  How to get out of this triangle. What are we enforcement/enabling when we always rescue. [[24012022 Systemic Group Supervision]] ^da8801 --- - ## LUUUUTT (from CMM coordinated management of meaning) https://www.slideserve.com/buzz/coordinated-management-of-meaning - - ![[Screenshot 2022-02-07 at 3.17.30 PM.png]] Untellable stories bring alot of #shame, secret [[202103082054 Keeping secrets causes sickness]] Communication have to be coordinated. Do you have the pressure to "fix the family?" What is the counter-transference of the CM towards the mother? - CM is being the "rescuer" When we have a guarded patient, we need to think of safety #safety - No absence of threat, but presence of connection. [[24012022 Systemic Group Supervision]] #gaslighting -- i am thinking of how case worker may have self expectation, to work on this case. ==In a disorganise system, the CM need to take charge, to control the flow. The whole intent is that it have to be on your own. So must know the intention. == ==In a disorganised system, we only go with ONE thing that they want change at this interaction.. To manage the chaos. Summarise and redirect to the purpose of this call.== ==Need to keep the focus on the well being on the patient, that there is someone looking out for her== - may be difficult because of trauma history, related to trust. [[Attunement, Affirmation, Acknowledgment, Adaptation]] ==Send out affirmation, but it's OK if they don't want it.== We dont want to play into the pushback dynamics. We push ourselves back instead of patient pushing back. #strategic ==When patient got no boundaries, we have to set boundaries== But having an inactive case on the caseload, can be anxiety provoking How to pace with mother, father, brother and patient? - Useful to take on a systemic view, to see not only patient as "symptom bearers", how to form empathetic connection with different members. - Most drawn to - younger brother - Least - father - ==It is the patient least drawn to that we are perpectuating, and sidelining the person. Precisely the unlovable that need love== ==Emotionally, Ambivalence relationships are the worse. More toxic. More painful then bad relationships== . Easier to make sense when it's consistently bad. ^9fa564 What will be hope, desired outcome (whose?) for this family? Do you work differently compare to other cases? The more pressure, expectations for this case? ## Interventions - When anxious parents coming in on us, need to differentiate whose anxieties... return to the parents / patients their anxieties. - Differentiate the different emotions, whose's emotions. "What are you most afraid of mum?" - "Then what are you going to do about it mum?" - *I just feel that when we work harder then the patient, i feel like we are not practicing patient-centered, respecting patient's ability and resourcefulness. - Coach mum, how to use her empathy and concern to reach out to the daughter, instead of doing it for her. - Rather then, we become the spork and hub, we coach people to connect with each other. We work through the caregivers. - ==Exception -- You won't know bad durian until you tasted good durian. You won't know know bad unless you have experienced good.== The word Independence bring a sense of responsibilities. That is anxiety provoking. My hope for u, u can feel confident to be on ur own --- # Takeaway Message - At first was chaotic, but then returning the anxieties. - Connecting with everyone similarly. - [[202202071519 LUUUUTT Model]] - Centered, Grounded - Knowing my intention of what i am doing. -- related to [[Einstellung effect]] ## Notes - [[What predisposes a person to pivotal mental state]] - [[Crisis bring people into a pivotal mental state]] (Relational) - **Trauma impact not only immediate victims, but their family members and next generations.** ^6e887e - **Children of depressed mothers have risk of growing up insecure and anxious.** - **Trauma changes brain physiologically.** - **Three ways to manage and help trauma victims, (1) talking about it, (2) medication, (3) allow body to experience those trauma** - **Trauma causes one to lost trust in self and others. Become closed up.** - **Shame experienced for allowing trauma to happen to themselves.** - **Victims of trauma feel emotionally numb, unable to connect with people.** ^0b8bc6 - **Once traumatised, victims become wary and project their trauma on everything. Like chinese saying "bitten by snake once, 10 years wary about ropes"**. - **Not being able to imagine about future, and possibilities, lock us up with the present/past.** Book - Bread and Spirit - Therapy with the new poor. Diversity of Race, Culture, and Values by Harry J Aponte. --- Thinking how i can be like Julianna, to be so gentle and gracious.