This post presents an example of integrating a new tool or paradigm into an existing process or structure. As indicated in the previous post, the development of the relatedness trait list occurred over the last few months of the practice, during the inception period of the outcome study. The compilation of adult Axis II clinical resistances and defense mechanisms was created long after the practice closed. These newer tools are applied to the basics of this therapy process. The emerging caution is that the resulting summaries, judgements, and recommendations coming out of this analysis, while augmented by considerable experience, have obviously not been field tested. Most conclusions are basically suggestive.
Unlike the information about symptoms, problem areas, history, family relationships, etc., gathered during the assessment process, relatedness traits become evident more through observation of client and process over time. The clinician may accurately speculate about the presence of pre-Axis II dynamics based on initial contact and history, but confirmation can take time. One major question is whether a client’s identified traits are to be explicitly included on the problem list and therapeutic goals, or remain internal considerations within the clinician.
Note: As a reminder, the following comments and suggestions emanate from the vantage and perspective of the private practitioner, particularly toward child and adolescent work.
Approaches to clients with relatedness trait problems will vary depending on the severity of their particular trait system and the nature of their specific traits. Those cases with four traits or less have demonstrated a capacity to more easily resolve relatedness traits with standard family and CBT-type therapy. These particular clinical gains occurred as a byproduct of work on the other diagnostic and problem areas.
While isolated traits did demonstrate an ability to be resolved for those cases involving five or more traits, these complex systems of multiple traits were more intransigent toward treatment. Gains in the other diagnostic and problem areas of these cases nevertheless did occur, albeit at rates that averaged less than half of those made by the four-and-under group. Trait resolution itself occurred with even less frequency. The work was yet more complicated by client resistances, adult defenses, and relatively more administrative and logistical impediments.
In order to change, the five-plus trait cases likely require prolonged family and/or individual treatment focused on personality change itself. Family work that identifies problems and inaugurates a process of positive change seems to be a reasonable prelude to more extended individual work, or perhaps could be the treatment of choice in and of itself throughout. A strong clinical relationship with the youth is a necessity. The clinical ability to help guide the youth through developmental stages is also requisite. Applicable technique is a mainstay.
A second treatment consideration is the determination of content.The therapist does need to take into account client and parent sensitivities that, if activated, could result in resistances and premature terminations. Putting traits on the overt problem lists and treatment goal lists can be a risky tactic. An adolescent being led to directly address, say, their contemptuousness, or lack of remorse, or solitariness could quite well bring about terminal umbrage. Sometimes the clinician has to bide time until an inviting opportunity appears to overtly introduce the problem into the treatment plan, or find other, less explicit means.
Contemporarily, decisions to make any or all traits part of the treatment plan and goals can be influenced by forces outside of mental health itself. Since the late 80’s, the mental health industry has increasingly moved toward symptomatic treatment programs, and away from the traditional processes focusing on life problems, family, and social relationships. Symptomatic treatment is seen as more efficient. Efficiency has been the driving force in American economic policy since the late 70’s. (read The Economist’s Hour by Binyamin Applebaum, 2019, for subtext re: efficiency). The problem is that symptomatic approaches to relatedness trait problems may well be counter-productive.
Their sometimes intransigent natures and accompanying resistances and defenses mitigate against change. Without change, cases usually terminate with some degree of displeasure. Understanding typical adolescent ambivalence about therapy, anything that reinforces a negative view needs to be avoided. The traditional focus on general diagnostic and life problem areas may still be the treatment of choice from an effectiveness standpoint.
At one time or another, all of these traits listed above demonstrated a capacity to change with family-based treatment. With the exceptions of suicidal ideation, cutting, and aggression, the traits were generally not explicitly on the listed case problems or part of the treatment goals. As stated earlier, change occurred as a function of broader improvements with depressive, anxiety, and/or behavioral issues, and resolutions of family, school, and/or social problems.
Some traits are clearly more receptive to outpatient therapies than others. Suicidal ideation, non-compliance, and aggressive behaviors generally were resolved. Indifference to praise or criticism, detachment, and entitlement, for example, are among the types of traits that generally did not change much, although even those three can show a capacity to improve in uncommon circumstances. Still, putting these traits on the explicit problem list runs the risk of being illusory, leading to disheartening results from the client’s perspective.
In hindsight and from the perspective of a line practitioner, the more resolvable traits seemed to be more a function of pre-disposition, circumstance, experience, modeling, and conditioning. Those that were less inclined to change were presumably more the result of the genetics that drive these wider networks of traits, five traits and above. Another way of viewing the dichotomy is that the more difficult traits are driven by compulsions essentially beyond the ability to be consciously re-directed, where the milder versions are receptive to the reasoning and instructions of standard cognitive and experiential psychotherapies. The difficulty lies in understanding which may be which.
The traits more inured to changed include: manipulation as part of a conduct disorder; avoidant; anxious of rejection; indifference to praise or criticism; entitlement; need to be center of attention; solitary, detached; perfectionistic; odd beliefs; magical thinking; and paranoid ideation.
Several of the traits appear in Oppositional Defiant Disorder cases, to include: defiance; non-compliance; deceit; vengeful; spiteful; both verbal and physical aggressiveness; problems with remorse and empathy; and, oddly enough given the penchant for chaos that ODD kids can create, some perfectionism. Over the time of adolescent growth and development, all these can be resolved, again in the context of ODD and not its more serious behavior disorder cousin, Conduct Disorder.
Anecdotally, having had a successful sub-specialty in oppositional-defiant disordered youth and having tried early in the practice both individual and family approaches, family work was clearly the most viable path. Specifics on the treatment approach to ODD will appear in the Middle Work Section of the Therapy Process, which in itself will follow the outcome study’s conclusion.
Five traits can present immediate concerns about safety. They include: cutting; risky behaviors; addiction; physical aggression; and suicidal ideation. Each present their own management dilemmas.
Four cases in the study involved cutting. The few cutting cases seen through the years were in the milder ranges of the disorder, the cutting being skin-deep and generally sporadic. The treatment for more serious patterns of deep flesh and slashing wounds are usually handled by psychiatry and psychology practitioners with diagnostic and treatment skills in the area. Supportive family therapy can be a helpful therapeutic adjunct. The formats used for the cases in this study were both conjoint and individual.
In particular, two of the cases were among the 17 relatedness cases, and the other two from the 39 others. Three stopped the cutting during the course of therapy. One non-relatedness case began having suicidal ideation and started cutting after beginning a course of SSRI’s for depression prescribed by a consulting psychiatrist. The symptoms stopped shortly after discontinuing the medication. The other non-relatedness case stopped cutting during the individual counseling, but the case terminated prematurely for administrative reasons. In my opinion, the cutting was still prognostically vulnerable to resumption. Both relatedness cases stopped cutting, but other trait problems persisted. One terminated normally with a modest clinical gain, and the other was referred out for individual work separate from the family process that itself stopped shortly thereafter.
The treatment approach for this level of cutting was to view the behavior as stemming from depression and/or anxiety issues. The cutting was not necessarily the clinical center of attention, and in fact was sometimes served more as a point of reference than being a clinical focus. The assumption that the behavior for these milder cases were within the ability of the client to resolve appeared to be substantiated.
One clinical dilemma that occasionally appeared over the years was the client’s expressed need for confidentiality that conflicts with the parental need-to-know for reasons of client safety and therapeutic support. The clinician is in the middle, so the client – parent – clinician relational triangle becomes a concern. One basic tenet of child and adolescent work is to keep all three sides as strong as possible. Again, these were relatively mild versions of the behavior that allow for some latitude in parental notification. My inclination was toward parental involvement and most clients concurred. On uncommon occasion, though, the process deferred to the client’s wish for individual counseling. The work was toward resolving the problem and simultaneously help resolve the client’s anxiety in regards to the parents. These types generally resolved.
Epidemiologically, the incidence of cutting has clearly increased.. Cutting is closely associated with suicidal ideation, which itself has increased 30% over the past 30 years. According to one study, cutters are seventeen times more likely to take their lives than the overall population (Hawton, Harris; PubMed.gov; National Institute of Health; 2008; original research at Oxford, UK). Washington State now has mandatory suicide trainings every six years for licensing accreditation. Sooner or later, more specific community standards of treatment will likely be developed for cutting as well, particularly if the incidence rate keeps rising and also given the omnipresent trend within health care in general toward specialization. Hopefully, these standards will be sensitive to the severity of the cutting, and not lump all cutters under the same clinical expectations of treatment. The dynamics at either end of the spectrum seem based different etiologies, courses of development, and effective resolution processes.
Patterns of risky behaviors were not common. Isolated tempts of fate do occur, like a youngster spraining an ankle jumping off a staircase from too many steps up. When the youngster does not learn from the behavior and continues to challenge reasonable limits, they are demonstrating a pattern that needs to be overtly addressed. That also would be a low level of risky behavior.
Two cases in this study included risky behavior as a presenting problem. One six-trait mid-adolescent swatted the home of an antagonist. The inevitable swatting retaliation some months later landed the client and father facedown on their front lawn, watched over by armed sheriff deputies while their house was searched. Once the son admitted his involvement, the parents initiated counseling. What emerged from the assessment and early phase of the family therapy was a moderate conduct disorder that had developed over the previous two years. Adolescent-onset conduct disorders are usually less severe than childhood onset (DSM V), and more treatable. The risky behavior did stop in the aftermath of the incident. Eventually the case terminated on the basis of partial gains and the boy’s request. The parents were agreeable.They could always return, and were given another name if an issue arose after my office was closed.
The second case involved drug dealing, some of the product on credit followed by debt repayment scrapes. That case was referred to an inpatient alcohol and drug treatment center covered by adoptive grandparents. The PTSD-type losses within the family history paradoxically raised the prognosis prospects. Some promising responses to the conjoint therapy suggested some substance within the young man.
The above case referred to an inpatient treatment facility received follow-up treatment provided by a Washington State Certified Chemical Dependency Counselor (CCDC) to whom I referred. Having a CCDC referral source for casework and consultation is a necessity for a private practitioner, in my opinion. At the very least, the collegial relationship helps reduce the client’s anxiety of moving to another professional. A call to grandmother six months later indicated that the young man was still in treatment, and she was optimistic. The case was also an adolescent-onset conduct disorder.
A non-relatedness case presented with excessive gaming. Other problems included a moderate depression following a family trauma. Once the depression resolved and the family dealt with certain family aspects of the fallout, the parents took the client to an MD process addiction therapist. Via mother’s later report, the results by her account were somewhat disappointing, although the parents eventually reached an accommodation with the boy on their own after termination there. Two years later, the now-16 year old was described by his mother during a phone call on an unrelated matter as doing well in all areas, but still gaming too much. I think she was probably right. To what degree the process addiction work helped is unclear. What’s clear is that one did follow the other. Excessive gaming being an addiction, per se, rather than an obsession is debatable, but that viewpoint admittedly runs counter to conventional thinking about the topic.
Physical and Verbal Aggression:
Problems with aggressiveness are always part of the treatment plan. Physical safety of the client becomes an issue with both types of aggressiveness. All four cases had verbal aggression, and two had physical aggression as well. All four verbal aggression problems were resolved. Physical aggression was resolved in one of the two. The one with both verbal and physical aggression reming had four other traits. A therapy process with some promise over the first fourteen sessions was abruptly terminated by the parents, who redirected the treatment to a different kind of health care.
The clinical techniques that were typically employed with aggression issues include: language shaping; socio-cognitive work; narrative; behavior management; family communication skill building.
Language shaping helps channel discussions toward clarity, objectivity, and inclusiveness in a family process. The early sessions that involve aggressions are almost always conjoint, and in general those early sessions almost universally use brief language shaping interventions to facilitate discussion.
Socio-cognitive work used with aggressions aids with the development and improvement of empathy and remorse. The clinical technique is akin to mindfulness, but rather than focusing on self-management, this exercise works on client understanding of others’ thoughts and feelings, particularly in regards to the client’s own actions. The guiding reference is a five-stage model of socio-cognitive development devised by Robert Selman (best presented in Piagetian Dimensions of Clinical Relevance, Chapter 4, Hugh Rosen, Columbia Press, 1985).
Narrative work helps with insight about motivations and leads to solutions of alternative, healthy behaviors. Among other benefits, going through the relevant histories helps re-define issues of anger into those of anxiety or worry (also an element of language shaping) that leads resolutions toward thoujght and understanding in lieu of angered action and reaction.
Perhaps the main behavior management objective is to keep the consequences involved with aggressions instructive rather than punitive, and inculcate the use of reinforcement of the opposite behavior, in this case appropriately managing oneself in the face of provocation.
Clear family relational processes aim toward meaningful reconciliation, among a myriad of other functions and situations.
All these CBT-type tools will be discussed more fully in the Middle Work Section of the Therapy Process portion of this blog.
A separate section on Suicidal Ideation and Behavior follows this one on Relatedness. The trait is always an explicit part of the clinical problem list and goals of treatment.
21 cases presented with suicidal ideation to one degree or another, from eleven with fleeting or occasional thoughts to two who approached an implementation of a plan. With the exception of one older adolescent client, parents were aware of the issue.
The initial clinical assessment of the client during the second session of this therapy process always included going through a list of ten symptoms of depression (derived from the DSM III R and DSM 4), the last one of which addressed suicidal thoughts. Over time, the percentage of clients endorsing the symptom rose from an estimated 15% – 25% to this group that represented 37% of the study group.
One older adolescent did acknowledge some periods of rumination, although in other important ways did not manifest immediate concerns. The parents were unaware. Strategic thinking is that casework is enhanced by parental knowledge and adroit inclusion in the clinical process. Whatever wrestling occurred in my own clinical thinking during the first ten sessions of what was looking like a prognostically promising, long term process was another case cut short with a sudden termination by the mother for administrative reasons. That never sat well, particularly because the treatment withdrawal was triggered by an administrative oversight of my own. But stuff does happen, less so with experience, but realistically possible at any time.Two and possibly three cases in all left treatment without a clear and recognized resolution of the suicidal thinking.
No guarantee could be made that the problem would not return at some point after treatment, at the end of treatment, but that’s generally true for most any mental health issues. The chances, though, are much reduced, and that’s the purpose of therapy. Among the 10% of cases that were the split process cases – those in which the client and family finishes a process only to return at some point in the future – none returned with a repeat suicidal ideation. One case that did not have suicidal ideation during the first therapy process did return five years later with a serious suicidal concern. That problem did get resolved, and tied up some loose ends left when the first process terminated.
The emergence of suicidal thinking usually galvanized the family of the troubled youngster or adolescent. The upcoming data suggests that parents had a greater tendency to see the process through to a mutually agreed upon conclusion. Anecdotally, they seemed to function during the time of therapy with less dispute and rancor that may have been the case leading up to the phone call for help. An old psychotherapy tenet from the 70’s is that children functionally sacrifice themselves for the benefit of the family, i.e. get depressed, anxious, or act out to prevent the family from breaking apart. To assert that axiom as a truth would be too much, but when the casework is seen from that vantage, the saying does make sense. To the degree this is true, family therapy is again the treatment of choice. And why wouldn’t family therapy be the treatment of choice anyway?
The one clinically technical problem that could arise on uncommon occasion is when the 13 + year old client divulges mild suicidal thinking, not rising to concerns about immediate safety, and refuses to either inform the parents or authorize the therapist to do so. This leaves the clinician in the unenviable position of trying to convince the client. Helping is part of the job, not so much convincing.
Several clinical considerations arise in regards to this particular confidentiality problem, where the task is to help both the youth and the family through a serious clinical problem. The first is having available a dependable treatment approach that incorporates the parents into the process, best from the beginning and onwards. Another is educating the youth about how the process works, particularly in regards to the countervailing realities of confidentiality and parental responsibilities. Others are developing, repairing, or reinforcing the young client’s ability to trust (using the clinical relationship as an example if necessary). and integrating the client’s demonstrated strengths into both the individual and family therapy discussions as a matter of validation, in essence reinforcing the opposite behavior. Lastly, having consultation available when in need, either in a consult session or in an informal collegial format, is useful to everyone concerned.