Multi-Dimensional Therapy with Families, Children and Adults

The Diamond Model

Shlomo Ariel

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351587945
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Multi-Dimensional Therapy with Families, Children and Adults: The Diamond Model is a comprehensive introduction to a model of multi-systemic, integrative, culturally competent, child and family-oriented psychotherapy: The Diamond Model.

This model integrates a great number of concepts, methods and techniques, found in diverse fields such as the various branches of psychology and psychotherapy, cultural anthropology, biology, linguistics and more, into a single linguistically unified theoretical and methodological framework. Through this model, the author presents clinical cases to help explore various internal and external factors thatlead individuals and families to seek out therapy. The book also reserves a special place for examining play therapeutic and culturally competent techniques.

With vivid clinical examples throughout, Multi-Dimensional Therapy with Families, Children and Adults serves both as a theory-to-practice guide and as a reference book for therapists working with children and families in training and practice.

Part 1

Theoretical and methodological foundations

Chapter 1

The Diamond Model – essentials

Case 1.1 Nonny

His mother pushed him lightly into my office, as if his legs refused to carry him. He was slim, pale. He had a strange look: gray eyes, staring inwards, expressionless face, except for a vague smile that seemed to me slightly mocking. He stood motionless, limp, his arms hanging. He wore a long-sleeved winter shirt, buttoned to the neck, though it was a very hot, end-of-summer day.

Nonny, a nickname for Noam, thirteen years old.

Nonny’s father did not show up. He told Nonny’s mother that he “didn’t believe in psychology.”

When I asked Nonny to sit down, he did not respond, and when I tried to engage him in a conversation, he did not cooperate.

I was a clinical psychology intern in a community mental health center in Jerusalem.

After further attempts to secure the father’s cooperation had failed, my supervisor, Daphna, instructed me to interview just the mother. I was required to fill in a standard intake questionnaire, of which the purpose was to obtain data on the child’s symptoms, milestones in his development, his family and the circumstances of his life. The standard intake procedure was also to include administering a battery of psychological tests, but in Nonny’s case this was impossible.

Nonny’s mother, Tanya, looked exhausted. She spoke in a barely audible voice, with a Russian accent. She immigrated to Israel with her mother from Ukraine when she was sixteen. She was the one who decided to seek therapy for Nonny. Since the beginning of the school summer vacation, he had been locking himself up in his room, refusing to come out. In the safety of his room, he would spend the time obsessively writing in notebooks in tiny, dense, unreadable characters, which looked like an illegible, meaningless scrawl. Only after his mother had pressed him over and over again to tell her what he was writing, he said, “TV series,” and when she asked him why in such dense script and tiny letters, he said, “To save paper.” Indeed, his mother had to buy him scores of notebooks. He insisted on eating in his room and would barely touch the food. His mother would put a tray of food on his table and he would nod her out. Social ties and activities out of home were of course out of the question.

Nonny was born with hypotonia (“floppy baby syndrome”), a state of low muscle tone, which impaired his motor development and therefore his social development as well. As a preschooler, he spoke a mixture of Hebrew and Russian, because his mother could not speak Hebrew fluently. This was another stumbling block on his way to social adjustment.

Tanya evaded, not so skillfully, probing questions about her husband, Shalom, and her relationship with him. From that first and later conversations with her, however, I managed to learn that Shalom had the habit of spending money obsessively on the soccer lottery. In this way, he compensated himself for the loss of his status as a soccer star. His gambling addiction got him entangled in heavy debts. There were rumors that he had embezzled some sport club money and that this affair was hushed up. The family was forced to sell their apartment and move to rented apartments in “bad” neighborhoods. Shalom used to borrow money from loan sharks. Often creditors were knocking on the door, making threats. Tanya was making desperate efforts to cover the debts. She worked as an accountant and, after work hours, she cleaned homes. These efforts put her under great physical and mental strain, but also strengthened her position vis-à-vis her husband. She accused and criticized Shalom scathingly, and he reacted by being on the defensive, making all kinds of excuses. He also poured unsolicited gifts on her, which only increased the family’s debts.

Shalom grew up in Tel Aviv in a low socioeconomic area. As a child, he often failed to attend school, spending most of his time playing soccer. He had barely finished elementary school.

My supervisor, Daphna, qualified herself as a Rogerian humanistic, person-centered, non-directive psychotherapist (see Rogers, 1942). She had read Virginia Axline’s Play therapy (1947) and Dibs in search of self (1964) and was deeply impressed by Axline’s approach. She said that Nonny’s symptoms were his way of asserting his autonomous, independent self in a difficult, stormy family situation. She suggested that in my work with Nonny I adopt a non-directive, child-centered approach. I should let him write his “TV series” in my office and have on my table all sorts of objects such as games, books and even a soccer ball that could remind him of his father. My only role would be to provide him with an accepting and empathetic human environment, without suggesting anything to do and without interfering in his own choices. I should only use non-judgmental reflections to give Nonny the message that I am there for him. The therapeutic process would take care of itself, she predicted.

I lacked a more in-depth analysis of the complexity of this case, nor was I convinced that the treatment method Daphna suggested was the right one for this case. I suspected that Nonny would experience my presence as intrusive. I was afraid I would feel like a Peeping Tom. The assumption that the process would happen without my active involvement seemed to me unfounded. Furthermore, our workplace was a public clinic. We could not have all the time in the world to work with each case.

What I did, eventually, was suggest to Nonny for us to write his “TV series” together. To my pleasant surprise, he agreed. Our conjoint creation, at first in writing and later orally, was, for all intents and purposes, a fruitful therapeutic dialogue, disguised as dramatic scenes in an “American TV crime series”, which, as expected, related allegorically to the realities of Nonny’s life. That metaphorical dialogue opened new and unexpected avenues for continued multi-systemic therapy. Individual sessions with Tanya led to Shalom’s consent to participate in couple therapy, followed by family play therapy (see Chapter 9). Shalom joined a gambling addiction therapeutic group. That drama series terminated in a happy ending. In the final scene, Nonny was seen riding toward the horizon, a mentally healthy and normative adolescent.

But let us go back to what directly followed the intake. Nonny’s case was discussed in a multi-disciplinary team meeting. The clinic director, a psychiatrist, said that although he still had no conclusive diagnosis, his impression was that this was a case of simple-type schizophrenia, settled on a pervasive developmental disorder infrastructure, perhaps the first step toward catatonia. He said he had not yet decided on the suitable medication, but suggested that the patient be hospitalized for observation. A cognitive-behavior therapy (CBT) expert proposed behavior therapy, using positive and negative reinforcement (e.g. giving Nonny a notebook and a pen only if he comes out of his room for five minutes and, if he did so, he would get one pen and one notebook for every minute he was out of his room). A family therapist with a strategic, solution-focused leaning suggested using paradoxical injunctions such as prescribing the symptoms and endorsing the triangulation of Nonny by his parents. A psychoanalyst spoke in a complicated, obscure Kleinian and Winnicottian jargon that I couldn’t make head or tail of. The discussion was like the dialogue of the deaf. I came out of that meeting utterly confused.

It was such mental state of bewilderment and disorientation, experienced by myself in the early stage of my retraining as a mental health professional and later by my trainees, that led me to develop The Diamond Model.

Students of mine, especially in the initial stages of their training, were expressing difficulty with the systematic rigor of the model, which they experienced as being “dry” and “cold”. It seemed to them inconsistent with the richness and inherent vagueness of the clinical encounter. They expressed concern that internalizing the model would extinguish their intuition, imagination and creativity. My standard answer used to be that the model was like the “dry” and “cold” grammar of a language, or the theory of music, which serve as frameworks for endless possibilities of creating original productions. I like to quote the title of the book The Structure of Magic by the founders of Neuro-Linguistic Programming, Bandler and Grinder (1975). They explicated the “grammar” underlying the work of gifted psychotherapists such as Virginia Satir and Milton Erickson to make their methods and techniques available to less gifted psychotherapists.

What is The Diamond Model?

The Diamond Model is a complete guide to integrative psychotherapy in general and to integrative play therapy in particular.

The attributes of The Diamond Model are that it is multi-systemic, integrative, linguistically uniform, rigorous up to a certain extent, explanatory and technically eclectic.

The Diamond Model is multi-systemic

Every case brought to therapy, whatever the presenting difficulties, is multi-determined, a product of a dynamic interaction between factors (programs) belonging to different internal and external subsystems. Therefore, The Diamond Model is multi-systemic. In designing and carrying out the therapy, all the relevant programs and their interrelations must be considered. Ignoring relevant programs found in any of the subsystems can result in understanding the case incorrectly and choosing an ineffective or even harmful therapeutic strategy.

The internal subsystems (within the individual) are: the body (the brain and the nervous system, the genetic, anatomic and physiological subsystems); the cognitive and psychomotor subsystems; conscious or unconscious emotional concerns (emotives), emotional conflicts and emotional defenses; the individual and social personality (self and body images and concepts, object relations, self and body boundaries, attachment, egocentricity and narcissism vs. empathy and prosocial attitude, reality testing, self-control, psychosexual development and moral development); and the internalized culture.

The external subsystems are: significant life events; the family and other social systems; the ecosystems (the human and non-human environments at large); and the culture.

Each of the subsystems and all of them can be looked at synchronically (a cross-section at a particular time, usually the beginning of therapy) or diachronically (from the past to the present, developing through time).

Nonny’s case, like any other case, is multi-determined in this sense. To understand this case and treat it effectively, a therapist should scrutinize the dynamic interaction between programs belonging to all the above-listed subsystems as they are manifested in this specific case. In this procedure, the therapist will form hypotheses about the various programs and their dynamic interrelations, to be confirmed or refuted by further data. Attending only to some of the relevant programs while disregarding other (e.g. treating just Nonny’s symptoms while ignoring his hypotonia, his social isolation, his father’s addiction to gambling, his entanglement with the conflict between his parents, the absence of his mother in the evenings, her cultural and linguistic background, his cognitive potential, etc.) could lead the therapy astray.

A sample, just a sample, of the relevant programs in Nonny’s case and their interrelations is presented below. In a full analysis of a case, the relevant programs will be organized in a different format that displays their dynamic interrelations (see Chapter 7).

In the following informal presentation, the programs are looked at from both a diachronic and a synchronic perspective. Past events are relevant inasmuch as they have a continued impact on the present. The subsystems that each part of this presentation belongs to are placed in square brackets. It should be stressed that most of the following statements are just hypotheses, to be confirmed or refuted by more empirical data.

Shalom, Nonny’s father, grew up in a low-socioeconomic neighborhood, where children used to spend a great deal of their free time out on the street [the ecological and culture subsystems]. He did not like school, maybe because he had an undiagnosed ADHD, maybe because his learning abilities were low, maybe because he could not get along with authority [the cognitive, psychomotor and social subsystems]. But he was sporty, with a talent for and powerful attraction to soccer [the psychomotor subsystem; the subsystem of emotions]. Soccer was the arena where he could have high self-esteem and enjoy social prestige [the personality development and social subsystems]. As an adult, he reached the rank of national socce...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Preface
• Acknowledgments
• Introduction
• Part 1 Theoretical and methodological foundations
• Part 2 The internal and external subsystems
• Part 3 Multi-systemic diagnosis
• Part 4 Therapy
• Epilogue
• List of cases, examples and observations
• Index