#38 – HARD CASES – INTRO AND TWO VIGNETTES

Loss and escalating tensions in the context of divorce can create potent emotional reactions. The venerable Holmes Scale lists divorce and prolonged separation from a mate # 2 and #3 on the scale’s 43 identified adult stressors, following only the death of a spouse. For children, an exacerbated insecurity at some point can merge into the realm of terror. Via dictionary.com‘s definition “the experience of terror is an intense, sharp, overmastering fear that is somewhat prolonged and may refer to future or imagined dangers”. James Garbarino’s definition of terrorizing is a parent or other adult acting in ways that “makes the world seem capricious and hostile” (The Psychologically Battered Child, 1988). How far down this path the following three clients went is an interesting question. They certainly went beyond normal anxiety.

The Clients

All three boys were described by their mothers during the initial parent interviews as being ‘super bright’, and those descriptions to a large degree were borne out. Their ages at the time of their assessments were 13, 12, and 7. The older two were 7th graders, and the younger was in 2d grade.

The primary presenting problem for the older two was Oppositional-Defiant Disorder. They had demonstrated elements of that problem as toddlers, before their parents separated and divorced.The older boy could be occasionally spiteful and vindictive toward his mother, making his ODD more serious. These two were also among those 19 (of 56) clients in the study who were seen as having relatedness, or pre-Axis II kinds of problems. The 13 year old demonstrated five traits and the 12 year old six. In terns of severity, they were in moderate serious range of youth with relatedness issues. All three children were additionally experiencing anxiety symptoms. 

While the older boy did quite well on the self-esteem, socio-moral, and ego-development elements of the initial assessment, on a couple of occasions he did demonstrate possible problems with socio-cognitive perspective and functional memory, raising some question about executive functioning. That might account for his historically low – modest school performances while being otherwise talented. He could argue with the best. For a single mother, he was often the taxing handful that he could be.

The 12 and 7 year olds also presented with depression symptoms. In particular, the 12 year old made suicidal statements and could appear extraordinarily sad at times during sessions, but he was adamant that he had no further thoughts of how he would take his life. Upon the inquiry of what would stop him if matters were at their very lowest, he immediately talked about his concern of how others would react were he to attempt or succeed, and did not want to create that reality for them. In my own view at the time, the severity of a client’s suicidal ideation turned on this factor of awareness. That sensitivity to others mitigated the likelihood of serious attempts. 

The 7 year old was diagnosed with an Adjustment  Disorder with Disturbance of Emotions and Behavior. He was probably high functioning, one of the two clients in the study who were likely operating in the superior range of 91 and above on the Child Global Assessment Scale before his troubles began.  When the marriage became irretrievably bitter months before the call for help, he fell into the mid range of the mildly disturbed decile.

Brief Family Histories

The parents of the oldest boy split when he was 3, and were divorced within six months. The father moved into the home of a friend about twenty minutes away, and had lived there since. The mother had full custody. The son stayed with father every other weekend. At the time of the separation, their son had shown a stubborn persistence and anger as he entered toddlerhood, and since then had developed patterns of defiance, entitlement, verbal aggressiveness, and  excessive independence. The father indicated that he experienced little of these problems during his son’s two day visits. The reality was difficult to discern. The father had not participated much in parenting during those first three years, was not particularly involved in any kind of coordinated parenting efforts, and was not interested in having more time with his son let alone taking the youngster full time, something the mother had recently raised as a question. 

The father of the 12 year old left his family when the boy was 15 months old along with a 3 year old brother. He re-married shortly thereafter, and later had two children. The mother had full custody of both their children, and the father had every-other weekend visitation. He remained discontented with that outcome throughout the ensuing years, making several formal and informal attempts to have the care arrangements more equalized. None were successful. A year before the therapy process began, the mother voluntarily changed the arrangement to week-on, week-off in an attempt to reduce the tension. Neither of the two boys were elated, but they both cooperated.

The parents of the 7 year old child also had a 15 month old daughter when the therapy process began. The parents had already agreed to divorce. The father moved out after the child assessment session that followed the intake with the parents. The decision to move out within a day of his son’s clearly positive reaction to the assessment session was notable, to say the least, but the meaning was unclear at the time. The inference about why the father wanted out of the marriage had something to do with the mother’s behavior and/or habits. The mother complained of psychological abuse and physical intimidation. Legally, the interim child-care decree was a nine day – five day split every two weeks, with the father having the nine day period. Each parent had considerable family support, the mother with her family of mother and sisters often helping with day-to-day care, and the father’s with the personal and abundant financial support from his own family. The nine day – five day split was frankly puzzling. The father also disclosed a new relationship within a few months that became cohabiting shortly thereafter. She had two young children of her own.

The Mothers

The mothers all worked outside the home. The mother of the oldest boy was a production quality control manager for a moderately-sized manufacturer. Her work in the male-dominated environment required considerable precision in assessments, collaborative skills, clarity in decisions, conflict resolution skills, and adroit use of the hierarchy. She had a broad perspective of task and was firm in a way that some would call tough. Her hardest task at this time of her life was this very bight, stubborn, and oppositional only child. 

The mother of the 12 year old was a section manager in a large communications corporation with a budding interest in human services. 

The mother of the younger boy was a contract worker for a large Seattle advertising firm. 

The mothers of the two older boys were single, and the third was, obviously, separated. None were in serious or steady relationships, altho the mother of the oldest boy was in a casual, infrequent dating relationship that was fairly separate from both home and work life. Neither of the older boys’ mothers detailed or demonstrated mental health or relational issues above and beyond adjustment-type anxieties and frustrations related to their difficulties with parenting in the 21st century and dealing with their exes. “Tiring” was a common complaint.

The mother of the younger boy seemed to generate reactions from others outside her own family that suggested concerns and difficulties. Diagnostic hunches included the possibility of vulnerabilities hidden by strengths, and/or chaotic life management issues, and/or alcohol abuse. Substance abuse seemed unlikely. Significant stress with her difficult marriage was clear. PTSD relative to the marriage could have explained uncertainty, vulnerability, and fright, but her problems seemed to go further. In the therapy of her son, she was dependable, responsible, prompt, participative, lucid, and unquestionably dedicated, but she may have struggled with being forthcoming. That could well have been a function of the divorce process or a guardian ad litem evaluation, but could also well have been broader in scope. She was in individual therapy herself. Her own therapist was approached with a release of information for consultation but did not respond. All in all, something was amiss. Her mother and sisters provided substantial love and support for her, but also provided for the boy some structure, teaching, and shaping that helped enable him to become the leader among his peers that he appeared to be.

The Fathers 

Unlike the three fathers from the previous post who made no contact with me, the fathers in these three cases did so in unconventional ways. The encounters were brief. Where the mothers were generally seeking help for their children and for their own parenting, the contact purposes of the fathers were opaque. The fathers of the older two evidenced skepticism, if not disdain, about their sons being seen for therapy. What became clearer at the end of the process involving the younger boy’s father, who had initiated the therapy, was an apparent agenda that was separate from the therapy for his child.

The knowledge and clinical judgement about the fathers was almost entirely based on these brief encounters and second hand information such as the marital and family histories. The most relevant sources were reports coming from both the clients and their mothers as they shared updates and experiences during their session time, and from simply following the sequence of events of each therapy process from beginning to end. This small body of knowledge was then counterbalanced against what was more typical of fathers whose children were clinically involved. Validity and reliability problems with this approach are obvious and acknowledged, so please keep that in mind.

The father of the oldest boy attended the intake along with the mother. They were comfortable in each others presence, but any empathy of his towards her parenting plights was not evident. She provided the bulk of information and, as I recall, he added a small few supplemental observations and experiences. The oppositional-defiance and argumentativeness that mother experienced at her home were reportedly much less apparent at the father’s home, but these were weekend stays of little expectation and considerable screen time. The father did not seem particularly engaged. In the rough session notes, the only reference to him was being extremely fidgety, evincing a high level of anxiety.

I had a particular way of approaching the distracting problem of client fidgeting in the office.  Around 2000, I read an English study summary of fidgeting’s physiological impact. The major finding as that fidgeting raised an individual’s serotonin levels. My rough translation was that fidgeting actually helps either a poor mood or anxiety or both. So, when a youth – mostly older children and younger adolescents – began fidgeting during a session, the discussion of the moment was stopped. 

I’d turn to the youth, note the movements, and say: “You know, I always wondered about fidgeting, about why some people do that, and then I read a study that was done in England, and I don’ know exactly how they did the study, but what they found was that fidgeting raised a person’s serotonin – you know, the chemical that’s the body’s way of regulating mood. So, if someone’s fidgeting, then we know that they are either feeling sad or worried about something, or maybe even feeling guilty about something. So, the question I have for you is what you might be feeling sad or worried about right now?  Nothing? OK, no problem. But if you do feel sad or worried about anything, I’m really always interested. How you feel is most important. OK? OK.”

And go from there. When the child started fidgeting again, I’d ask what they might be feeling worried about, and they would reiterate ‘nothing’. The fidgeting stopped, and tended to stay stopped thereafter. When they occasionally lapsed, all I had to do was interestedly look their way, and they stop, often smiling, maybe with a slight grimace, occasionally even grinning at being “caught”. The intervention almost invariably worked.

Being just noticeable, this father was not distracting but was clearly anxious beneath his social patina. The presumption at the time was that he would become a participant in the process in some way, so opportunities would be available later to better understand him and perhaps be of some help. That assumption was incorrect. According to the mother in the ensuing assessment summary-and-planning session, his intent was simply to see what this counseling or therapy was about. As his son began to make some gains, the mother would check with him to see if he was seeing similar changes. Generally the answer was ‘no’. She suggested counseling was helping, but he seemed to eschew the thought, at least in her view. She didn’t see this as problem in and of itself, but rather another example of a his broader pattern of minimizing. I did not see or hear from him again. The question of his anxiety remained unaddressed.

The divorce decree of the 12 tear-old’s parents included a clause that counseling had to be approved by both parents, or, perhaps more relevantly, could be stopped by one or the other. Agreeing to the clause was one of two mistakes the mother cited she made along the way. The father was persistently discontented with the four day, every other weekend care awarded by the divorce decree. In an attempt to assuage the father’s truculence as the boy entered middle school, she offered to change the child care to a week on – week off arrangement for both sons. That, she cited, was the second mistake. The change occurred a year before therapy began. The client’s personal struggles continued to grow. The transition from elementary to junior high school undoubtedly also exacerbated the boy’s anxieties. A few months into 7th grade, the fact of suicidal thoughts burst out in a moment with his mother, and she sought this help. The father did not make the offered appointment with me, again as per the norm. We did have cordial handshakes in the waiting room two or three times as he dropped the boy off at the office.

The process for the youngest boy was initiated by the father on a referral from Children’s Hospital. A communication mix-up between the two parents led to a rather tense beginning of the intake, the father coming in late with palpable irritation to which the mother clearly braced. The announcement by the father at the beginning of the time with them together that the couple was separating was not surprising. The mother indicated the union was irretrievable. The boy had been having uncommon difficulties at home and in school during the past few months. They wanted counseling help for his emerging issues, and provide him with extra emotional support. 

The assessment session with the boy the following week went well. The summary and treatment planning session for the parents another week later began with the father announcing that he had left the home shortly after the boy’s assessment interview. Both parents wanted the boy to continue counseling based on his positive experience. The father stipulated that the therapy was to be individual, but they concurred with my own stipulation that I be able meet with whoever brought the boy to session.

From a clinical standpoint and in hindsight, four of the six adults evidenced Axis II defenses, including all three fathers. Two of the fathers were overtly splitting, and the third may well have been in manners that went unseen and unreported. All three were likely manipulative. One father was in denial concerning his child’s problems where the other two openly acknowledged their concerns. Two were openly demanding and aggressive. One had a marital history of lying. At least as could be inferred within my limited exposure to them, a lack of empathy and remorse was also a factor for these three fathers that likely made them more problematic than the fathers of the “Held At Bay” group. 

Processes

Nathan

The 13 year old 7th grader was easily engaged and quite talkative. Nathan’s view of the issues  closely resembled those of his parents, including the observation that most of the problems involving him were occurring at the mother’s home. He allowed that the expectations at his father’s every other weekend were low, and that his mother had the harder job. He nevertheless preferred his mother’s home. He had an unusually detailed view of problem frequency, a bit minimized and emotionally removed from the realities, acting perhaps like a reporter, but fundamentally vouching his mother’s accounts. Like his father, he fidgeted often but stopped doing so after the behavior was addressed during the first session with his mother two weeks later.  

His self-esteem evaluation came out high for behavior, intellectual status, physical appearance, social status and overall happiness and satisfaction, but only 4 out of a possible 10 for anxiety, suggesting mild anxiety issues. To have only anxiety of the six rated areas at less than 5 on the scale was uncommon. Unlike his reporting about the home problems, his self ratings for behavior and school performance were clearly overestimated. His ego development evaluation (using Hy and Loevinger’s system) came out at Level 4, common for a 13 year old but perhaps one level low given his intellect and observational skills. The socio-moral evaluation, using a somewhat modified version of the Heinz Dilemma, came out to a Level 3 (using Kohlberg’s Stages of Moral Development), common for his age. Again, he probably had the intellect to be at level 4. 

As with most ODD youth, anxiety stood out as a prevailing emotional issue in addition to anger outbursts, defiance, non-compliance, arguing, and iritably ill-tempered with an irritable on occasion for a day or two. The underlying issue with his anxiety issue was unclear, but this was only the assessment and the issue would presumably arise as the process continued. In general, so far, so good.

The mother came in for the summary-and-recommendations session alone. The father declined to participate for reasons not clear, having left a text just as the mother arrived at the office. She agreed with the overall assessment: Nathan was bright, anxious, ODD in general and argumentative in particular, interested in the process from an intellectual point of view, enjoyed  the testing part. To what degree the lack of introspection might be a function of age and maturity on the one hand, or being in self-protective denial on the other was difficult to say at that point. The recommendation was for mother and son to be seen together. Because the father at least attended the intake, the mother was to let him know that he could attend the conjoint sessions. She did so, and asked him to do so two more times during the process. Implying considerable doubt and apprehension about counseling, per se, he declined.

Leading up to the first conjoint session, Nathan had a rough week at school. More likely, the school had a rough week with Nathan. He and his mother listed what they would like to see get better for both Nathan and the two of them together. In elaborating on the identified problems, they worked well together, unusually so for a first session involving an ODD adolescent, male or female. The exercise provided a cogent baseline. 

A game of Jenga followed. They chose to build up the stack rather than compete to see who would win, another indicator of Nathan’s cooperative side, one that often coexists within that ‘other’ side of an ODD youth. The two didn’t set any record, twice toppling the tower at about twelve levels, but they had relaxed fun together. The closing clinical suggestion was for them play more games as opportunity allowed at home, and perhaps offset some of his excessive gaming time. That was listed as an area of desired improvement. So far, so good.

At the outset of the following session, Nathan volunteered that “I don’t want to be mad anymore”. Part of that session focused on feeling identification. In order he identified happy, sad, and anxious. Ironically, he had not listed anger, needing help to identify both that feeling and guilt or shame. 

Youth from age 8 and up almost always identify happy, sad, and anger in one order or another, and get help identifying fear or anxiety, and guilt. I tended to believe that the order in which they named the first three was related to the degree that each as experienced relative to the others. 

Nathan’s answer that included anxiety buttressed his self-esteem evaluation. He essentially complained that the anxiety was about his mother getting upset with him. Mother acknowledged a need to tone down her corrections. However, the clinical source of Nathan’s anxiety was remained a question. The mother could get critical, but hardly rejecting. The anxiety issue would  presumably be understood and addressed later. 

Given his age of three when the father left the home and the apparent paucity of communication between the two, a reasonable hypothesis suggested that Nathan may have been experiencing a dearth of paternal approval. The father’s involvement in the process was being encouraged by the mother, but he continued to decline.

The fifth and sixth weeks – third and fourth conjoint sessions – were unusually good, a common family experience using this particular format. Nathan then went to his father’s for a weekend and returned in a poor mood for unknown reasons. A “big blow-up” occurred toward the mother that included foul language and physical intimidation, the latter of which happened for the first time. He was getting bigger and presumably more testosterone-ed. The question of what led to the episode proved difficult to answer, although he did at least acknowledge his mood and apologize. Acknowledging and taking responsibility for his own mood shift was for him uncommon. The session’s presenting issue  provided a good opportunity to introduce the socio-cognitive technique of trying to identify what the other was thinking and feeling at each major step of the conflict. The last task was focused on improved self-management of his “big” feelings, as he referred to them with a roll of his eyes. He left the session somewhat better though still argumentative and somewhat defiant during the week. 

As the immediacy of Nathan’s demanding behaviors lessened, the work over the next couple of sessions focused more on the mother’s patterns of responses. Converting disappointment, irritation, and/or chastisement into instruction about handling situations in better and more effective ways was one of the main clinical tools used. Ignoring provocation, where possible, was another. Use of both targeted and random, unanticipated reinforcements was a third element of the parenting work done in the context of the conjoint sessions.

That night was ”horrid” as she maintained the ignoring. What followed was “the best week ever” between the two, according to the mother with Nathan’s somewhat abashed concurrence, as if the kudos were beneath the dignity of the young adolescent, male-ish male. 

The next session dealt with renewed problems at school that included an instance of refusal to go by not arising before mother left for work. His attitude in the office was mixed, at times interested and cooperative, and at times argumentative. As stated earlier, he was among the most apt at obfuscation. Angling toward what led him to get anxious was not yet fruitful. Basic trust was slow to come, also common with ODD youth. He and mother did continue to do better and at times they had fun during evenings and weekends. 

This first string of sessions was par for the course of ODD treatment. The change line is typically vacillating with an overall curve that slowly moves upward. While the reversions toward the baseline are almost inevitably taxing for the parent(s), the clinician’s posture best remains nonplussed, thoughtful, creative, and encouraging.

While life at home was somewhat more cooperative and amenable, the third quarter grades had fallen more than a full point into the middle C area, a result that caught the mother unaware. During the session, social problems at school involving some male peers also emerged. He would “handle that”, and that was fine, “if I could be of some help, let me know”, etc. The discussion in the next session focused on the grade issue, what he wanted for himslf, how might he get that, what support from his mother would be helpful, etc., all fairly routine. 

Returning from the father’s home again, a repeat of four weeks earlier occurred, replete with irritable mood, two instances of school refusal, and a marked increase in non-compliance. The mother talked with the father. He said Nathan had been no different when he was there, and then openly wondered about the efficacy of counseling.. He said Nathan had been grumbling about having to go. The father’s spoken perspective was that his son was “just a boy being a boy”, and he’d be fine. The mother implored her ex.

The question was whether to weather these new episodes or somehow act on the patterns that seems to involve the father. As long as the boy’s overall status was on an upswing and the process was in a relatively early stage, the more conservative approach of weathering seemed more appropriate.

The conjoint work was about twelve sessions in. The progresses and regressions on a low – modest incline of improvement was common for ODD. The unusual aspect of this process was the single mother factor. For reasons I never did come to understand, the vast majority of ODD cases in the practice involved two-parent homes. Most were biological parents, but others included step-parents, other family members, and adoptive parents. Having two parent figures available to do the clinical work and working in tandem with this kind of problem is much preferred. The N of single parent ODD cases was too small over time to make an estimation of relative outcomes, but an average outcome that was 50% lower for the single parent ODD cases compared to two parent families in treatment would not have been surprising. Single parenting is hard enough. Add ODD and ‘hard’ sometimes looks impossible. A consistent, objective, and encouraging clinical demeanor is helpful.

In another session closely following a weekend with father three days later, Nathan was dysphoric, complete with fidgeting. At least he smiled a bit bashfully when looked at slightly askance and entirely stopped fast-pumping his knee. The excessive independence typical of ODD kids characterized his attitude that day. He could take care of the academics “by myself”, the social problem which persisted to some unknown degree would resolve, he could take days off if need be and be fine, and he insisted he was worried about nothing. He was getting therapy savvy. With such a broadside and looking for a fruitful line, the discussion was shifted to how he saw himself in the future. That did seem to help in the moment, and set a goal of some sort.

I asked to talk with the mother alone for the last few minutes of the session, explaining to Nathan the need to talk about an insurance issue, this for the first time. Coming to understand the father’s motivations here was emerging as the major unanswered question. Like father, like son, both were difficult for her to access thoughts, feelings, and even the identities (not her words, but to that effect) of her brooding men. She had been periodically keeping him informed, but he seemed to respond in the same manner as he had during the intake, in hindsight physically present but guarded. I suggested that she ask him to attend a process review session.  

While he was in the waiting room, Nathan erased this wonderfully colored floral scene drawn on the art wall’s dry erase board by two young sisters during the preceding session with their mother, and he wrote “Run for you life out of this place!” While the damage was minor (the nationally regarded child psychiatrist Richard Gardner told a small group of 1977 UW MSW grad students about an adolescent who set his waiting room on fire as he left an appointment) my office had never been vandalized before. The one fact I knew was that he couldn’t have heard his mother and I talking in my office, as a couple of precautions had been taken. His act came from some other place.

After another evening of mood and rebellion that night, Nathan was better, as per the mother’s next session report.

In the next session, I told him that I read what he wrote, it was very clever, and I managed to erase it before the next client. We arrived at an understanding that he was worried we were talking about him. Extrapolating that admission to being more generally anxious about how he was being seen by others met with resistance, but the approach was meant more to introduce the notion and return to the subject at a later time. He was more attentive and cooperative on this particular afternoon.

This was the one point in the process where I regret simply moving on. This could have been a point of inflection by arranging to see him alone the next week and basically assess his suitability for an individual approach in a split-session format. 

During this last few weeks of school, his mood and behavior were better. One more instance of negativity coming home from the father’s place did occur, but passed quickly. He could identify how he worked himself out of the mood. His mother teared up. This was now at the end of the school year. They were taking the summer off from therapy to accommodate vacation plans with each parent. Nathan was setting up odd jobs in the neighborhood to save money for a new gaming rig. 

When Nathan returned to the office in September, the mother bought up an insurance issue about which neither of us had been unaware. The particular corporate health insurance policy had an unusual, for them, fixed session limit. They had two sessions left. The mother could not afford to pay out of pocket by herself, and the father had refused to contribute. However, eighth grade had been off to a very good start for Nathan, so resuming in January seemed feasible. If an emergent situation arose, they had these two sessions available.

* Practitioners who take insurance payments were/are not allowed to use sliding scales for private pay clients, as doing so technically constituted a fraud upon the insurance company. If discovered by an insurer, the practitioner could be required to pay back all fees paid to them, not only for the one case but possibly for all cases covered by that particular insurer. I knew of one such outcome on a colleague that resulted from an audit in the early 90’s. The fact is that a large proportion of practitioners do use a sliding scale under this circumstance, among whom are many not even aware of the rule. The insurances themselves rarely audit. Putting oneself in a position to be anxious on an on-going basis, though, seemed ridiculous, so I abided. However rare, rescuers can become victims in this situation as well, as had happened to my colleague. 

In late December, the two came in and used the two remaining sessions covered by insurance. During the previous three months, Nathan had regressed almost back to baseline. He had been a bit more cooperative at home in the midst of this elevated defiance, and hadn’t engaged in any verbal aggression or physical intimidation, but the problems of attendance and non-compliance at school had probably worsened from baseline, and now his social relationships seemed to be suffering as well. In spite of the resurgent defiance, he was cooperative in returning and helpfully communicative in session, so the process renewed.

Two weeks later and now in the new year, the mother came in alone for what became the last session. Her son had once again returned from the father’s in a negative state, stayed home from school twice in the first week following the holidays, and was adamantly opposed to coming back. Mother had already contacted the father, who said Nathan had been the same as usual, including complaints about therapy again. 

Something somehow happened at the father’s. Once having overcome her tendency to negatively critique, the mother had been a consistent and encouraging presence. These bursts of defiance returning from his father’s were something different. These were not manic episodes, but rather seemed to be something fomented. She strongly believed the father was encouraging the rebellion toward therapy, implying that passive-aggression was “in his wheelhouse.” But why was the father protecting himself, and from what? She didn’t know, or perhaps didn’t want to say. 

At the September termination, Nathan’s closing CGAS score would have been in the mid 70’s, with the remaining issues of compliance at home and to a lesser degree at school and occasional bouts of contemptuousness keeping him out of the ‘normal’ decile of the 80’s.

The mother felt that the verbal aggression and threatening postures may be in the past, and my tendency was to appreciate a mother’s intuition. The basics of their relationship were better. However, he was now struggling socially as members of his longtime clique were dispersing into other groupings and not inviting him to come along, at least as she could infer.  She was giving him plenty of space after returning from his father’s. He was adamantly refusing even the mention of resuming therapy.  

At the point Nathan stopped altogether in January, his overall functioning had dropped back into the moderate disturbance decile of the 50’s. He actually had the second lowest CGAS gain within the 56-case study group at + 3 points (the lowest was a – 5). The mother at least was more confident with her parenting, citing the critical tendencies she had abandoned and the skills and posture she had absorbed. 

Clinically, the client’s outlook was guarded. His relatedness problems could well endure into adulthood and become fixtures. Sad, because he had demonstrated the capacity to make and maintain changes for the better. The question was whether for the better he could incorporate the self-awareness of his mother, or for the worse he would maintain a tendency toward contemptuousness and egocentricity when avoiding truths and the difficult situations they present..

In some ways and at some times, all that can be done is to take the client as far as circumstance allows. That reality is why clinical gain that can be identified and reinforced early in the process is important in establishing momentum. Sometimes, too, those circumstances involve strategic clinical decisions and/or tactical errors. Distinguishing between circumstance that cannot be helped and clinical oversights or mistakes that could have been avoided can be difficult.

Given the range of problems here, nineteen sessions was far too short. Even still, the client and parent at least have a good idea of how much better individual and family life can be, and also have viable notions about how to effect further change. That much the help had accomplished.

More general comments about the case will be covered in the second half of the next post.

Patrick

The presenting problems for seven year-old Patrick included throwing fits, screaming, disrespectful language and attitudes, non-compliance, missing assignments, lack of effort in school, and hyper-focused on screens when at home. While he may have had mild tendencies toward two or three of these behaviors, the issues became overt, frequent, and concerning as the marital problems escalated over the previous year.

For a child that age, Patrick was unusually comfortable, organized in thought, and forthright during his first meeting. When asked the standard opening question,’What can I do for you?’, which is rarely answered directly by kids of any age, he unhesitatingly went into a fairly lengthy portrayal of his parents “fighting”,  meaning frequent and and vehement arguing. In answer to the question “what do you think while they are arguing”, he immediately asserted “They have to stop!” 

When asked how he felt when they were fighting, he said “weird.” When asked what kind of feeling ‘weird’ was, he rather adamantly repeated “Weird!” This led into the exercise of identifying the five basic feelings, which he handled reasonably well. When we were talking about being scared or fearful in general, I asked him if “being scared is what you meant by feeling ‘weird’?

He looked off and upward, thought for three or four seconds, and replied “Well, it’s in that family of feelings.”

A bit taken aback by this precocity, I just looked at him for a few seconds as he looked back with unblinking surety, and said “that’s a pretty good answer” to which he simply nodded, like, ’I know’.

“So, this arguing is what’s worrying you, right?”, and he nods. 

“So, if you would, tell me about your family.”

Patrick went on to talk about his family, particularly his 15 month old sister who he likes pushing around in her stroller. In particular, he emphasized his paternal grandfather and maternal grandmother, people with whom he had considerable contact, and who help his father and mother, respectively. A paternal aunt was also mentioned as involved. With a depth of fondness, he talked of his maternal grandmother and three aunts who were a steady presence in his life. Their involvement was in some part driven by an international culture that stressed a traditional family focus. In Patrick’s world, he does see family first, and while that may change over time living in America, meaningful bedrock values had been firmly implanted. He also came out at a solid Stage 4 for the ego-development evaluation, common for latter elementary school students. He was the first second grader to do so in this practice out of an N of perhaps 30 kindergarten/first grade students over the previous decade. 

As per the father’s directive at the outset of the process, the therapy was individually-oriented. The mother would typically spend 10 – 12 minutes individually at the beginning of every other session, but the rest was with the boy. The fits, screaming, and disrespect subsided within a few sessions simply talking about the problems, having him come up with alternatives, making a suggestion here and there, and reinforcing improvements that were reported by the mother. Increasing self-awareness was the thrust, more so than behavior therapy per se. Much of the work was standard play therapy. Clients under the age of 8 often received this kind of therapy, commonly in a split-session format but every once in a while the process is predominantly individual, as with Patrick.

The mother took advantage of parent time during the every-other week sessions. The father used the service twice. One time was about developing a clearer overall strategy on managing his son. The other was a full session with his  father, who had requested the opportunity to voice his own concerns about the relationships between his son and his estranged wife and the impacts on his grandson. The healthy triangle perspective was used as a conceptual tool in both his own session and that with his father. He was openly appreciative after both. Other than those two sessions, the father spent time in the waiting room with his increasingly active, still toddling daughter. When bringing Patrick out to the waiting room at the end of a session, his father would just as often be on his laptop as he would be doing something like building blocks with his daughter but that was common behavior for both fathers and mothers with toddlers. While the family itself was seriously strained, nothing particularly unusual about the therapy was being noted. Plus, the client was making gains.

Around the tenth overall, the father brought Patrick to therapy and the mother picked him up at the end of the session in a switch-off. The interaction between the two parents was terse as all four left for the stairs to their cars. After straightening the waiting room for the last clients of the evening who had yet to arrive, I walked over to my desk and looked out the window. Coincidently, their two cars parked next to each other were below the office’s second story bay window. With Patrick and his sister already in the mother’s car, the parents were between their vehicles engaged in an angry, toe-to-toe, and index finger-to-index finger exchange that had already lasted longer than a minute. The episode in front of their children was brought up to each parent with a caution about anger in front of the kids, and both parents were appropriately apologetic. The process continued unabated, but the visceral experience provided a peek into what must have been the boy’s racing heart, let alone what must have been a terrified toddler.

The play therapy included the use of Richard Gardner’s Talking, Feeling, Doing Game and a couple of other games that opened discussion into any number of topics. At times the experience did seem like one with an engaged, insightful fourth fifth or grader. The barometer of Patrick’s changes, though, turned out to be a story-telling technique using a collection of eight small, differently shaped wooden blocks (purchased at a Starbuck’s coffee shop when they were selling table games around 2010). Beginning around the 8th session (out of 22 total), he was asked to make up a story using the blocks, either by building something or using them as characters, or a combination of the two. His initial enthusiasm did wane over time – “oh no, not again” – but once he began, he was completely immersed every time. The exercise’s measuring capacity over time was helpful.

The theme was always battling. He would divide the blocks into two sides, four-on-four, or two-on-six, or one-on-seven. The stories were all different and involved. For the first seven or eight sessions using the story-telling technique, the battles ended with the death of members on one side, occasionally all, maybe once or twice with a death on the victor’s side as well. Twice the battle came down to a single fighter fighting battling three or four with the lone soldier coming out the only one alive. During the last three sessions, the fighting ended with peaceful, verbal resolutions without casualties, or, as he put it, “everything was better.” While the limited contact with the father made judgements about his own change or lack thereof almost impossible, in the office the mother was less frustratedly anxious and sad, and more focused on Patrick.

After 21 total individual therapy sessions over a nine month period, Patrick was easier for both parents to manage. He was still academically underperforming, although not to the point of requiring special efforts on the part of his private school. X Box and other mesmeric screening were less of an issue, but still present. He was simply unenthused about learning, which had not been the case in kindergarten or first grade, although now he would do all the work as he used to do. Functionally, he was operating in the high 70’s of the CGAS, much closer to the 80’s decile of “normal”, but still well short of what appeared to be his cognitive, emotional, and social capacities that would put him in the CGAS 90’s. He began in the low 60’s. In other words, even though he was close to normal and continuing to get better, the recommendation for continued work was justified. And he remained engaged. 

In what turned out to be the last session over eleven months and some 23 sessions after the process began, the father announced that the divorce decree had been adjudicated. The 9 day – 5 day split in child care with the mother was upheld. In essence, he was the primary caretaker. The mother was overwrought, but the grandmother in particular was crushed and livid to find out that her almost two-year old granddaughter would be more the charge of her son-in-law and his live-in girlfriend of a few months. From the vantage of her own culture, the verdict was a genuine blasphemy. 

The winter holidays were ten days away, so the next session was set for early January. The day before the appointment, the father left a laconic message terminating the process.

Patrick and his mother asked to see me a year later with a serious concern about an ongoing situation that sounded potentially of a CPS nature. The two came into the office twice. He had continued to improve since last seen, now functioning in the 80’s, still a bit under capacity. 

Before the third scheduled session, that brief process was abruptly ceased once again, this time via the mother’s phone message. The inference in the message was that the father had insisted the process stop but the circumstances were not clear. I called the mother and advised her to consult with Patrick’s pediatrician if the episodic problem continued.

Making sense of the entirely unanticipated termination was not difficult. Given the odd and unusual referral from Children’s Hospital, the start of the process occurring just as the separation began, and the sudden end of the process after the judge’s gavel went down on the case, the therapy itself appeared to be part of a larger legal strategy. Custody was the objective; therapy was a posture, certainly one that helped the client, but still just a means to an end desired by the father.

To the degree leadership qualities of a child can be projected into the future, Patrick will likely be one. The question would be what kind. Multi-generational support over the years will help shape that direction.

Note: Summary comments will be presented in the second part of the next post.