The first family meeting is the last of the structured variety. The number of participants ranged from three to six, mostly of two parents and one to four children. More than four children would have certainly been welcomed, but in fact that only happened two or three times over the years. Oftentimes when the participants were a single mother and one child or adolescent, the process moved directly from the summary and recommendations session into straight clinical sessions, the two having been long accustomed to working together.
Roughly a third of the families bypassed this session and moved directly into clinical work. In addition to the few mother-child dyads, cases involving multiple family-wide issues that required immediate attention and recommendations was the primary reason for skipping the routines of the fourth session. These could include manifest conduct disorder types of aggression, delinquencies, suspensions, and resistances; self destructive behaviors; threats to safety and security; and lingering post-divorce issues that pull the child(ren) back and forth, creating a prevailing atmosphere of inhibiting anxiety and dread.
Nietzsche once wrote that “out of chaos comes a dancing star”. These situations cited above were usually among the most difficult, with a higher percentage of early withdrawal. But those that stayed the course and really got somewhere new and healthier could be seen as the dancing stars. If the clinician can work them, meaningful degrees of peace and even beauty can emerge.
The purpose of the fourth overall session is threefold. The first is to accustom the group involved family members to working as a group in the office, for the most part an entirely new endeavor. The second is to establish a family-determined baseline of desired changes. The session is split into two separate sections, and one function of the second half is to observe the family playing a neutral and entertaining activity that also provides an opportunity to engage with the participants more informally.
After the induction of family members attending for the first time, the session begins with: “Is there anything of immediate importance that you need to discuss today?”
An affirmative was uncommon, and most of those situations were deferred to the last few minutes of the session.
The follow-up was “What I’d like to do is to hear from each of you what it is that you’d like to see get better in your family, so whoever wants to start, go ahead.” After a few seconds of looking around at each other, nine times out of ten that person would be the mother. Staying in the role of interviewer rather than director, who came next was left up to them.
The first process consideration concerned time. Minimally, twenty of the fifty minutes were going to be used for the session’s second half game, and preferably twenty-five. One intent was to use the same amount of time interviewing each family member present during this first section, so these mini-interviews had to be structured accordingly. If the group in the office numbered three, that would leave eight minutes or so for each; for six that would be five.
Before shifting to the game they were to play, a quick summary of what the group had identified as targets for improvement was given. I ask if anyone has anything they want to add or elaborate of change.
The list forms the family baseline, different from the clinical. Together, they make an outline of reference points that will help shape the termination session review, whenever that occurs.
For an experienced interviewer, this work is fairly easy, enlightening, and as so often with kids, sometimes pretty fun.
Language Shaping
In addition to establishing baselines, much of the clinical work during these early sessions involved two kinds of language shaping. The first is a small body of suggestions for the participants as they related thoughts and pursued changes, all toward facilitating manners that are more descriptive, specific, and positive in nature. The other involves interviewer phraseology, modeling what can be viewed as a collegial style as differentiated from a directive one.
Shaping Vis-a-vis The Participants
All of these following examples recurred over time, enough that a standard response was developed to intercede for most. Any of the first four could and would surface in this fourth session or early thereafter, and the others would arise more randomly.
“You should…” or “should not”
‘Shoulds’ were actually not used very often during session, almost surprisingly so. Shoulds were usually used by a father reproving a son during this first family meeting. Before the youngster could answer, I would interject, “There are no shoulds” (highlighting the ‘are’ as a mild emphasis)”, so what I’d like you to do is restate your point without using the ‘should’.
Almost all the rephrasing parents created a better and less challenging restatement. That they did so unquestioningly was a kind of revelation. More importantly, the restatement itself could be highlighted as being more to the point and effective, thus providing some unanticipated, random reinforcement, always the most potent kind.
Only two fathers that I recall challenged the assertion. Both were lawyers, and they both used an example, like “Of course there are… ‘you should pay your taxes!’’
And I replied “A should is really just an opinion presented as an imperative.”
And both shrugged, accepted this proposition, and went ahead with their revisions. With an exception or two, the use of ‘should’ by the adult being addressed fully stopped. The important part was that these parents, particularly the fathers, were likely putting more thought into their messages rather than bering reflexive. In the office, anyway, the children were more attentive at that moment of revision. In and of itself, the last point could be randomly reinforced as well.
Defining objectives in positive terms
To a parent who has just told the child he needed to, say, cut down on computer game time: “Now, could you phrase that in terms of what you want to see happen rather than what you want to see stop happening?”
For some parents the transition here is challenging, affording an early opportunity to be of straight clinical help in shaping their new message. Possibly that work might include how the parent could aid or facilitate what they’d like the child to be doing. Would the child like the parent to be of a bit more help with homework, that usually being what the parent wanted the kid to do in lieu of gaming at the outset. Basic CBT.
Beneath most anger is fear
This approach can be particularly effective in the office. From a clinician’s standpoint, switching the focus is a shortcut around what can be the laborious and time consuming task of unwinding the anger itself, and the parents now have a new and easy tool to use at home.
“What might you be worrying about here?”
“Can you say that in a quieter way? You’ll be heard better”
An alternative to the approach above. If the occurrence of anger was frequent, one could also use a family narrative approach, asking the parents if either of them or other family members of theirs had the same kind of anger pattern.
“Use “I”
In response to the parent talking about themselves in the third person, e.g. “Mommy’s is disappointed about (what you did)”.
I interjected, “Use ‘I’.“ The belief here is that third person-ing induces more in the way of guilt, and produces less in the way of thought.
“I’m just lazy”
This statement appeared maybe only a half-dozen times over the years. The use is essentially a dodge of responsibility. Every one was by boys.
The response was: “I don’t believe in ‘lazy’. There’s no “lazy” gene. You may have problems with motivation or focus and concentration, but those are problems of mood and/or anxiety, not of who you are, and I can help with those.”
The following discussion was about which of these symptoms applied to the client, what might they be worried about, what actually happened when they tried to focus or concentrate, what could be done by the parents and even sibs to help an improvement along. Follow up in the next session is important to consolidate the gain, presuming one occurred.
Complaints by client of boredom
This sentiment usually took a bit of time to emerge and not to be ignored. As parents of apathetic, listless, or overwhelmed children would testify, tackling this problem with guidance, persuasion, or pure pleading, structure, reinforcers and consequences, tight reins on the one hand or ’s/he’ll grow up’ on the other, etc. etc. etc. can be draining.
Eventually pieced together, the approach used here was reality-based, sharing a set of observations about other youth who complained or asserted this state of mind, to wit:
“I spent some time thinking about the kids I’ve seen here who say they’re bored, and found they have some things in common. So, I’m going to share them with you. Some seemed to to be kind of young for their age: some may worry about how they’re being seen by others; some may have trouble initiating activities and interests; some may feel lonely; and some sometimes just feel sad, almost for no reason.”
Because this is a lot of information to absorb, the delivery is slow. The question is whether the client experiences any of these themselves. The list was given mostly as information simply for them to consider. I avoided pushing any narrative about the pertinence of the list to the child, but rather just asked if any did pertain. If so, the discussion went toward that area, carefully, and in turn could lead into conversations about the young person’s realities in one or more the of cited areas and maybe others.
The particular emotional and behavioral problems the young person had been experiencing have already been defined during the assessment phase. The work had started and likely began to generate observable improvements in other areas like school performance or social activity. Some adroit reinforcement for effort is always in order. Gently exploring once again feelings of worry and sadness can marshal a sense of support for the client, and while not quite the same as acquiring a friend or getting an A on an assignment, the experience in the office can help reduce that sense of isolation. Seeking joy comes next. Least important but notable is that with these clients, the phrase “I’m bored” usually didn’t surface again.
The use of “I don’t know”
Not knowing an established fact is one thing. Being unable to a have a semblance of how one feels, what one thinks, or what one did is quite another.
The response would be one of two:
“You know, ’I don’t know’ in this office usually means ‘I do know but I don’t want to tell you’. So, assuming that’s not true, let’s try this again.”
“ ‘I don’t know’ just doesn’t work in here, so, let’s try this again.”
With either, the important part of the response is to actively help the client reformulate, then praise, For most of these cases, “I don’t know” has long been reinforced, so reinforcing the opposite behavior, one of knowing and responding, and making something positive out of the challenge through the subsequent exploration is constructive.
Clarifying feelings from thoughts
Raising awareness about a client’s own feelings and and recognizing those within others is an intrinsic part of child and family therapy work. As part of that mission, a majority of the children and adolescents who went through the assessment were given the feeling identification exercise (see Post 47 – Assessment). Those who did not would frequently be given this test during this session as part of his or her interview.
The use of that tool continued into this first family meeting. As part of that 5 – 10 minute time interviewing the client youth, many of those who were not asked to go through the exercise did so here, i.e. “OK, there are five different basic feelings that everyone has. I’m going to ask you to name the five. Very few people can name all five, but I’ll help you. So, what are they?”
Part of the purpose in doing so in the family session was to introduce the rest of the family to the concept of feelings as differentiated from thoughts.
The fun part was when one of the parents, again usually the mother but occasionally a dad, do the exercise themselves. These would be for instances where the child has already done it in the assessment. The first step was to carefully pick out the parent. The last thing needed was to embarrass one of them. Some were not that conformable yet, some still not persuaded about therapy itself, some naturally more introverted, inhibited, or inherently anxious. A parent who demonstrated equanimity, forbearance, and humor was ideal. Finding a prompt during their short interview was simple, and from there, “OK, there are five different feelings….”
Since the client child had already gone through this process during their assessment session, they always sat forward, usually with this big smile because they knew the answers. The younger the client, the more animated they would become just sitting there, they can’t was, and the parent knew their jig was up. Watching a child occupying the proverbial catbird seat is a real treat. Interestingly, the parents struggled in the same way as their child in identifying all five. They’d name three, a few four, and I don’t recall anyone getting all five. Every once in a while, I’d have the child help the parent identify the last one or two, and that was satisfying to watch. Fun helps.
Through all this attention on behavior, an accurate awareness of what others feel may be paramount.
“But, I’m ADHD.”
In the first thirty years of doing child and family therapy, this line did not arise. Beginning around 2010 and for reasons I can’t explain, this utterance started appearing.
An old axiom is: ‘If something happens once, take note; if something happens twice, you have a pattern; and if something happens three times, you have a problem.”
“But I’m ADHD” appeared more than three times. Like with the declarations of being lazy or bored, the use of the particular diagnosis was usually a dodge.
Interestingly, all of the maybe four or five of these clients during those last five years of practice were adolescent girls. With the same basic intent, boys used “lazy”or “bored”. Also, the male use of being lazy or being bored always occurred in the context of conjoint work, as if to lay out a challenge to the parents. The ADHD declaration, on the other hand, usually occurred while the young women were being seen individually during split session processes. That point is significant because they likely never would have used the diagnosis as an explanation for deficits in front of their mothers and/or fathers. In this instance, one has to appreciate female discretion re: the family as a whole.
Charles Mann’s 500 page book “1491”, described by the NY Times as a “sweeping portrait of human life in the Americas before Columbus”, looked into the social structure of the Haudenosaunee nation of the U.S. northeast. He summarized that the leadership of the tribes were divided into two discreet roles. Women ran the politics and men provided the defense. And then one thinks about the contemporary U.S. Republican Party….
Creating a generic response to particular client avoidances and resistances requires a few episodes to develop, and four or five is probably not enough. Eventually, I used the following approach with the last one or possibly two of them, not enough to be validated, and in this instance certainly not to be recommended due to being a little over the bar. But for these two, this worked in the sense that the need for the excuse seemed to dissipate and the discussion matured. They stayed with the program, so to speak, by adjusting.The other difference was that with the lazy and bored declarations, the interviewing demeanor was definitely sober because of the feedback’s serious nature. This approach used an affable exaggeration, to wit:.
“Is there anyone else with whom you used that one…and it worked…it kind of got them off the trail…like they just throw up their hands… and turn away…and you say to yourself… in a surprised tone… ‘It worked?!….’
The discussions then tended to move toward what the experience with ADHD was like, what some of the problems were, how they coped, what worked to pass or even pass-plus, how they felt about themselves before and after, where they got their A’s and B’s and how did they do that?
I think this approach to adolescent males would run the risk of generating a more smoldering sort of reaction that diminishes the clinical relationship. These millennial females seemed more responsible.
Abiding the notion that behaviors speak as well, two types occurred in the office that warrant some kind of attention, if for no other reason than they are distracting, they being yawning and fidgeting.
Yawning
Again not particularly common, but a pattern of yawning by the client was noticeable and presumed to be meaningful in the office. Going through the relevant articles online about yawning, the cause and meaning has yet to be firmly identified, making the action one of the more mysterious human behaviors. Many associated yawning with the state of boredom, or lack of brain activity. The large intake of oxygen is proven to be energizing. Others postulate is that yawning “cools” an overheated brain, one that’s undergoing stress. From this perspective, the latter hypothesis is more to the point under the circumstance of a therapy session. The experience for a client and other family members working together in the office together is anything but “boring”.
A pattern of yawning was presumed to be an indictor of a client’s specific anxiety related to the overall topic or tenor of the session, and likely needed some attention.The incident(s) were generally not cited at the time, but rather noted to be addressed later. That would usually be during the next session or two.
Yawning did dissipate, and probably would have over time without attention. The behavior offers an entry point into work with anxiety and other discontents.
Fidgeting
By one published study (not noted), fidgeting increases the amount of serotonin in the system, so the behavior pattern becomes a biological way of improving mood.
Fidgeting can be either random and fleeting, or a significant condition. Instances of restlessness, nervousness, and/or impatience at the beginning of a therapy process can be expected for some plurality of children and adolescents, particularly so when in the presence of parents. When being seen individually, they refrain and tend to be more focused. Those early manifestations of situational anxiety would be overlooked as they evanesce fairly quickly.
On the other hand, fidgeting as a condition, meaning the afflicted just cannot refrain, is another matter altogether. The longest case in the 58 case study – 162 sessions over 6 1/2 years lasting from sixth thru twelfth grade – was also the epitome of persistent movement and fiddling with whatever nearby caught his attention. He’d be redirected, and within a few short minutes, he’s back at it, then redirected, then back….
Nate presented with multiple behavioral problems at home and school that amounted to an oppositional disorder, a depression with anxious features, social isolation and victimization, and obsessiveness beyond mere fidgeting. Perhaps superseding all was a socio-cognitive deficit that did not fall well into spectrum criteria, nor of a low IQ, nor any aspect of reality testing. Three diagnostic specialists in the area of socio-cognitive disorders who had evaluated the boy had differing opinions, but none that led either to a cogent understanding or an effective treatment. That included multiple attempts at medicating. The last medication was prescribed by referral of mine to a regarded child psychiatrist specializing in this general child and adolescent area. In a follow-up conversation, he agreed that the boy had a deficit, but one that defied categorization. He added that these more vague problems were not all that rare.
Fortunately for the client, his parents were Ohioans replete with midwestern values such as family-orientation, honesty, competence, belief in hard work, and persistence. Both were mid-level administrators, one in the private sector and the other in local government. The older daughter by three years was a high achieving student and athlete with an active social life, eventually getting accepted to a top-tier West Coast university. She participated during early sessions and was helpful filling in details about the younger brother’s strengths and difficulties.
From the very outset in my office, Nate was easily distracted by the minutia around him. He sought to examine and manipulate anything from the clock to a small potted plant to the couch buttons and even more than once to a dust bunny. Such behavior occurred even when being seen alone in the assessment session, and would require redirection more than once or twice during a session.
This process was the first and only psychotherapy process the family used. The mental health work done prior was mostly evaluations and programmatic recommendations that could lead to modest improvements which then waned. Medications hadn’t seemed to help. The psychiatrist to whom I referred him prescribed an SSRI during his fourth year in treatment. Within three weeks he became suicidal, was taken off, returned to his old state, all providing us with a sharp startle.
The therapy here was a standard combination of behavioral, relational, affect management, and personal growth or insight techniques. The fidgeting was not a central focus. Rather, the attention focused on re-direction, praise for maintaining attention, random unsolicited praise for his propriety during sessions, etc. The overall problem list was long and concerning, and the fiddling became a secondary concern. Making the fiddling a central feature of the work felt like fiddling itself, given the extant of other issues.,
As the process proceeded into years length and he had presumably become accustomed and less anxious about being in the office, the fidgeting did decrease, but very slowly with considerable and sometimes steep ups and downs. That matched his school performance over time, where he would have periods of reasonably good work and then flag, and a social experience that would also wax and wane. All those areas of unstable life activities did not necessarily rise and fall in conjunction with each other, in a way demonstrating a modest but profound lack of integration. Particularly during junior high, his schoolmate experience could be emotionally brutal. But the overall plane of functioning as seen over months and ultimately years did rise, however slowly. The fidgeting per se was not tracked, but the sense here is that the activity lessened more quickly and more linearly, likely gone by his junior year in high school, if not sooner.
Reinforcing the opposite behavior was probably the most frequently employed tactic, certainly during sessions both conjoint and individual. Various home supervision and programmatic ideas were floated during sessions. A few were employed by the parents with success for a while and then waned. Being in therapy, the parents were less isolated in their parenting struggle. Never particularly punitive, their irritation levels could nevertheless rise and hang over the home atmosphere, a major incentive to try therapy again at the elementary school counselor’s recommendation. The clinical work itself helped reduce the isolation. The mother in particular was a relentless advocate, with the father’s allegiant support.
I worked with the three school counselors involved with Nate from elementary through high school, mostly during junior high. His eighth grade was probably the worst year of his life up to the time he terminated as the social machine ground up the litter. During that time, though, Nate developed an interest in origami, of all things and a perfect outlet for a fidgeter. He showed a skill level that probably eclipsed any of his other endeavors, excerpt online gaming. The idea of him doing an origami project for class credit came up in a family session, and he was unusually animated. The school counselor thought that a display of his work in the school’s rotunda was feasible and was similarly enthused. So Jenny and I agreed to approach the school’s up-and-coming vice principal, by reputation a ‘tough guy’, but the class credit idea just seemed so innocuous and potentially spiriting. She set up a meeting.
He took a seat behind a large circular lunchroom table by the entryway, setting himself about nine or ten feet apart from where we sat. Jenny and I were both experienced, generally known and respected professionals, comfortably and ably involved with the student and family both. With thanks for meeting with us, I outlined the problems. She explained the proposed plan.
Homework was only one of several problems in school, not the least of which was hallway bullying. On the other hand, his ability to produce something artistic had emerged, the first appearance of a tangible, abiding interest that could be relevant to school and community. Showing the work might help reduce the denigration and occasional victimization. The credits would matter and may encourage a better academic effort via the greater degree of confidence.
The taciturn VP took all of this in with a question or two, sometimes with eye contact, mostly looking down at his pad on which he had made couple of notes, maybe fiddling, hard to say. When Jenny finished our input, he paused as if to think for a bit, then as he was rising and with a hint of disdain he declared “If my eight year old daughter can do her homework, he can do his too.”, got up, turned around, and strode out the door, clearly put out. Jenny and I had a wordless few seconds of eye contact, shaking the heads, and got up ourselves. Both of us realized on the way out to the parking lot that the meeting needed to be between the principal and the parents rather than the VP and two mental health people. That was a mistake, and in this business, clinical mistakes are not that easily countenanced.
This story is shared because the experience with this human intransigence was something of a metaphor for the therapy process itself. Nate had serious problems. He also had unflagging support from his parents and reasonably competent, diligent, and creative professional help. He’d been climbing a hilly road with steep inclines, declines, and patches of bumpy traveling surfaces to tread. He would make some progress, for example academically, recognize his efforts, and then tailspin like some cold, implacable, internal force inside thrusted a “Nope”, only later to bring himself up just a bit further up that hill, again into new territory, and then “Nope”, only again later to.…
Some of his problems he created for himself but those such as a cognitive deficit were created to endure. Declines followed inclines, but successes could also follow setbacks. Finding that one key, know for a fact what he really thought and felt why he did what he did seemed to be the task of Sisyphus, but nevertheless he was getting better at interchange. The team of parents/therapist employed what felt like everything. Nate was slowly clueing in to the experience of others, slowly over six years, and the directions that the therapy had been taking seemed reasonable, providing direction, avoiding the punitive, and reinforcing the gains. He could acknowledge disappointment, recognize what needed to be done, but that too could quickly wane. The parents were struggling to find the narrow space between too much and too little involvement because that line’s placement in life readily shifted within Nate. As for behavioral action, his stimuluses and effects were quixotic, and not in the glamorous sense at all. Stuff happens, but still, growth can prevail, emphasize the word ‘can’ as opposed to ‘will’. Just as the VP’s response, the ‘stuff’’ this kid endured was not common, at all. That was just one more.
Our professional charge apparently shrugged about the result of the meeting, perhaps relieved in some way, kept up with the origami for a short while, then turned toward some other interest. His one advantage was the more enlightened version of fidgeting. He was always into something.
Nate carried on into 12th grade. He was now passing most everything, had a small coterie of friends, but still a distance from the normal social experience of latter teens. He had a part-time afternoon job at a farming supply store where he was doing reasonably well. And then he decided to quit high school and go to the school district’s award-winning voc tech. He also independently decided to conclude therapy.
The termination session was more perfunctory than most long terms. His social relationships had developed some warmth for him, so the coolish demeanor didn’t really indicate a lack of capacity to care for those who value him. His parents were not particularly effusive all along, but always friendly, and appreciative when intervention successes and progress occurred. Right or wrong, I associated the reserve with their strain of midwestern personality.
I felt warmer during the termination session than he, the work having been reasonably effective and one always wanted to root for the kid. The mindless fidgeting had not appeared for a long while. I reminded him about that. He looked a bit puzzled, and then shrugged, underwhelmed. As per the custom, I told him any time he wanted met be of some help, I’d be glad to do so. This generated his more affirmative nod and smile. He left with a good, firm handshake.
Via my own scoring using the CGAS scale, he had gone from being in the upper side of the severely disturbed decile, estimated to have been a 38, changed and grew through the serious decile, then through the moderate, and finally operating in the mildly disturbed area, estimated at a 62. He still had a level of disturbance, but momentum itself in a case like this can push the progress forward. At the same time, were it not for his parents, the therapy would never have gotten this far, so ultimately, he has also been lucky.
More broadly, the process could also be seen as plodding. From certain contemporary perspectives emphasizing efficiency and cost minimization, that may be hard to dispute. Granted, the complex of problems was somewhat daunting, particularly driven by the cognitive deficit. A small congress of third parties with differing vested interests charged to evaluate a therapy for that length of time over that many sessions involving that many people would minimally have a contentious time. But the critiques that become valuable are those that are couched by the realities of early 21st century mental health practice in real life, out there in the community, away from brilliant lights.
Indulging in my own musings with an eye on both history and the concept of developmental growth by stages, the science of mental health treatment can arguably be in the prepubescent stage of development. We know enough to concretely understand the basics, but remain far from an overarching, formally, and scientifically reasoned understanding of the brain, the person, the community, the environment, life itself as an operative aggregation of all these variables. We’re what, 150 years old as a profession? That leaves a far and long way to grow. Talk therapy may become relatively primitive when thinking about just how far technology has yet to take the effective treatment implementation, likely will remain a mainstay because we are social at heart…most of us, anyway.
Maybe where the profession is now? If all extant outpatient treatment types were divided into, say, five discreet categories, talk therapy bring one, and a comparative outcome study including, say, 2500 cases all treated by chosen community-based practitioners that create an equal distribution among the five expertises, my guess is that the differences between four of the five would be empirically insignificant and the fifth would a bit fall short, and that none would empirically stand out from the others in standard deviation terms. One may turn out to be significantly lower, and that would not include this talk therapy. That’s an estimation of where we are.
So, we choose how to work among the contemporary options, get the training, stay up to date, and do the best we can, and for the time being, that’s more than acceptable until we as a species know a lot more and something emerges as categorically better by some significant measure to resolve the problems that come through our doors.
If there’s a message here, hard cases are certainly out there and you can get them anytime, and they will challenge in many ways, some that might be insuperable but many that provide an almost unique human satisfaction as did Nate and his folks.. So…. Stay the course. Be diligent. Trust your skills. Be Kind.
Note: The following post will address in order: interviewing language; the family game; and the fifth session that essentially presents the basic structure of regular family and individual sessions.
