Preamble: Johari’s Window
While first learning the basics about mental health practice during the 70’s, one concept used to understand therapy process at that time was Johari’s Window. My introduction was through a visiting speaker at the long-defunct Karma Clinic, who used a soft “a” in the introduction, and didn’t go any farther to cite its origins. For the longest time, I assumed the Window’s origin was Hindu, some kind of mystical thought-fruit. As discovered only now, the concept was developed by psychologists Joseph and Harrison (Luft and Ingham, resp.) known in contemporary research circles. More formally know as a “2 X 2 Design”, the concept has been used over time. Google ‘Johari Window Examples’ to gather the varieties of ways in which the tool has been applied. In this instance, the use is clinical.
During therapy, certain qualities and experiences about the client’s emotional, cognitive, and behavioral states are known by both therapist and client. That body of information occupies the top left box. Moving to the upper right, relevant information is known to the client, but not yet disclosed to the therapist, if ever. The lower left box represents what the therapist knows about the client but not yet shared to the client, if ever. Diagnostic hypotheses, dysfunctional relational patterns, and other explanatory would be the most obvious examples. The lower right box indicates that area of knowledge about the client of which neither is aware.
As taught at the time, the clinical belief was that the most important developments during a therapy came from that lower right box, when a significant aspect occurs or emerges about which neither therapist nor client had been aware. More broadly, of most importance to the therapy’s effectiveness was increasing the size of that upper left as much as possible, that which both knew about the client. The improvements gained in one’s mental health were assumed to be correlated. I don’t know of any published study that empirically verifies that, but just anecdotally, some kind of correlation does exist. Understanding takes time. So can healing.
All 56 youth in the study who went through the assessment process continued into the summary and recommendations session with the parents. Total cases remaining in treatment stayed at 56 out of the initial 58.
Like all other sessions, the youth assessment was also 45 – 50 minutes in length. Once a year or so, the process was extended to a second session in order to complete the basic work.
The client assessment was the usually the centerpiece of clinical engagement. Engagement was seen as the establishment of a client’s trust in the therapist’s basic competence and relate-ability, developed over a relatively short period of time. If the child is in need and willing to be involved, the parents and other members of the family are likely to be fully supportive. That development enhances family relationships to some modest degree right from the beginning. Also, though, clinical trust is presumed to be circumscribed, contractually based on the narrow need for help in the here-and-now rather than a relationship of potentially lifelong duration. For some, if not most, that trust can come easily and quickly. On the opposite end of the continuum, those who struggle mightily in some way or another with basic trust, the attainment of this particular type of trust in the clinician can be a longer evolution.
At least as I interpreted this sense of the term, a working clinical trust held by the client and parent(s) was generally in place by 10 weeks, most earlier than that. As an informal measurement, terminations thereafter were mostly a function of progress and change, and a few due to administrative roadblocks. To what degree these case endings were due to untreatable problems or to clinical skills simply not rising to the occasion was, to me, a riddle never solved. Getting the child or adolescent on board, though, was a central goal, hence the importance of the assessment.
Unlike the parent intake and the summary and recommendations sessions, this one involved bit of choreography. Doing therapy is far from an act, but here a little bit did seem to help the youth adjust to something they could have well experienced as anxiety-provoking or even forbidding. Balking could be a particular concern here, considering that 50% of the clientele were 12 – 14 year old boys. Where “freedom” is the raison d’ etre during this early phase of identity development, as per Erikson, most of these boys were moderately-to-seriously unhappy at the proposition of “counseling”. Little about them would be light-hearted if they remain distressed, so, why not introduce a bit of that?
The overall structure of the assessment session involved four sections.The first part of the interview followed a 5-tiered set of questions designed to enable the new client to talk about themselves and why they were in the office, usually taking just a few minutes or less, depending on their degrees of openness. The second part was focused on their own narrative and perspectives about the problems they and their families were experiencing, as well as identifying strengths. Generally, this would take 20 – 25 minutes. The third was the use of four diagnostic and developmental status testing instruments, an exercise that virtually all the kids found interesting and one that generated genuine effort.The last is the summarizing section focused on any specific questions they may have had, feedback from me, and talking about choices in the therapy to follow. All 56 remained involved, including a serious consideration of the format options for on-going therapy.
In a few ways, the assessment process for most 5 – 8 year olds is substantially different, and will be presented in the next post.
The first two steps here are essentially introductory. Over a few years, the simple matters of introduction and finding out what name the new client would prefer to be called developed into this little sequence that may seem contrived, but was one that categorically worked as a lead-in to the serious questions concerning their particular situations, whatever they may be.
With children under 10 and adolescents over 15, the initial greeting in the waiting room would appear to be normal and casual. The parent would usually introduce the youngster, I’d explain about the meeting, and then escort them into the office. With the middle group, the large majority being boys, a certain kind of pose would be assumed. The express purpose was to overcome any nascent resistances the new client had at the moment and be led into the office.
I’d walk into the waiting room, give a quick nod to the parent, walk over to the new client and extend for a handshake, all per the norm except a steady, serious countenance with total eye contact. Most kids stood up, a few sat, but that made no difference. I explained that we’d be meeting in the office for 40 or 45 minutes, that I may want to talk to the parent afterward, that she’d be waiting for him while we met, and ‘OK, let’s go’, and they go though the door I held open. Every once in a while, the boy would give the mother a beseeching glance for reprieve, but she’d simply point to the door, sometimes with a word of encouragement, a lot of times with relief.
I’d sometimes find out in the summary session with the parents that the client’s passive compliance to the quick introductory instruction belied a row in the house and/or in the car with the boy denouncing the appointment and threatening a refusal and worse, leading the parent to legitimately worry about getting the child to cooperate. What dawned on me years later was that my own faux demeanor was almost like a warden preparing the inmate for his walk to the chamber.They invariably preceded me through the door held open. And then that transient experience stood in somewhat stark contrast to the first interaction in the office.
They’d sit on the couch, and I’d ease into my overstuffed rocker, saying in a kind on monotone while lowering my head toward the writing pad “So, it’s John, right?”
They’d acknowledge the name, and continuing with head down in a deliberate monotone, I went on with “Parents call you John”, “Yes”, “Teachers call you John”, “Yes”, “Friends call you John?”, “Yes”, and then slowly raising my head to say with an identical “I’ll call you John?”, gaining eye contact but this time done with a bit of a grin. And usually, the new client would catch on to the parody, grin a bit back, and almost viscerally relax. Some didn’t notice, but they were no worse for the wear and may also have lightened up a bit.
Occasionally, the client did had two name versions parents, like John and Johnny, and we’d work out which I’d use.
Enough idiosyncrasy in these interchanges probably left many of them puzzled if not outright curious, which are steps up the ladder from the low rungs of defensiveness. That fit well into the next question.
Part 2 – The Clinical Intake
#1. The Opening: “OK, so…what can I do for you”?
This was how all initial sessions with a client were opened since early in the practice, which may sound strange for a 5 year old except a small few really young ones actually did begin talking, and some quite well. The rest had a variety of “I don’t know” responses from a simple shrug to a wrinkled smile. Maybe 1 out of 30 would actually respond with a meaningful answer with this first question, on a percentage basis girls more so than boys, and they did stand out. All others went on to the next question, and to them…
# 2 The Follow-up: “No problem, that’s OK. So, what brings you here?”
Being a little more specific and offering some kind of framework within which to respond, maybe 10% – 15% are talking relevantly following this question.The respondents here were more across the age spectrum, more verbal, probably more confident, still representing a greater percentage of female clients than was the case with males.
Aside from being easy and direct, one advantage to this somewhat unconventional two-step start has to do with Johari’s Window. The summary and assessment session with the parent(s) includes a review of how their child fared with the routine questions and tasks. In support of the clients who did answer positively and clearly to either of these first two questions – particularly the very few who began at Question 1 – I made a point of letting the parents know of their child’s advanced response, it’s coherence, and its rarity, ever more so as the child was younger. They learn of a new quality about the child, something neither they nor I could not have anticipated. This represents positive feedback coming from that lower right box, information neither of us knew, and brought into the upper left where we share the knowledge together, enhancing that incipient growth of trust. Furthermore, the feedback has an observational foundation, and not simply a subjective opinion. Random, unanticipated positive attributions are the strongest type of reinforcer, memorable for the parent, good for the child, good for the process, and maybe even under the circumstances, a kind of little peak experience for the family.
For the rest, on to the next.
#3: More Directly: “OK, no problem. So, who brings you here?”
“My mother!?”, from the 13 year-old boy with a little edge, but the question is so concrete as to be a jest, and I’m smiling.
“Right. And what’s your understanding about why your parents(s) wanted you to come here?
More than half of the youth begin to answer and start getting involved at this point. The interview then explored that particular interchange or discussion between parent and child in some depth. The content that followed would likely include problem history, differing opinions about the “problem”, parental actions taken, the impacts on the client, strengths, absorbing the family story, all toward gaining a situational understanding and generating a working relationship with this new young person. In other words just interviewing, following the narrative with open mind and interest, and always contributing at least a bit of valid, random, unanticipated, positive feedback at some point.
And then for those who would answer flatly, “I don’t know”, translated as ‘I do know, but I don’t want to tell you.’
#4 Onward: “Alright, no problem. How did you find out you were coming here?”
Usually answered, “From my mother”
“So, tell me about that conversation, if you would. What did she say to you?”
Sometimes, that question was all that was needed and the interview proceeded as per #3, but on the whole, this estimated 15% – 20% had more difficult parental relationships or life circumstances, hence more depression and/or anxiety and/or behavioral issues, and thus the recalcitrance. Being virtually all boys at this juncture, their resistance would naturally have taken the form of being oppositional.
To simply get a response to easy question of what was said to him could take as much as a few minutes work of trying this, that, and the other thing just to get the right angle in, but usually a working pathway was created. Patient, thoughtful, even-toned inquiry is a given.
The task was to first establish the difference that the new client saw between his perspective of the problem and what he believed as being the parent’s perspective. The fact that I’d already seen the parents was a usually non-thought at this point.The productive part started with the client’s view of the parent’s concerns, worries, complaints, whatever they identify. Once established, the focus shifts to client’s explanation of “the problem” and their view of themselves vis-a-vis the parental concerns
The youth at this point may actually be getting interested, if for no other reason than his stance was getting a competent, respectful, and non-judgmental hearing. Continued interviewing would likely get into the problem history, the nature of the parent-child relationships and those with other family members, then into other aspects of his life including both problems, strengths, and accomplishments, and then into what he would like to see changed or be different.
As straight-forward as the opening here may have been, Question #4’s simple request of what was said by parent to the son about going to counseling could still falter for the remaining, say, 2 – 3%, but by no means does the foray end.
#5 Gambit: “No problem. So I understand that you have no real idea about why you’re here. Right? They just brought you. So, knowing you don’t know for a fact why you’re here, why do you think they want you to be here.? All I want to do is understand your point of view and how you see all this.”
Or something else that might come to mind as a potentially productive way into a narrative about themselves and their experience. The circumstance presents the opportunity for creative experimenting, all in the effort to create the dialogue. More often than not, these efforts do enable the child to speak freely, identify clinical issues, give another view of family dynamics, establish the beginning of a narrative, and lay the groundwork for a functional therapeutic relationship.
All 56 clients here were communicating by Question 4.
At some point though, time left in the session can become a problem. While asking for a second session to finish the assessment could be done, discretion suggests to move on. Second assessment sessions were scheduled when the client had much more to say than could be finished in one meeting, and not due to avoidance.
If I was getting nowhere, we would seamlessly move on to the next section. They did cooperate with the new tasks that were not so personal at all. The task then was to, in some way, tie responses to the evaluative questions of Part 3 with what I knew about him or her based on the intake with the parents and what I’d just learned from interacting and observing him, and open up avenues to his clinical picture, history of the problems and relationships, and other relevant information. These were all boys.
Part 3 – Evaluative Testing
This section consisted of four diagnostic and evaluative instruments. They included: a 10-question depression inventory with an additional screening question concerning anxiety; a 6-question self-concept (or esteem) evaluation; a 4-question ego development assessment; and then a story-and-answer exercise measuring stages of moral development.
All youth aged 8 and up were led through the evaluative exercises. Younger children were more optional, some by their situation and others more out of my interest. If the youngster had blurted out a wish to die, that would trigger the depression evaluation. If their maturity level as evidenced by parental descriptions, the child’s verbal skills, and their non-verbal behavior or presence, then other parts of the list would be employed.
Depression Symptom List
The depression inventory used a combined version of the symptom lists from the DSM III-R and two DSM IVs, with a bit of adaption to accommodate the 5 – 18 year old population. The DSM V was not represented.
The DSM’s before the V were reasonably self-explanatory, clear, and convenient. Professionals and other interested parties bought their copy, familiarized themselves, and put the book to use. The more complicated DSM V necessitated a system of workshops and CEU presentations to teach its manifold systems of qualifiers and diagnostic options to users. I went to a workshop taught by a research psychologist who had worked on one of the V’s clinical section committees. By his own comments aside, clinicians were reportedly not enthused, but researchers in particular were complaining that with so many variables being created for specific diagnoses, doing field research was made much more difficult. To the degree that assertion was true, the new DSM posed a problem in one way or another for many.
1- Do you find yourself feeling sad and/or irritated more often than not, more days than not
2 – Do you have difficulty falling or staying asleep, or do you sleep more than 12 hours a day
3 – Do you have any problems with your appetite, like sometimes you’re not hungry for days, or sometimes you just can’t stop eating
4 – Do you find yourself feeling agitated, like you just can’t stop moving even though you really want to
5 – Do you find yourself feeling fatigued or tired often or have no energy for days
6 – Do you have a hard time focusing or unable to concentrate
7 – Do you find yourself feeling worthless
8 – Do you find yourself feeling guilty a lot, even though you may not be guilty at all
9 – Do you feel hopeless, like things just aren’t going to get better
10 – Do you have thoughts about not being alive or harming yourself
11 – Do you get headaches, stomach aches, or frequent anxiety
Mostly I just noted the answers and asked a couple of elaborative questions to assess severity here and there. Broader discussions about particular positive responses did not occur often. Much of this information would have been covered in the just-completed clinical intake. As was clear with the parents, this was simply an assessment. Attentions would come later.
The Self-Concept Evaluation
This scale was the first of these three assessment instruments to be employed in the practice. “Self-concept” is defined as “The idea or mental image one has of oneself and one’s strengths, weaknesses, status, etc” (dictionary.com). Research psychologists Ellen Piers, Dale Harris, and David Herzberg developed the original scale in the mid-60’s. Their 100 page monograph about self-concept that accompanies the test kit is an excellent work on the topic. Among other findings, the research concluded that one’s sense of self-concept, or esteem, is in place by age 5 and tends not to change thereafter. “Tends” is an important word here, because emotional events like a positively impacting corrective emotional experience or a damaging trauma, the do have impacts one way or the other on how one sees oneself. On the whole, therapy is very much on change’s positive side, and that was demonstrated in the few times I did a post-test.
The Piers-Harris evaluation begins with an 80-item questionnaire using a yes-or-no format to measure self-concept in six personal areas. The test was validated for the 8 – 18 year-old age range. Eventually, I stopped using the questionnaire itself and just asked the clients during the interview to rate themselves on a scale of 1 – 10 for each category. The range of responses seemed similar to the formal test results. At least the self-rating method sufficed for the intended purposes.
The six areas are: Behavior; Intellectual and School Status; Anxiety; Physical Appearance and Attributes; Peer Status and Social Skills; and Overall Happiness and Satisfaction.
The client hears:
1- On a scale of 1 to 10, how would you rate your behavior, with 1 being that you’re in trouble most all the time, and 10 is that you’re almost never a problem to any one?
2. How do you feel about your intelligence and your school performance, like combine the two and average out the scores?
3. How do you feel about your physical or athletic abilities and your appearance?
4. How do you feel about your anxiety; 1 is that you’re anxious most all the time, and 10 is that you’re almost never anxious or worried”?
5. How do you feel about your peer status and social skills. 10 is that you’re liked and get along with most everybody, and 1 is the opposite?
6. How do you feel about your overall happiness and satisfaction in life?
Moral Development Evaluation
Lawrence Kohlberg’s stage model of moral growth offers another plausible way to assess an important aspect of a child or adolescent’s cognitive state and maturity. The instrument is based on the concept that one’s sense of morality grows along a path of identifiable stages. Kohlberg developed the stage structure and then incorporated an evaluative system where moral dilemmas are posed to individuals, who are then asked what they would do were they in that situation. The answers were subsequently applied to a descriptive that characterized typical responses for each of the six identified stages.
The stages include:
1 – Obedience and punishment orientation – obey rules and avoid being punished
2 – Instrumental or Self-interest Orientation – what’s in my best interest
3 – Interpersonal Accord and Uniformity – want approval and avoid punishment
4 – Authority and Social Order – obeying rules is valuable and important
5 – Social contract orientation – What meets the greatest good for the most people
6 – Universal Ethical Principles – Orientation toward justice, obligation to disobey unjust laws
In the practice, the instrument was used as an assessment device, but seldom used to measure growth during a therapy. The exceptions were a few times with cases that went beyond three years. Moving from one stage to the next takes time.
The morality play Kohlberg commonly used is the Heinz Dilemma. The source of the basic story is not clear. Kohlberg’s rather harsh written version, clearly for adults, appears in the Wikipedia entry for ‘Lawrence Kohlberg’s Stages of Moral Development’. Briefly, the story involves a woman who develops a potentially fatal cancer. There exists only one cure for the cancer, stocked by only by one pharmacist who sells the remedy for an outrageous price. The husband cannot afford to pay the price, and the pharmacist refuses refuses to negotiate. Ultimately, the husband steals the drug, and the question is “Should or should he have not stolen the drug, and why?” I created my own verbal version, taking into account child and adolescent sensitivities. A transcript will be an addendum in the post following this one.
Answer examples to the Heinz Dilemma question for each stage:
Stage 1 – No – stealing is bad
Stage 2 – Yes – he doesn’t want to lose his wife
Stage 3 – Yes – he loves his wife and wants her to live a long time with him
Stage 4 – No – he could go to the mayor or a rich guy for help
Stage 5 – Yes – I couldn’t hold my head up if I let her die, we have to do what’s right
Stage 6 – Yes – Family is the most important part of life. I have to do everything I can to keep her alive for everyone’s sake; it’s the right thing to do, even if illegal. The pharmacist is wrong
Ego Development Scale
Hy and Loevinger’s measurement system of ego development was the last of these four instruments to be added into the assessment format. That the scale was used to measure outcomes in a clinical study published by the Journal of the American Academy of Child and Adolescent Psychiatry was intriguing enough to send away for the package and incorporated it into the assessment.
One definition of ego development is: “The nature of self-understanding, social relationships, and the mental processes that support connection between the person and his/her social world.” (Theories of Adolescent Development, Newman and Newman, 2020).
According to the authors, “One of the newborn’s earliest tasks is to construct for him or herself a stable world of objects, more specifically “constructing the world of objects and constructing the correlative (read ‘constructing the self’)”. This would be Stage 1.
A hierarchy of 8 subsequent stages of ego development, numbers 2 – 9, was devised by Hy, et.al. They included: Stage 2 – Impulsive; Stage 3 – Self-Protective; 4 – Conformist; 5 – Self-aware; 6 – Conscientious; 7 – Individualistic; 8 – Autonomous; and 9 – Integrated.
The team then created 36 phrases to open a sentence that would be completed by the subject. Based on their initial test runs, Hy and others developed representative answers for each of the 8 stages for all 36 phrases. All this information is published in “Measuring Ego Development – Second Edition” by Le Xuan Hy, et. al.” After getting the manual, I experimented with a few clients and subsequently incorporated the system into the assessment format.
Based on my experience with about 350 youth over a 10 year period that included a few of the 5 to 6 year olds seen: Stage 2 Impulsive was typical or average for children under 8; Stage 3 – Self-Protective was typical for 2 – 4th graders; 4 – Conformist was typical for 4 – 7th grade; 5 – Self-aware was attained with increasing frequency from 5th through adolescence; 6 – Conscientious, much less common but appearing in increasing frequency from mid-adolescence into adulthood; 7 – Individualistic appeared for a small few older adolescents; 8 – Autonomous may have appeared in one or two cases, and while nothing registers in my memory, with that many youth at least one would have probably appeared; and none for 9 – Integrated. I probably would not have been able to distinguish the last two from each other anyway. The issue never became germane, as 7 was the highest achieved among those tested here.
As a matter of reference, some significant proportion of adults themselves do not get beyond stage 4, with a few percentage points even lower. An interesting question is the degree to which the ego development is dependent on parenting, education, and similar experience vs. intrinsic drives. A research question could be whether the children of adults who answer in the lower levels could themselves attain higher degrees.
Examples from the practice using the four beginning phrases. This being a family therapy practice, the chosen four opening phrases were: 1- Raising a family….; 2 – A good father….; 3 – A mother should….; and 4 – I am….
8 yr. old boy:
1) is hard (Stage 3)
2) will always be good to his children (Stage 2/3)
3) always cook for the family (Stage 3)
4) respectful to others (Stage 3, and ironically one of the client’s main problems)
10 yr old girl
1) has hardships and fellowships, ups and downs (Stage 4/5)
2) should be there for his family and be a positive role model (Stage 4)
3) love her family and help set family goals and make kids desserts (Stage 4)
4) Whoever I want to be and will always be who I want to be (Stage 4)
14 yr. old boy
1) taking responsibility and working their best to help children be successful (Stage 5)
2) someone who cares about you, has fun with you, and takes care of his family (Stage 5)
3) Always looking out to take care of her family, raises them as best she can, and loves everyone (Stage 5/6)
4) wondering what is going to happen to me, what I’m going to do, like do ` something good (Stage 5/6)
The shift of focus or affect shown by the youth as the interview moved from the problem orientation to the second part’s testing format was notable.
In contrast to the unfolding of sometimes difficult descriptions, disclosures, stories, and uncertainties, the second half was more like an academic challenge which was usually taken seriously, often eagerly. Answering the posed questions in the evaluative section was more impersonal, concentrated, and touched their creative sides, like the client could and would step outside themselves, leave the drama behind to achieve the perspective necessary to answer the questions relative to depression, self-confidence, ego, and moral thinking. The appreciation from a nod to a comment to an explicit praise of their responses was appreciated by them in return.
The first part of the assessment interview focused mostly on the client’s narrative, that being their views about current problems history; relationships; disappointing, disturbing, or traumatic events events; losses; and doubts that linger. Virtually all clients had at least couple of these experiences; some had more. To one degree or another, most all re-experienced their downside of life once again, but by the end of the overall assessment interview most all had some sense of optimism, if not outright relief. Their transition out of whatever emotional state their narrative brought on during the first part of the interview was a useful data point. When that shift demonstrably occurred, a nice source of feedback was provided, both to the client and later to their parents during their next session.
Among other uses, the depression and self-confidence evaluations assess the client’s state of being, meaning how healthy and how content one is with one’s self. The moral and ego-development evaluations can assess aspects of intellectual growth. The first two can identify areas of emotional strength and symptoms of distress, while the other two can identify strengths of maturity and perspective, and those who have deficits.
When administering these devices, one track of the interview was the search for positive reinforcements. Think of Johari’s Window and the power of observations that come from the lower right box, where neither the client nor the therapist were aware of something important about the client. Giving positive reinforcement only for the sake of doing so runs the risk of lighting up the client’s phony detector – assume they know when words don’t match their reality -but in the midst of answering these various challenging questions, the spontaneity of a response to their answers adds to a sense of authenticity.
The addition of the ego development evaluation opened up a whole new mine of reinforcement opportunity. The stages are sufficiently proximate to each other that answers from higher-than-average stage for a child or adolescent were more common than those from the moral development system. Additionally, the opportunity for creative answers could be given four times during each evaluation compared to the one coming from the Heinz Dilemma.
Sometimes the best available praise was a recognition of the young client’s difficulties and in what way they were trying to do their best in their given situation. However, I could usually find something in what they portrayed either during the narrative half, or among their answers to all the questions provided during the evaluative half. The feedback was also conveyed to the parent(s) during the following summary and recommendations session.
Again, these are usually examples of the lower right box in the Window, where the child and parent and therapist are learning something of positive substance about which no one had particularly been aware, i. e. random, unanticipated positive reinforcement, the most impactful of its type.
Vis-a-vis the Depression Symptom List
This adapted construction of a depression inventory ended with a global indicator of child and adolescent anxiety. If they endorsed one of the three possible problems posed – headaches, stomach aches, or frequent or overwhelming anxiety, the assessment continued to the DSM III- R’s 15-symptom list for generalized anxiety. This particular list was the most helpful for generalized anxiety among any of the DSM’s. In addition to thoroughness, the list was divided into three sub-groups, the first of which seemed to be about the anxiety created by chronic stress, the second one about the anxiety of how one is seen, and the third about the anxiety that foretells danger of some kind or another, a convenient overall schematic.
The anxiety question ending the depression list also ‘buried’ the suicidal question, so that disquieting consideration wasn’t left like a dangling participle.
Understanding that the community standards of assessment and intervention processes for SI are in the midst of significant change as the problem of child and adolescent suicide in this country has been upgraded to epidemic status in the past few years, the following paragraphs are presented only as “this is the way it used to be done” and not as a contemporary model, per se. Whatever they be now and however vague, community standards are never to be ignored.
37% of the study, or 21/56 cases, involved suicidal ideation difficulties for clients from 8 to18 years old. Over the years, an average of 8 – 12 new SI cases were taken into the practice annually. Based on the study cases, their average length of treatment and average number of sessions were about 15% higher than that of the other 35 cases combined. These cases also had higher levels of problem resolutions and fewer premature terminations. The sense I had was that once satisfied with the therapist, these parents in particular were determined to stay the course. Perhaps counterintuitively, once the suicidal ideation began to abate, these cases on the whole were easier to manage, treat, and help create change, and the parental involvement was clearly an aid.
Suicidal ideation and behavior was the prompting problem that led the family into the office for all 21 SI cases in the study. The issue was usually disclosed during the initial phone contact by the parent, and if not, during the intake. Most of the 21 clients also disclosed the ideation during the assessment interview. If not, they would do so during the depression evaluation itself. Maybe once in this group I had to bring the topic up for verification.
The assessment work was to establish where on the continuum, from an isolated blurt to a manifesting plan the young person was functioning. Whatever the conclusion, initial severity would be part of the assessment debriefing with the parents during the following summary and recommendations session, a step about which the client understood.
If the SI was isolated or had been managed to the satisfaction of safety concerns by the parents at home, no specific action was necessary at that time. The therapy thereafter would tend to the underlying issues. As with the others, all SI cases did continue into treatment.
If the safety of the child was still in question at the end of the assessment session, the accompanying parent would be called in and included to make a management plan to everyone’s satisfaction, client, parent, and therapist alike. If the client was concerning and balking both, the ER was an option. That happened a couple of times years earlier than the study. One cooperative 13 year old girl was escorted to the psychiatric hospital intake next door. The most common intervention outside the office was to have an outpatient child psychiatric assessment which would normally include a medication evaluation. Psychiatrists’ admitting privileges were an important adjunct and consideration in the referral.
Parenthetically, I can tell you that having a child psychiatrist as a referral source who thought clinically before pharmacologically is a gift.
One particular interchange was choreographed if the thoughts had been persistent but had not advanced to imminent threats of attempts that required the efforts in the above paragraph. To the client, I’d say “So, if you got to your very worst, where everything just seemed sooo bad, and you were thinking about doing it, what would convince you not to do so?”
One of two types of answers came forth. By far the most common reaction was the client identifying the pain that family, friends, teachers, and/or others would feel. The concerning response was something like “because it’s stupid.” The first is appropriately other-directed, and the second is a concerning self-absorption, dearth of empathy, and perhaps impulsivity.
The clinical response to the self-absorbed stance was the one planned intervention that regularly took place during the assessment itself. Together we would walk through several family members, friends, teacher, and others of importance to the client and discuss how each would react if the client did take their life. An instructive approach to help broaden the client’s perspectives of others under these particular circumstances can be corrective, and part of the subsequent work included a focus on empathic growth. The work did seem potent to the client. Occasionally, though, someone was unimpressed, and that youth would require more supervisory care and at the very least that referral to a child psychiatrist or psychiatric hospital.
One complication of SI being revealed by the client during the assessment was when the issue was an unknown to the parents. That happened maybe three or four times total. None of these study cases were involved. In general and if the child were under 13, I would do the evaluation, talk with the child about how and when the parents needed to be told during the assessment session. A good deal of therapeutic effort and support might be required, perhaps the length of the session itself. The carry through was usually toward the end of the session, with time made for appropriate planning.
If the child is over 12 and insists the disclosure about SI remain confidential and this being the State of Washington, the therapist has a problem. A discussion ensues about why the need to do so and why the need to include the parents, but that could go nowhere. Know where they are on the continuum. The issue of safety is determinate, replete with all the involved subjectivity just to further the difficulty, and an intervention may be necessary. Concerns about “losing” the case are moot. Concerns a unilateral act might trigger an attempt are not idle, but certainly not common because Lord knows we’d hear about it.
I went along with the insistence at least once, I think possibly twice. Nothing bad happened. Issues that skirt the rules of conduct do arise, and that’s one of reasons we have professionals, and one of the reasons we become one. These situations need tender care.
All this is said having not experienced either a suicide or an attempt during my practice. To what degree this is normal or talented or lucky is impossible to sort out. Come retirement, I did feel very fortunate.
Vis-a-vis the Moral Development Evaluation
All clients 8 – 18 were tested during the assessment session. Depending on maturity, 7 year olds were occasionally included, one rather remarkable 6 year I can remember, and none under that age. The test was given regardless of the child’s particular family circumstance, e.g., cancer in their own family, other premature deaths of parents, etc.
I remain thoroughly impressed with the almost universal way the 1000+ kids carefully listened, thought with appropriate gravity, and answered with a caring creativity concerning Heinz’s Dilemma, regardless of their own circumstance.This is not hyperbole. The story does have a capturing quality, to be sure, but still, these were just kids. Their answers were always interesting, and a point was made to share them with the parents in the next session.
The answers always focused on the husband, as per the question at the end of the story “should he or should he not….” The pharmacist was hardly ever a part of the answer, as if a neutral character, until somewhere in the 2000’s, during which he started being identified as a problem participant in a quite a few responses through to the end of the practice in 2015. These particular respondents were not limited to older adolescents.
As an aside, another observation of a change in patterns of child and adolescent behavior occurred at roughly the same time. Among other creative supplies in the waiting room was a set of about 70 old wood blocks of different sizes and shapes, out of which kids would create their own structures on the waiting room floor. These included siblings brought in with the parent to wait through the session, so lots of kids made all sorts of structures. Parents, by the way, in the era of electronics loved this activity. I also had them leave their creations there on the floor at the end of their sessions rather than putting them away, which the kids loved doing, because other youngsters coming in later would sometimes add to them. Getting back to the point here, boys would generally make structures that rose upward while girls tended to make wide and low enclosures, like villages or wide castle grounds. Again during that first decade of the century, girls increasingly made towers and such structures as well. What to make of either of these pattern changes I do not know.
Vis-a-vis the Self-Concept Evaluation
My take is that self-concept and self-esteem are essentially flip sides of the same coin; cognition is to self-concept as affect is to self-esteem.
The overall average of the clients’ self-concept was around 5.5 on a scale of 10, this in spite of the fact that their average overall functioning was 55, or moderately disturbed, on the CGAS scale. Statistically, the range of “normal” on the CGAS is in the 80’s, so one might expect a lower-than-five average among the study group. The catchment area of the practice is middle-to-upper middle class, leading to the question of whether that factor equates to higher-than-average self concept scores in general. And then what effect that has on overall mental health, which could lay question about national and global resource distribution.
The self-confidence evaluation was most helpful as an additional diagnostic, particularly with anxiety and depression. Those issues are directly evidenced through the anxiety and overall happiness and satisfaction scales, and indirectly by the degree of low scores across the six scales.
Unfortunately, the results are more inclined to point out existing difficulties than unanticipated strengths. In the search for potential sources of reinforcement, looking for areas in which the depressed or anxious child rates themselves at 7 or higher among the four categories occur with regularity, and the use of reinforcement in those instances did seem on the whole to have the desired impact, particularly with parents. The results of the self-concept evaluation were more often helpful to expand the understanding of the parents about their child than they did on the children themselves, but help is help and not to be discounted.
The utility of the tool was more oriented toward giving good, specific feedback about their child’s view of themselves to the parents. This afforded the parents to more objectively view their own parenting and begin to start thinking about adjustments big and small, mostly the latter. Discussions followed both in session and, presumably, afterward. ‘What is it that can get better here’ started to become a bit of a mantra in session. Most all this would be done in the following summary-and-recommendations session. The self-concept exercise was by far the most helpful to the parents of the four tools used on their child.
The one pattern I noted over the many hundreds of administrations was that the cases where an outcome that has low anxiety and overall happiness and satisfaction scores while the other four were above the mid-line usually had as a primary problem the relationship between the client and the mother.
Very few clients gave themselves uniformly very high grades, ie. 9’s and 10’s, or very low, ones 1’s and 2’s. To me anyway, this tended to reinforce the sense of overall validity in the answers.
Only on occasion would children under eight be given the questions. The problem was not so much understanding the questions. Objectivity may be more difficult for the young ones, but the concept of self-rating on a numerical scale made the interpretations of profiles problematic. The best example of a younger client’s struggle with the numerical rating system was another 6 year old boy who rated himself as a 1 for behavior, anxiety, and overall happiness and satisfaction, and 10 for the other three including intellectual and peer status, physical appearance and attributes, and peer status and social skills. He was absolutely correct about which were a strength and which were problems, but did not understand the mathematics of nuance.
Vis-a-vis The Ego Development Evaluation
.Ironically, the evaluative tool that was incorporated into the assessment format some fifteen years after the others became in ways the most valuable of the three. The same clinical benefits that the moral development evaluation offered, those of assessing the client’s state of personal growth, apply to this evaluation as well. Two other advantages also were present. Given that the four questions all pertained the family, the subject clients will often disclose salient perspectives that enhance the picture and offer threads to be followed. The second is that the instrument can be used with 5 – 7 year old children. The Piers-Harris system was validated for 8 yrs. old and above (although a contemporary 7 year old is likely to be more advanced than 50 years ago?), and I was just not comfortable presenting the Heinz test with most kids under age 8. The ego development tool includes all the children 5 and above.
Using Hy and Loevinger’s sentence completion system provided a better platform for unanticipated and meaningful positive reinforcement. A few respondents had answers that were levels higher than average for their age. Again, think of Johari’s Window – I’m clearly impressed at the moment, they could not have been aware of this particular precocity, and the relationship is subsequently enhanced just that little bit.
One specific observation pertained to older adolescents whose responses indicated a stage 7 on the ego development scale, advanced for any adult, let alone vulnerable 15-16 year olds. Relating to peers could be sadly problematic. Taking into account at the outset that they are entering counseling because of emotional, family, and/or social difficulties, they did seem to have particular problems establishing close confidential relationships. Dating relationships for the females seemed especially difficult as their partners tended to be older an/or players, leaving the client to be caught in painful double binds and a lack of peer support.
Part 4 – Summary and Planning
With some 5 – 10 minutes left in the session, the clinical information gathering and evaluative portions of the assessment were concluded and the conversation switched to summarizing, planning, and concluding. As stated earlier, this particular approach to the client assessment was generally for youth 8 years old and up.
The transition question was something along the lines of: “OK, so I’ve been asking a lot of questions”, pause for a nod, somewhere between faint and vigorous, “So, do you have any questions you’d like to ask me?”
With uncommon exceptions, the answer was a shake of the head. The question was asked as much for foreshadowing as for a response, establishing a facet of the clinical relationship that encourages the client to think about their questions and ask them later on in session. Those that posed questions were generally either older adolescents who may have questions about something I asked or said, or by the 5 – 7 years olds who might have something they wanted to ask about me. I usually answered anything expeditiously and moved on.
The next question was: “So, I’m going to be meeting with your parent(s) next week. Do you have any concerns about that?”
Some just shook their heads. I’d confirm “so you’re comfortable with that?”, and they’d nod. Most, though, came back with “Well, what are you going to tell them?”. That response more directly opened the summary of their interview to share with them, including clinical, evaluative, and impressionistic observations. Even with most of those who were ‘comfortable’ with this prospective parent meeting, a few minutes of extemporaneous review would follow.
Every experienced clinician has a method of taking notes and keeping a running side commentary, establishing the given facts and noting impressions, typically leaving the impressions for the margins. For the most part, the summary to the client of what I’d be telling the parents came from the margins, but also the problems that people wanted to see get better in some way or another that were central to the narrative. Those issues may be symptoms, relationships, losses, traumas, heartbreaks, or other unresolved hurts. The margins also contain noted strengths based on the clients words, history, performance during the evaluations, demeanor, and character as witnessed.
The young client wants to know that the therapist knows, that divesting of private and personal information has a value, that a helping route can be seen, all possibly without melodrama, maybe just get better. The praise that occurs must be based on direct observation and plausible conclusions. And don’t take more than a few minutes. In their realities, 50 of them in a therapist’s office can feel like an eternity.
“OK. So there are three ways we can go about working with these things. What we do is not my decision or your parents or yours, but rather this is something that we just work out among us. But if this were your decision, I’m interested in which one you’d choose. Number one, I can meet with you and your parents together. Or, I could meet with you and your parents and your sibling(s) together, like the whole family. Or, I could meet with you alone and meet with your parents separately, either split an hour here or see you for a full session and your parents the same at a different time. So, which one would you choose?”
If they choose being seen alone and I am normally thinking family, I’d ask them how they would feel if family work turned out to be the most favored choice. Again for the most part, they are fine with that, but occasionally the counter argument has real merit, and that gets taken into the parent meeting.
“Is there anything else you’d like to add?”
Usually not, and then comes a quick and genuine summation, apt to the person, including constructive, supportive feedback, and particularly what was appreciable about their input, cooperation, etc. Particularly for the difficult 11 – 14 year old boy, some kind of comment about having “…done a good job here, I think this could probably be of some help, and I look forward to seeing you again…” That helped. Just ten, fifteen seconds, not wanting important words to get lost in a tide.
What did not occur:
No given diagnosis, certainly not before conferring with the parent, but no youth of any age ever asked for one, that I recall. That may have changed during these past few years as the American population gets swept into health-speak.
No therapeutic assignments. No clinical contract with the parents yet, and no youth ever asked. That, too, may be changing. The main reason is that I want to see what was the impact of the session itself on the young client, what kinds of changes may have spontaneously developed. That is important information for treatment planning and part of the work with the parents in their following session.