Posted by Dave: I have often noticed that in the weeks following the extended family interview, something happens, something that gives evidence of change. In this clinical illustration the something happens, but it is not very subtle. The something that happened was the result of the therapist, me, being assertive with a domineering grandfather.
The Case: Four months after his mother’s death from cancer, Dick, 8, was given the diagnosis of attention deficit disorder (ADD) based chiefly on his behavior at school. The ADD clinic at the university child psychiatry clinic treated him with methylphenidate (Ritalin). Three months later the family 
doctor referred the family (Dick, his brother Paul, 11, and his father) to me when the boy took an aspirin overdose. The father, an engineer, acknowledged distress about his wife’s death, but said they could not grieve forever; it was time to move on. He also minimized the significance of his own hernia surgery, scheduled for 3 weeks ahead. The father did not grasp the fact that Dick was naturally concerned that he (the father) might die from the surgery. The father had all the affective range of a robot in a suit.
I was concerned Dick’s behavior was the result of a fixed communicational impasse in the family living and the father’s apparent inability to talk about life. I didn’t think Father knew how to get anything out of therapy, that is, he didn’t know how to be a patient. More people were needed, so I suggested they bring more family members to the next session. The father’s father and sister, the most geographically available members of the family, were invited to the next interview. The father’s mother had died two years earlier.
The grandfather, a successful engineer, was domineering and harshly matter-of-fact, indicating that his father died when he was young, and he had managed just fine; the implication was that grieving was an unnecessary self-indulgence. He encouraged positive thinking in such situations. I pressured him with some of my questions about his growing up. Then I challenged his rigidity, saying “It looks like there is a rule against pain or sadness in the family, and Dick is bearing the brunt.” In the manner of many accomplished domineering positive thinkers, the grandfather sneered, “Psychiatrists don’t know anything.” My response: “You don’t know much about what I know, or what I went through in order to be sitting in this chair.”
At this point the father’s sister, who seemed suspicious of me initially, joined in, saying to her father and brother, with tears and anger, she could not believe neither of them had shed a tear at their wives’ funerals. The father, her brother, defended himself: “I needed to set a good example for Dick and Paul.” Suddenly tears began to flow from all but the grandfather. Then Dick described his worries. He was afraid his dad would not survive the surgery. And Dick thought the aspirin overdose would kill him, so he could go find his mom and help her if his dad died from the operation.
The grandfather smirked and said to no one in particular that I had “planned the whole thing”. I complimented grandfather with a small dose of irony, “You know you are not only pretty tough, you’re also smart. But here’s something I don’t think you know. Emotions are unbalancing, and I think you are afraid of these emotions you pretend are unnecessary. But even worse, as tough as you seem, I think your family protects you by not talking about anything emotional. They feel obliged to protect you.” “That’s ridiculous, nobody needs to protect me,” he said and prepared to walk out, but his son and daughter prevailed upon him to stay until the session ended.
I saw the father and the boys once more before the surgery and twice after that. It was curious, but Dick’s hyperactivity faded into the background, and not only did the robot’s heart begin to beat, he gave evidence of being more openly interested in others, the interest showed up in how he talked about people and relationships.
So the “something that happened” here was me disrupting the family rule system. I broke an implicit family rule that did not allow comment on the patriarch’s domineering manner.