#48 -Assessments For 5 – 8 Year Olds – Part 2

The Family Drawings

The last section of the previous post discussed several clinically notable elements of childhood family drawings, to include: who of the family are included; who’s left out; extra characters included; the presence of a yellow sun; the streaking of the yellow sun with orange; the usage of red and black; baselining; and the relative size of the characters i.e. who is portrayed significantly bigger or smaller that real life relative to others. Not discussed there but obviously of central importance is the nature of the family activity and the affects portrayed by the drawing client. 

This next area involves pieces of the drawn picture that are missing. These include drawing everyone in the family drawing with no faces, hands, or feet, or having drawn no people at all. The constriction of colors to the use of only one for the drawings turned out to be clinically associated with these missing pieces as well.

As mentioned in the previous post, for evaluative purposes I went back four years prior the study and pulled out all the 5 – 8 year olds, producing an N of eighteen 5 – 8 year olds. All these cases save one produced the three drawings requested. The family drawings as a whole produced previously unregarded and completely unanticipated results.

Out of the eighteen, they included:  

Four who drew characters with no faces, hands, or feet

Four who drew those with no hands or feet

One who drew no people at all 

Four who used only one color (three of them included among the three types above)

Note: Using only one color is associated with perfectionism (look up on Google). At the time these cases were being seen, the significance of one-color usage was not recognized, but neither did the broader problem of obsessiveness and its various sub-categories receive fair due either. The data above was the result of research for this post, and not particularly noticed at the time of services.

The question then became what distinguished these ten cases clinically from the other eight.  What follows are brief case summaries, as might appear in a chart of the ten.

No faces, hands, or feet  

#1. 7 year old 1st grader; parents divorced 2 years; mo. in custody; father ? depression, acted out; client is dysthymic, occasions of aggression, ?ODD; 2 older bros. w/Aspergers; mostly conjoint process with later split sessions, initially mother and all three boys, later just with client; father never involved; 72 sessions, over 2 1/2 years; mutual term, much better, normal functioning

#2.  7 year old 2d grader; fa.?bi-polar w/ family history, aggressive, suicide gesture w/ gun; mo. situationally depressed, marriage in trouble; pt. ? OCD/ODD or RAD, but no family history suggesting the latter; poor social skills, rocking, hard time with directions, obsessive, easily agitated and reactively aggressive; IEP at school; also drew with one color; 8 sessions, split session format; did not respond well to tx, difficult to have him focus; unilateral termination; likely getting psychiatric eval.

#3.  8 yr.old 3d grader: both parents professionally successful, Ivy League bright, depressed; fa. w/ culturally-based belief that depression is moral failure; mo. situationally depr.; pt. non-compliant, easily irritated, situationally aggressive, soc. probs, ODD(?); drew w/ one color, playful but no faces, hands or feet; two processes a year apart, seven conjoint and six split sessions each; doing much better at term., significant gains; pars pulled out, unanticipated unilateral term, but kid picked up soc. skills, more extroverted, prognosis good

#4.  6 yr old 1st grader, adoptee from eastern Europe; obsessive, perseverates, falling behind in school, OCD-type, can’t stay on task at school, takes up “80%” of mo’s time; adoptive father tech exec, mother homemaker, both OK; Picture of self included two sisters and “another kid” hanging on a playground jungle-gym type apparatus, no face, hands, or feet; ten sessions, conjoint process; showed good progress during #s 4, 5, 6 and 7, then mother’s mother suddenly died at home in Northwestern Europe, process interrupted for a month, came back, client regressed, started to pick up again; the tenth session ended the school year, mother and children returned to Europe; cancelled Sept session; unilateral termination, got the sense they were pursuing an OCD eval.

No hands, no feet             

  1. 7 yr. old 2 grader;  Pars separated, going through divorce, both OK mental health, fa. may have had OCD in family history; child reported perfectionistic, hyper focused; since 6 1/2, has rapid escalation of OCD-like symptoms, irritability, uncommon aggressiveness, i.e. throwing rocks a classmate in a pique, and adamant non-compliance at home; in assessment, he was nervous, fidgety, but made an effort; drawing picture of family was almost tortuous, all in black, dividing page into four squares, the X-ing out each, flipped paper and did the same thing on other side, except drawing his father in the last, bottom right box with vaguely angry look, no hands, no feet, all evidencing seriously contradicting self-directives beyond the youngster’s ability to manage;  conjoint process w/both parents, client active and involved, showed nice improvements over sessions 4, 5, 6, increasing and sustaining; went for psychology group OCD eval resulting in dx. of PANDAS and Lyme Disease, and they took over treatment; mother later wrote re: finishing co-payments, said progress was slow, up and down but overall getting better.

 2.   8 yr.old 3d grader; marital conflicts; fa’s parents divorced when young, hasn’t seen father or 25 years, OCD in his mo’s family; evidencing OCD-type behaviors, ritualistic, hyper-focused, considerable anticipatory anxiety, easily irritated, memorizing license plates, recognizing and naming people by their plate numbers, as a toddler could roll toy train wheels on his palm for long periods of time, etc; family pictures bright, big yellow sun, colorful, no hands, no feet; conjoint including older brother; 30 sessions over a year, mutual termination; modest gains,  improved in areas  w/some cycling back and forth; more social, stabilized school performance; probably heading for OCD eval.

3.  8 yr. old 3d grader; father OCD, off-on-off meds, depressed, caustic, agitated w/son when fa. was off meds, not recognizing own behavior at the time; mother stressed, marital probs; client defiant, aggressive, interruptive, controlling, bit perfectionistic, ?ODD; fam pic. characters indistinct, no hands, no feet; 21 sessions, modest gain w/ compliance, fa. stayed on meds, social, school perf. better, case looking long term; headed for ADHD eval.  

4.   7 yr.old 1st grader; ? RAD/PTSD; parents divorced when two years old, live in rural area, mother in a commune, father re-married with two step-children about clients age; client mostly with father but parents basically split care; huge child for age, more height than weight but has both; multiple concerns about boundaries, often casually acting like none exist, occasional bursts of anger the might include throwing rocks, pleasant when not limited, multiple behavior issues, “management problem everywhere” as per father; both parents report their own self-control issues as younger parents, fa depr., aggressive, mo. alcohol, boy lives with fa more; family drawing immature, no hands, no feet, all black, both parents smiling, he’s not in the picture; conjoint involving several family members over three generation; began living more with the mother by agreement of all three, mo. reduced alcohol; started getting better reports all the way around, including school via school counselor; had ten sessions, took off summer, cancelled just before school began.

No people at all in family picture:

8 years old, 3d grade; Family of three, father in business, mother at home and volunteers; client dx. w/Aspergers, no previous treatment; obsessive, perseverates, dropping school performance, only one friend, out of 3d grade social loop, does self harm, other symptoms of depression; mothers sister died suddenly a year before process began, client responded by carrying a large clock 24/7 for a week; OCD in mo’s family, probably depression in father’s who chose to not participate; picture of family was a bowling alley, ball scattering pins, family member’s names on an alley scoreboard, all in nice detail, yellow lanes, blue scoreboard, and black ball and pins, no people; picture of self was a pool game with numbered balls, a cue held by a hand on an odd, wavy non-table surface, almost like a small bay;  69 sessions, conjoint with mother over two years, significant progress all the way around, 5th grade started well.

Use of One Color

6 1/2 year old girl, 1st grade; father corp. exec; mother job shared in retail management; fa. no mental health history, mo. MDD as adolescent, two recurring episodes since, controlled with medication; family referred following traumatic event on playground w/ badgering autistic child; ?PTSD, initially seen as anxiety manifesting in a number of daily routines, phobic, obsessing, controlling, aggressive when distressed, could be early OCD (said now in hindsight); mother’s level of expectations, constancy, and persistence also suggests her own  perfectionism; three drawings each one color, light purple, pink, then brown, drawing with no faces, family members sitting watching TV; conjoint process; 15 sessions; considerable settling at home yet still mixed results, some problems emerging after others subsided, worked on accommodation/assimilation, particularly with mother; +50% results; parents comfortable w/ direction; mutual termination.

Client Likely Dx. Summary

6 OCD-like

1 PTSD, (evidencing possible OCD onset)

2 ODD

1 RAD

Family Histories

5 OCD in parent or in family history

2 with one parent dx. Bi-polar

1 MDD

2 Basically negative

In contrast, N = 8 Diagnostic Summary

Client

1 Autistic

3 Adjustment w/Anxiety

3 Adjustment w/Depression

1 Adjustment w/Behavior

Family 

5 divorced, or separated and filing for divorce

2 Significant marital problems w/paternal depression

1 Marital problems w/ ?OCD mother, ?depressed father

The disparity in parent’s marital status between the “obsessive” group of ten cases and the other eight is notable as well. Of the OCDish group, three set of parents had divorced, and the other seven marriages were intact. Five of seven marriages were reporting marital distress, but none appeared to be threaten the marriage itself. Within the other eight cases of the affective group of clients, though, two were divorced, four were separating and in the process of divorcing, and two marriages were intact. One of those last two were adoptive parents. Only one of the eight cases involved natural parents whose marriage appeared to be intact and functional.

The most obvious interpretation is the affective stress of marital dissolution on the child. That event is not necessarily the precipitant of the child’s mental health issues, but rather a driver into treatment that serves to bolster the child’s coping mechanisms. The question left is whether the existence of cognitive disfunction of a child acts as a relational binder for the parents. Of course, the differential findings within this small sample may not be statistically significant, but they are intriguing. For the parents of the cognitive group, the child therapy process implications lean toward parental learning and experimenting rather than correcting. With the affective group, the parents may get a recommendation to seek marital counseling – I did not do that very often – but again, the process focuses on growth and coping with considerable reinforcements, particularly those that are random. The marriages that heal may be those who take sincere random reinforcement to heart.

Heart v. Brain

Note: The following information is largely taken from the article “Yes: The Symptoms of OCD and Depression Are Discreet and Not Exclusively Negative Affectivity”, by Katherine A. Moore and Jacqui Howell, published in the Frontiers Of Psychology, 5/2017. 

In their review of the research comparing depression with OCD, Moore and Howell made several points about the similarities and differences between these two major clinical categories that are germane to these particular findings concerning the 5 – 8 year old clinical population. While the differences between the two are clear and clinically relevant, ultimately in treatment some of the core interventions effectively used with the depressed can be equally effective with the “obsessive” of OCD-type client.

Citing earlier research by Steketee (1993) and others, the authors concluded that OCD is fundamentally a disorder of disturbed cognitive processing, and not a mood disorder. Several streams of thought are used to make the point.  For example, Moore, et.al. state that while “OCD positively predicted depression within the OCD population, depression was a negative predictor of OCD…These results support the hypothesis that OCD and depression are discreet disorders. (Moore and Howell)” In other words, OCD individuals often get depressed, but the depressed seldom develop OCD-type symptoms, all creating a significant etiological separation. 

While “disturbed cognitive processing” is a clear descriptor, an overarching descriptor for all those disorders that involve emotions and behavior does not seem so readily available. Assuming human affect management difficulties manifest into behavior problems as well, perhaps ‘affective management’ 

Quoting the authors again, “High negative affect is composed of a wide range of factors, including fear, nervousness, anger, guilt, hostility, sadness, loneliness, self criticism, and self-dissatisfaction”. Negative affectivity is found in both OCD and depression; both generate mental health and coping problems as a result of mounting negative feelings about oneself. The difference is in how these emotions are processed.

The authors cited research that found depression was linked to inward but not outward aggression, presumably allowing for the uncommon outward aggression under extreme circumstance, i.e. “blowing up”. Depression is linked with “intro-punitiveness”, or inner directed hostility. On the other hand, they cite theory and supportive research that asserts OCD generates external aggressions when the levels of negative affect about oneself are high and one perceives external threats to their being, usually off-based. 

Among other applications to casework, this manner of OCD reactivity also explains the often bewildering aggressiveness of an upset youth who fits the diagnostic criteria for Oppositional Defiant Disorder. Which leads to the question of what characteristics and diagnoses fits into this area of ‘disturbed cognitive processing’. The term OCD is not an umbrella.

Paradigm of Obsession

In going through the chart notes of these ten young clients, several behavioral descriptors appeared multiple times. In emotional terms, they were feeling the negative affectivity of anxiety, insecurity, tenseness, and/or helplessness. Those are almost taken for granted in a children’s mental health office. Each one also exhibited obsessiveness, perfectionism, ritualism, and/or perseverating. As a group, they included likely diagnoses of OCD, ODD, Aspergers, and RAD. Are these four broadly linked in some disorderly cognitive processing way? 

Treating ODD was a specialty in my practice. The parents’ presenting problems were generally affective in nature, plus behavior management, more the former than latter. The work was more successful than most, hence the referrals, but probably still 10 – 15% less effective than the rest of my practice. OCD did not enter the clinical equations, and obsessiveness in general was seen as a behavior issue. 

The treatment was conjoint as much as possible. In that setting, a considerable amount of clinical energy toward the client was focused on the understanding of others’ thoughts, feelings, actions, and the client’s own reactions to life, the latter of which obviously included ODD patterns and outbursts. Self-understanding was seen as the byproduct, and not the central theme. Outside of reinforcing the opposite behavior, which was rife for these cases, behavioral work was done only on an as-needed basis.

That a young client had negative affectivity was presumed. A desired baseline outcome always involved lowering the negativity, both toward self and others. When evident, aggressive outbursts in response to losses, limit setting, and senses of deprivation were included. That the externalized aggressiveness generated by self-negativity was an OCD characteristic is new to me. Thinking of ODD as a cousin to OCD is also new, but the notion satisfactorily explains a whole lot. These kids do get obsessed, hyper-focused, some probably perseverate could on one  or another activity of life, in the next instance become purely chaotic, and in the aftermath with little cognizance of that paradox dwelling within. Paradox is not their forte; black and white can be more descriptive. ODD belongs in this broad category of disturbed cognitive processing.

The Asperger’s boy in the study had rituals and obsessions, not many, but enough that their disruption could cause a stir. Two other Asperger clients, a boy and a girl and both sixth graders, were seen for 30+ session treatment processes over the last few years of the practice. The boy clearly had obsessions that could pose serious social trouble, and the girl had interests in nature’s phenomena that were often preoccupying to the point of disappearing. As with the client in the study, both did well. Some kind of connection with obsessiveness exists with the Asperger’s cases I saw, but not to the point of being subsumed into OCD. Still, they do have cognitive processing issues and may belong in this paradigm.

Comparing basic outcome data between the ODC-like group of ten to the emotionally troubled group of eight, both groups averaged close to 20 sessions. Most cases were done prior to the study, hence not rated for gains made. My guesstimate is that the cognitive group’s overall outcomes were about 15% lower. The corresponding fact is that I was less knowledgable about their treatment needs compared to the more common ‘depressed’ group. 

RAD’s diffusion of maladaptive personal, familial, scholastic, and social behaviors that include externalized aggressions of one sort or another an can be dangerous to one degree or another seem obsessive in their persistence in spite of the meaningful attempts to connect of others. The diagnostic label suggests the affective etiologies of PTSD and major loss, but I do now wonder about an underlying kind of obsession for connection with little skill to do so?

Implications

To the degree that this correlation between a child’s obsessions and the dearth of detail on their drawn human figures is significant, some kind of explanation that could lead to enhanced clinical treatment would be helpful. One is offered here, fairly concrete but at least a place to start. The fact that this age group operates on a cognitively concrete basis may lend some support. 

The basic idea is that as the child’s preoccupations with rituals, hyper focusing, and rigid ordering absorb their small worlds, they lose sight of the broader social world.

Concretely, they can’t envision the important details of what constitutes another person. The portion of meaningful inter-personal engagement that leaves impressions is bereft. Two kinds of therapeutic actions come to mind. One is a slight alteration to the child assessment process, and the other is to incorporate a bit more drawing into the individual therapy process with the child, starting in this assessment itself. 

Virtually always, the presence of obsessiveness behaviors among a child’s pattern will be disclosed during the intake with the parents. In anticipation, I could have changed the sequence of drawing and have the child draw a picture of themselves first, the picture of anything they wanted to draw second, and saved the family picture for last. If the child leaves out features, then guide them to do fill in, starting with themselves. Then perhaps help the client pick out affects for each family member, and if needed, help them with their depictions. Then they could even develop a story about a family experience or adventure, and draw in a background. If the child is OCD-like, is accepting of me, and is invested in the drawing, this clinical intervention will begin to expand their sense-of-other, and set a precedent for doing so later in the therapy process. The problem is that the parents won’t see the unadulterated family drawing, but that’s a trifling matter.

The second approach is to incorporate drawing into arranged individual time with the client during one or more sessions. The process could also include some kind of gently guided story-telling done by the client, including the creation of facial expressions, activity, and movement. That may distract from the conjoint process, but again, if other-awareness is enhanced, missing some conjoint time is a worthy sacrifice. Or perhaps his or her drawing and story-telling could be incorporated into the conjoint process itself.

Other Points About Family Drawings:

These are common observations that were usually of interest to the parents.

Size distortions – I think these are usually the product of children under 5, and not seen much in 5 and up. They do have significance, but the clinician almost necessarily has to have parental input to determine what might be driving the new client to do so, personality or experience. The clinician’s role is to help determine if anything needs to be addressed, or if whatever the meaning to the child may be will simply dissipate with age and maturity.

Missing family members –  Separated parents, one or both of whom are in another relationship, can complicate this drawing for the children, particularly true if either or both parents have homes with children of the parent’s new partner. In my experience, the kids didn’t ask me something like ‘which family to draw’, so they went ahead and drew what they felt was their family, as per the instruction. If concerns arose on my part, again this would be addressed with the parent(s). 

Extra characters beyond extended family members  – uncommonly occurring altho that did arise here. The boy who drew an additional ten characters was the child previously diagnosed as RAD. He was certainly acting out, could be violent, scattered in his verbal interactions, impulsive, and socially inept, but the family history was negative for disturbed, chaotic, neglectful and/or abusive parenting. The identified problem behaviors did suggest an RAD-type picture, so his family drawing was intriguing, again in hindsight.

“No friends” came up three times in this cohort, not really surprising given the self-absorptions involved. That social state is often poignantly painful for the parents, and can bring out a depth to their individual and sometimes relational pain. Working toward an improvement to that parental sense of responsibility, feelings of guilt, or, sadly, blame on the spouse. The parents are apprised of that. “That must be difficult for you” is an easy entry point.

Picture of Oneself Doing Something

Again, the function of these drawings in the context of their assessment is threefold. First is to gather evaluative information in the anticipation of the following summary-and-recommendations session with the parents. The second is help create an atmosphere of familiarity and hence comfort for the new client. and the third is to facilitate the clinical relationship with the child by being there observing and interested, asking the occasional question, and remarking positively on what they have accomplished.

Because drawing is a major communication medium for a child, almost all these new clients are comfortable and even excited at the prospect. That helps with the development of trust and a clinical relationship, and the drawings add to clinically relevant information. The vast majority of these young clients were unhesitant as they began these drawings. At least in theory, their ease could be attributed to a normal child’s use of drawing at an early age to communicate with others. The child usually discloses to the parents about their drawings on the way home with some vigor, which helps the parents’ trust grow. The artwork is also a medium of reporting to the parents in the summary-and-recommendations session. Because of the latter point, I maintained an observer’s posture during the drawings.

The particular tendency to have missing bodily features continued into the self drawing, and thematically the second was usually a continuation of the family depiction. Coloration tended to be brighter and the pictures a bit more playful, their expansions presumably because they were getting more comfortable.

Picture of Anything

These drawings of the client’s choice were usually the most animated. By this time in the exercise, the youngsters are more comfortable and willing to spread their wings, so to speak. The contents run the gamut from space battles to gliding underwater. Unfortunately, as per the demographics of the practice in general during the last few years, the drawings are almost all by boys. With a couple of exceptions including the 6 year old who struggled to get much of anything drawn in the family drawing and couldn’t/wouldn’t continue, the artists were eager to narrate their stories.  The reactions, explanations, and color commentary by the parents in the next session helped lead into discussions which in turn led to treatment plans. 

Please remember these are almost all OCD-type clients. Examples of their work are as follows:

A 6 1/2 year old boy narrated his ‘anything’ picture as he drew, describing the volcano that was spitting out volcano balls (red fireballs) with two characters below, one of whom was doing flips because he liked volcanos and the other who tried to get into the volcano and “was spat out on fire.”

A family having dinner at an outside table with father cooking nearby at an elaborate grill that he made himself.

A space battle between good guy ‘Lightening’ and bad guy ‘Storm’ , shooting lightening bolts at each other as the good guy smiles and the bad guy frowns

A high school football field with bleachers by a boy who watches his older brother play in real life and he wants to play football too when he gets older

A space monster eating a spaceship

Swimming low beneath the surface with hair flowing and a big smile

A long squarish building with windows, an outside table, and a chair as smoke came out of chimney, no people, a picture with which I associated an Eastern European barracks out of which the boy was adopted. That attuned most precisely to the parents’ spoken concerns about loss and possible trauma.

The last one is example of the clinical material that can be generated by any one of these pictures. The drawings of ‘anything’ probably generated the most discussion with the parents in the next session.

Observation About The Drawing Exercise…In Hindsight

The pattern of the clients moving from a relative conservatism in the family drawing to a lighter, more artistically expressive picture of themselves, and then on to a more elaborative and sometimes narrative picture of whatever they wanted to draw was intriguing. This tiny bit of growth as they swept through these drawings could be seen as evidence of a burgeoning competence and independence, in a way a normal evolution through a new situation.  Half of the ten in the obsessive group demonstrated this progression, as did five of the affective eight.

Whether this represented a pattern or was a random novelty remains to be seen, and then the problem of meaning would need to be addressed.

Recognizing and understanding patterns of clinically relevant change, particularly those involving clinical gains, is a core element of developing and continually improving a therapeutic process. To recognize a pattern, obviously one has to notice, and this I did not until reviewing the charts of these eighteen  6 – 8 year old clients. As inferred earlier, I didn’t notice the relationship between missing identifying bodily features and the use of constricted coloration with obsessive young clients until now. Would that have made a difference in their treatment had this been known? I think absolutely. To spare myself, the number of times 5 – 8 year old children with obsessive concerns were seen for an assessment over the thirty year course of the practice may have been as few as 3% – 4% of the thousand children seen. An N that large would likely be needed to validate a significance. To be honest, though, I’ve used patterns to notable effect with lesser N’s. 

Other Evaluative Tools

The analysis of this OCD-ish group leads to the notion or hypothesis that a young child’s obsessiveness detracts from the development of other-awareness, something that can be addressed systematically in either individual or family therapy. Understanding of the ‘other’ was an intrinsic element of this therapy process, and did help with increasing a sociability that would have – almost surely did – reduced obsessiveness. If the clinical work facilitated the sociability of a client, i.e. having friends, the total obsessiveness would decrease if for no other reason than less time alone. Six of the ten in the obsessive group show social improvement, and two others began to evidence a progress in that direction before terminations in less than ten sessions. The following evaluative tools leant to that kind of process.

Note: Most commonly, three of these four evaluative aids were commonly used per child, two if the depression-anxiety inventory was used. Which ones were a matter of choice at the time. The feeling identification was used more often during a family session. The Talking, Feeling, Doing game was occasionally used asa regular activity during an individual therapy.

The Depression-Anxiety Inventory, Etc.

The depression-anxiety inventory, self concept scale, and ego development scale were occasionally employed with clients under 9 if need existed and the child’s capacity to do so having been demonstrated. The socio-moral was used very sparingly with this age group, and even then much later in the process. Perhaps this was underestimating the child’s objectivity and the parent’s faithful tolerance, but the Heinz Dilemma’s content of cancer, penurious insensitivity, and subsequent stealing seemed a bit much. 

The Feeling Identification Exercise:  

“OK, so there are five basic feelings that everybody has. It’s what makes us human. I’m going to ask you to name them, and what I’ll tell you is that you’ll be able to name three of them, you might be able to name four, you’re not be able to get all five, but I’ll help you.”

(Arguably) the feelings are happy, sad, angry, scared and guilty. Through the entire age range of the clientele, a large majority would identify happy, sad, and angry without difficulty. A handful of the thousand child and adolescent clients could not identify anger either. Maybe 7% – 8% would list “scared”. A very small number were able to identify “guilty” as well.

More often than not, this exercise was saved for some fitting moment in the first three therapy sessions (fourth, fifth, and sixth overall), but for younger clients I sometimes  to do this with them in the assessment. When we got into doing this in the first or second family session, I’d tell the youngster to let the others guess. Knowing something that the others didn’t would set them off into smiles and sometimes laughter as the others in the family struggled…and the others did so, just like all the kids.

The exercise also prepared the client for one aspect of being interviewed. If I asked a client how they felt about something that happened, and they answered “Well, that just wasn’t fair”, I would say “Well, I understand, but that’s not a feeling, so try it again and think about those five feelings.” Kids would catch on quickly, and that helped with both the maintenance of focus and pace of discussion.

Toward the topic at hand, this exercise may have a clinical value beyond facilitating the therapy process in and of itself. Developmentally, the basic personality is in place by age 5. Some standards say age 2, others later, but a general consensus is certainly by 5. They have moved beyond parallel play and are now engaging in friendship play in all its joys and struggles. Certainly by age 8, their social thrust is toward fitting in. The obsessive sub-population of 5 – 8 year olds is clearly struggling with this developmental task.

Where the statement “everybody has these five feelings…it’s what makes us human” is already presumed by most kids this age, for obsessive-type kids this may be an entirely new concept, i.e. “I have these feelings (they now know this as a result of going through the exercise) and everybody else does too, so, I’m kind of like them (and we know “…kind of…” is true), but this education is step by step. Plus, the exercise emphasizes an undeniable universality; this is being human, and wedges that door of other-awareness just that bit more.

Story Telling Using Blocks

A local Starbucks was selling small boxes of eight randomly shaped blocks, presumably for  caffeinated table entertainment, quite a few years ago. I bought one for office to use with younger clients, and found they were intriguing to kids. In short order, this became the basis for another evaluative tool.

“So, what I’d like you to do now is to make something out of these blocks, anything you want, and then make up a story that uses what you created, or use the blocks in some way to tell the story”.

A Rather Notable Example

This is the first time I’ve met with Joe, a young 7 year old brought in by parents with concerns about ADHD, anxiety, compliance, and a tendency towards obsessiveness. Joe came in quite willingly, very chatty, very friendly. He asked a lot of questions initially, lot of facial expressions. He seems to grasp concepts reasonably well. He also seems to take off in any direction from one particular topic and can get very tangential. He may have difficulty picking up on conversational inference. Eventually he acknowledged that he was here to “chat about school and how it’s going”, and then went on to say that school is good. In doing so, he went through an entire day’s schedule. I asked him if he had problems at school, and he replied “Can I think about it” and then talked about a reinforcement system they offer at school and then said “No, I don’t have any problems at school”. He has the ability to come back after excursions elsewhere. I explained what I did here and he then immediately started talking about a poorly behaved kid in school, so he seemed again to understand basically what was going on here, but had a hard time making reference to himself.

He does acknowledge the problem at home as far as bedtime is concerned and claimed he has a hard time falling asleep and is afraid of bad dreams. That would fit in with the overall picture.

I had him do the standard series of drawings. The picture of the family doing something was of a restaurant that was complete with tables, chairs, plates, wine bottles, windows, chimney, smoke, clouds, a sun, but no people. He used brown, blue, orange, and some yellow.

In the picture of himself doing something, he drew a picture of a playground with his two sisters on a piece of playground equipment and another unidentified kid beneath a slide, along with clouds and trees. He used gray, green, red, and brown. There are no facial expressions, no hands, and no feet. It was a nice picture with the exception of lacking of any sort of facial expressions and a somewhat young stick figure presentation.

Lastly, I had asked him to draw a picture of anything he wanted, and he drew a picture of a house with beds, a window, table, chair, smoke coming out of a chimney, and no people. It seemed mote like a barracks and it did make me wonder if this was some version of the place he lived while waiting for adoption in eastern Europe.

I then had him do the blocks and story telling. He initially made a path. He said the paths are for walking on. If there are no paths, you will fall down and not get a present.  And then he went into a functional description of paths which was very good itself, but didn’t tell a story. He then reconfigured the blocks and said it was a dragon in a faraway land, and inside the dragon was an egg and it popped out and then there were apples and then “it grewed up” and then the mother dragon said “You will have to find another dragon” and he found a girl dragon and “there was lots of fire in her tummy” and then there were more sentences about the experience of having a baby, and then there “was a big fire” and then “The End”.” The picture suggests some attachment kinds of issues, in addition to the apparent obsessiveness problems the parents had described  that may be worth talking over with them the following week. And ask about the dragon.

The activity is another way to acculturate the young client toward an expressiveness that aids our understanding of them during treatment. Ongoing issues can be highlighted and marked for clinical attention. As importantly, more elaborative material becomes available for the summary-and-recommendations session with the parents.

Again beyond an aid to the budding therapy process, this activity is also a lesson in parenting, one that emphasizes the interest that their child can generate with their own (probably special) creativity, and in doing so support and reinforce this perhaps developing ability. 

Matching Affects with Situations

Sometime in the early 00’s, I ordered two therapeutic games for young children on the spectrum from ChildsWork/ChildsPlay Inc. “The Understanding Faces Game” offered forty pictures of different children’s looks representing the gamut of feelings and circumstance. The child client’s task was to interpret the look. In the second game, “What Did You Say?”,  sixty situations that a child might encounter were posed, and the child’s task was to act out how they would react if they were in the situation. For example: “It’s pouring outside – what do you look like?”; “Your family is going on a great vacation – what do you look like?”;“You went to ride your bike but it has a flat tire – etc.”; “You are going to a new school and you don’t know anyone – etc.”; “You are staring but you don’t like what’s for dinner – et.”; You are worried about what to get your mother for her birthday – etc?”.

Neither game would be particularly helpful with my clientele, but when combined, they created a great game. I would distribute ten “Understanding Faces…” cards to each of us. Then one by one, I read ten of the situation cards. We would each present the Faces card that would best fit the situation, and decide between us whose card closest fit the presented situation. That card was then collected, as were all the rest, leaving us with nine cards left. Usually, the Faces cards between us would offer some reasonable facsimile of an appropriate response to the situations, and I would make sure both of us were in the game, the client ahead by one or two. The game ended with absolutely ludicrous faces for the last situations, and between the two of us we found these instances really funny. 

After talking about the presenting problems, what they thought and felt, how they impacted the client and family members, etc., just to establish the purpose and baseline of the process, the assessment sessions were really not particularly “heavy”. By this time the young ones were usually pretty comfortable. Having a game experience that offered the ridiculous humor kids this age generally adore is like icing. 

This exercise very directly works to expand other-directedness. 

The Talking, Feeling, Doing Game 

This is a board game designed by Richard Gardner, a well-known child psychiatrist in the 70’s and 80’s. Each participant moves their along a track with a roll of the dice. Most of the squares along the way are marked Talking, Feeling, or Doing. The player gets a chip if they answer the to the question posed by a card corresponding to where they land. The player who has the most chips when the game ends “wins”.

Examples of Talking cards: If you could make yourself invisible, what would you do?; Suppose two people were talking about you and they didn’t know you were listening – what would they say?; If you had to be changed into someone else, who would you be?

Feeling cards: What’s something you could say that could help a person feel good?; Tell about

 a time when your feelings were hurt”; Name a person you love very much. What does that person do that cause you to love her or him so much?

Doing cards: Act like a grown-up; Act out what you could do if you had magic powers; Do you believe there really is such a thing as magic?; Make believe you’re playing a musical instrument. What instrument are you playing. Why is it important to practice?

For the most part, the game was used during individual therapy sessions. One option was to have the family play during a session, but that was infrequent. rare occasion. This exercise was done if time remained in the assessment session. For this age group and regardless of their tech skills, the game does have a kind of timelessness, the questions are universal and non-controversial to most anyone, are educative, and can provide another source of assessment data to use with the parents. 

Having some option of this nature is helpful a child therapy setting, if for no other reason than the kids are interested in the clinician talking about themselves. For these particular clients with obsessive and isolationist tendencies, the give-and-take of interactive exercises like this directly promote other-directedness. 

One other factor to point out is that most of these young ones were not apathetic, displeased, negativistic, or in other ways avoidant in doing these evaluative tasks. With the occasional exception like the “RAD” child among this group of ten, a diagnosis that was to me dubious but nevertheless descriptive, they were active, reactive, interesting, interested, and capable smiles and the occasional laugh. All but two of these ten clients did show improvements in their behaviors and sociability, some just beginning on that track, but also some who showed  improvements to the demonstrable point that therapy was not needed, the parents wold manage. For OCD, this process may not have been everything, but clearly contributed.

Session’s Conclusion

Finishing the session was fairly simple when compared to the 9-and-up population.

The first question is “OK, so do you have any questions that you’d like to ask me?”

For the most part, the youngsters would shake their heads. “Am I coming back here?” was most common. Occasionally they might have a personal question which would be answered with a friendly dispatch. Rarely would they have clinically oriented question. Part of the reason for asking the question in the first place is to encourage asking questions.

The second question was: “So, I”m seeing your parents next week. Do you have any questions or concerns about that? “

Usually they would shake their heads again. The most common response, itself not very frequent, was: “What are you going to say?” The question about what I’d say led directly to the last point. 

The review that might take from two to four minutes began with a quick summation of the presenting problems and anything else in that regard that the client brought to my attention. Scanning the session notes while talking, something about the impacts of the problem upon the client would be covered. At least a couple of points about the clients strengths that were evident during the session itself, those that they could or would recognize as being a positive, were standard, necessary elements. Lastly, a reassurance, something like “I think I can be of help with the problems, and I’ll be talking with you parents about that, too.” And that would be it.

Harkening back to data mentioned in the previous post, two of the original 58 cases in this study dropped out after only that initial meeting with the parent(s). No cases dropped out after the client assessment appointment.

#47 – Assessment Process for Age 5 – 8 – Part 1

Assessment Process for Age 5 – 8 – Part 1

On Magical Thinking

From the opening paragraph of Wikipedia page on “Magical Thinking: 

Magical thinking is the belief that unrelated events are causally connected despited the absence of any plausible link between them, particularly as a result of supernatural effects. Examples can include the idea that personal thoughts can influence the external world without acting upon them, or that objects must be causally related if they resemble each other or came in contact with each other in the past. Magical thinking is a type of fallacious thinking and is a common source of invalid causal inferences. Unlike the confusion of correlation with causation, magical thinking dos not require the events to be correlated. In psychology, magical thinking is the belief that thoughts by themselves can bring about effects in the world or that thinking about something corresponds with doing it. These beliefs can cause a person to experience an irrational fear of performing certain acts or having certain thoughts because of an assumed correlation between doing so and threatening calamities. (Note: this entire Wikipedia page is a good introductory to the topic of magical thinking as a whole) 

Using Piaget’s stage model of cognitive development, the 2 – 7 year old is commonly in the Pre-operational Stage, characterized by wha Piaget defines as symbolic thought. Magical thinking is a component. With what appears to be considerable overlap, the 7 – 11 year old usually operates in the Concrete Operational Stage, characterized by operational thought. The subsequent stage covering adolescence and adulthood is termed Formal Operations and is characterized by the use of abstract concepts. Some children aged 10 and 11 years olds are capable of thinking in these terms.

Piaget writes about the psychological impacts of loss, trauma, and other upsetting events on this Pre-operational  bracket and how they differ from those reactions of people who are older children, adolescents, and adults. Again from the Wikipedia page, citing Piaget:

Due to examinations of grieving children, children of this age (2 – 7) strongly believe that their thoughts have an impact on the rest of the world. It is posited that their minds will create a reason to feel responsible if they experience something tragic that they do not understand, i.e. a death. During this age, children often feel they are responsible for events occurring or are capable of reversing an event simply by thinking about it and wishing for a change…Magical thinking is found particularly in children’s explanations of experiences about death, whether the death of a family member or pet…These experiences are often new for a young child, who at that point has no experience to provide an understanding of the event’s ramifications. A child may feel responsible for what has happened simply because they were upset with the person who died, or played too roughly with the pet. There may also be the idea that if they wished hard enough, or performs just the right act, the person or pet could choose to come back to life, snd not be dead any longer.

The vulnerabilities a young child may experience include a sense of responsibility when negative events occur to themselves or family members or friends. They may harbor personal remorse for the misfortunes of family members and friends that in reality have little or nothing to do with the child. They can assume that others certainly feel the same way that they do. Magic creates memorably beautiful experiences for the young child, but also produce an equally forceful dark side that can portend emotional struggles in the future, both near and far off in time. A good therapy can help.

The CBT-oriented family therapy approach to child and adolescent mental health assessment processes is usually a delineation of existing client problems, history, other previous and current   therapies, other mental health or relational problems among family members, and other individual or family life factors that may be impacting this new client. To the degree possible, the presenting problems are defined by the end of the assessment process in behavioral terms that can understood by the family participants and be measured in one way or another. Unless compromised by problems with cognitive development, the child provides important, objective assessment information for the therapist.

One could argue, with merit, that a secondary role for the therapist is to help facilitate the 5 – 7 year old child’s movement away from magical thinking and into a more realistic frame of reference. That objective could be sought in individual therapy, but family therapy is a viable alternative.The outcome data of this study suggests that 5 – 7 years olds improving to the same general degree as did the older youth. The family approach where the parent(s) are actively involved in one way or another to meet the client’s therapeutic needs was effective. Some kids were presumably still engaged with magical thinking at the outset of clinical work, and by the end of an effective treatment, they are thinking more objectively about the problems, the others, and most importantly about themselves. Even in modest gain, trust is enhanced. It takes a village, so to speak.

Beginning at age 5 and possibly as late as 8, the child attains the ability to objectively view themselves, describe their own thoughts, feelings, and behaviors, share their experiences and points of view, with degrees of accuracy develop opinions about the motivations of others and why sequences occurred as they may have. They may not be fully disclosing, or are shy, or fearful of new situations, or be initially distrustful, but what they can do in sincerity is participate in a reality-based assessment process by contributing information and experiences, given with a ring of truth to them. 

The 8 – and – older child may also acknowledge some responsibility for their problems, which they may or may not disclose, and can come to understand that others may have a different point of view to be considered. Human problems are almost necessarily overdetermined, a concept within which these concrete operational stage children can cope and avoid wholly blaming themselves. Magical thinking makes clinical approaches used for older children and adolescents assessments less feasible for many of these 5 – 7 year old clients. A different approach is likely needed for those who fall in the latter group.

In deference to the maxim “first do no harm”, the least desired impact of an assessment session  for a youth still engaged with magical thinking, s to reinforce their sense of perpetration or unworthiness. Lacking the objectivity needed to engage in frank and thoughtful discussions about self-and-others, they can answer probing questions about themselves and their families with some level of forthrightness and still end up feeling internally worse because their guilt or flaws have somehow been reinforced. 

About the Assessment

The two basic purposes of the child assessment are to inaugurate a therapeutic relationship with the new client, and to develop a cogent clinical understanding of the client to review and discuss with the parent(s) in the subsequent summary and recommendations session. With the older children and adolescents, coming to at least a rudimentary understanding of the new client during the initial meeting is primarily a result of the verbal information received from the young person over the course of interview. Secondarily, the subjective impressions formed through observing and experiencing the young person relate and act become part of the presentation to the parent in the following summary and recommendations session. 

Think of the assessment as having vertical and horizontal components. The vertical represents that portion of the interview dealing with the problems that the client is experiencing personally, including possible exploration areas of: the symptoms; length of duress; efforts to solve or resolve; adjustments or accommodations that impacts daily life; emotional, social, and scholastic impacts; various coping mechanisms they may be using; etc. The horizontal dimension could include a few elements of client’s environment: including: parents and how they impact both positively and negatively the problems the client is experiencing and the same for siblings and other family members; how the other family members relate to each other, including mother and father; interactions with schoolmates; expectations of teachers; and possibly even extra-curricular experiences. The interviewing is not formulaic. The questions are driven intuitively, based on the sufficient clinical training, supervision, consultation, and experience needed to conduct a therapy process independently.

The clinical intent of the younger child’s assessment session’s outset is to use the same approach as used with the older children and adolescents as far as possible.

For the older child, In Piagetian terms, the ‘concrete operational’ thinking typical for ages 7 – 11, responding to this kind of interview takes the capability of taking at least a basic objective perspective in which they can view themselves in the context of their larger environment. The session, at this point usually 25 – 30 minutes total, then moves from the interviewing into the evaluative phase preceding the conclusion. 

Some of the 6, 7, and 8 year old clients could meaningfully engage with the necessary objectivity to portray their realities accurately. The four 6 and 7 year old youngsters mentioned in the previous post who began talking with that first “So, what can I do for you? question could do so. Most clients this age, though, seemed less able to maintain that objectivity toward themselves as they answered basic questions, i.e. unsure, straying, timorous, hesitant, more inclined toward the uncomfortable ‘I don’t know’ response. 

Their transition from the more formal interview just described to the observational mode about to be outlined was usually comfortable.They generally enjoyed the tasks and play that ensued and began to offer more unsolicited, “chatter” during a game. The suggestion here is that their presumed difficulties with the usual objective interview was less due to discomfort and more toward inability. 

For the client age 7 and under, the relative degree of information coming from verbal information compared to observation and experience are effectively switched. With those under age 8, and the occasional 8 year old as well, the assessment is based much more on how the new client handles given tasks and the skill with which they interact. The particular tasks and activities used were chosen for their ease of implementation, the quality of responses received, and the interest they generated during an experience that could easily be anxiety-provoking. 

To Start

The assessment for the younger ones began with the same greeting, often kneeling in front of them for eye contact as they often remained seated while being introduced by their parent, and offer a short explanation of what was to occur while their parent remained in the waiting room. Once the child was seated on the office couch, that same opener of “what can I do for you” was used, which may sound bit ridiculous for a 5 or 6 year old save for two reasons. 

First, these younger ones did begin talking after that first question more frequently than their older counterparts. Four memorable young clients, two boys and two girls among the eight 5 – 8 years olds during the last three years of the practice did so. Secondly, among the benefits afforded by these first reactions was an opportunity to point out their precocity both to them and to the parent(s). Still, though, many were not sufficiently mature in their thinking capacities to help sustain a fruitful discussion about problems and issues, to wit and copied from the chart notes of the assessment session:

This is the first time I’ve met with Quentin, a 6 1/2 year-old first grader brought in by father and step-mother with concerns about oppositional defiant behaviors. Quentin was talking by the second question. He said he was here for “behavior issues” and “tantrums”. He says he gets mad and when he gets mad he starts throwing things, and then he gets in more trouble. He said that his family refers to him as “The Hulk” and “Godzilla” because he gets so angry. He says that at his mother’s house he has better behavior because they get to go more places. I’m not sure that’s the case. He said he gets angry when he gets in trouble because his brothers are “annoying” him, or when one brother is “bullying him”, and when people call him names. He talked about breaking a closet door. Punishments include going to the corner, going to his room, no video games, not being allowed to go to his brother’s room, toys taken away, and to sleep in the hallway because his bed is broken. He broke the bed by jumping on it after being told not to by his step-mother. He will also get punished for “lying”. He said he missed Christmas one year because he was in trouble and had been “bad at Mom’s”. I asked him how come he gets in trouble at his Mom’s and at his Dad’s but nowhere else? He said “Because my sibs bother me”. Then I pushed him a bit harder and he said he gets into trouble at home because he has “fun everywhere else”.

This very bright handful and youngest of four children in the family had a turmoiled couple of years following a split between his parents when he was a year old. Custody was initially shared with the children, going back and forth between his parents’ homes for a week at a time. His father became the residential parent when he became engaged to the current step mother, the mother then having every other weekend. Quentin’s adjustment was by far the most difficult. In hindsight, he was very likely engaged in magical thinking at the time of the therapy interview, still working out evident feelings of anger, but also presumptively from guilt and fear, neither of which were indiscernible day to day. By the end of a two year, full family therapy involving the six family members and covering multiple issues beyond those of the client, he had roundly improved.

The vignette is presented as an example of a cognitively pre-operational child in an assessment session. The initial part of the interview, which lasted maybe ten minutes, could have continued, but the result would likely be somewhat barren of detailed terms for the following summary and recommendations session with the father and step-mother. Hence the early shift into the next phase of the assessment interview. 

Into The Evaluative Portion

As a result of experimenting with younger clients over time, the evaluative portions of the older children’s session that included the depression and anxiety inventory, the self-confidence self rating, the ego development sentence completion, and the socio-moral response to the Heinz Dilemma were not particularly helpful. The tools could be used in select instances with the pre-operative children, but not very often.

For the 5 – 8 group, the depression-anxiety inventory was already collected from the parents during the intake, and the terminologies and inferences were often difficult to grasp. Again, one purpose of this interview was to begin establishing a clinical relationship, and going through the symptoms with kids this young was as likely to create more anxiety as not. The self-concept rating scale, most younger ones were confused by the ten-point self-rating scale for each of the six categories (behavior, intellectual and school status, physical appearance and attributes, etc.). Interestingly, I did give the self-concept evaluation to 6 1/2 year old Quentin, and while he rudimentarily understood the concept of the 1 – 10 scale, he rated himself a 1 in three categories and a 10 in the other three. That result would not be considered valid. As for the socio-moral evaluation, my tendency was to use the Heinz Dilemma for kids 9 or 10 and above. Those young people could adequately separate themselves from the Dilemma’s circumstance of possible death by cancer, where the younger kids ran the risk of internalizing.

The ego development sentence completion was regularly more frequently used with the youngest group. Answers ranged from the ego-development stages one to three, with one and two typical for kids in K and 1st Grade students, and two – three typical for grades  two – three students. Occasionally a level 4 answer came from an 8 year old, but none in this cohort. Responses with special qualities would generate a bit of unanticipated praise. The parents were also apprised during the next session, this time with an explanation of why and how the answer stood out.

Five other activities were commonly included during the evaluative portion with the pre-operational, which would typically take 30 – 35 minutes. They included: a set of three drawings, one of the family, one of the client themselves, and one of anything they wanted to draw; a brief feeling identification exercise; story telling; and one of two interactive games. Most child therapists have their own preferences, but for those who are beginning or considering this kind of work, these particular activities are presented as an example of an array. 

The family drawings in and of themselves could easily take up much of the remaining time, particularly with more perfectionistic kids. Getting to the interactive games occurred probably  half of the time, but on occasion with particularly anxious, wary youngsters, the interactive playing was inserted at the beginning of the evaluation or after the drawings. 

The most tangible source of information for the parents came from the three drawings the child completed. To them, their child at that moment is alive and talking as they imagine him or her at work. First and foremost, they could see for themselves the results. Virtually all the other information they receive is by word. The drawings provided a focus for observations about the child and family for all two or three of us, a conduit for an exchange of interpretations, insights, revelations, concerns, satisfactions, the uplifting and the sobering, and  emerging, new thoughts about their child and their situation. 

On Children’s Drawings in Therapy

During the same era as when Erikson and Piaget were developing their stage models concerning human growth in differing areas, Victor Lowenfeld published his initial findings in 1947 on the childhood stages of artistic growth. They are as follows:

Stage 1 – Scribbling, Age 1 – 2: Children at this age are engaged in the physical activity of drawing. There is no connection between marks and representation at this stage. However, toward the end of this stage, children begin to give marks names. This stage is mostly the enjoyment of purely making marks.

Stage 2 – Preschematic Stage, Age 3 – 4:   Children are beginning to see the connections between the shapes they draw and the physical world around them. Circles and lines may be described as people and objects that are physically present in the child’s life. It is in this stage that children first make the connection to communicating through their drawings.

Stage 3 – Schematic Stage: Age 5 – 6, where children have clearly assigned shapes to objects they are trying to communicate. There is a defined order in the development of drawing. Drawings at this stage have a clear separation between the sky and the ground. Often the sky is a strip of blue at the top and is a strip of green on the ground, and a strip of brown at the bottom. Objects are often placed on the ground instead of floating in space. Objects of importance are more often drawn larger than those that are of lesser importance.

Stage 4 – Dawning Realism – Age 7 – 9, at this age children are beginning to be more critical of their own work. It has become evident that a structured order to drawing objects is no longer sufficient. While a schema is still used to create drawings, it is more complex than in earlier stages. Overlapping can be seen, and a sense of spatial relationships is more evident.

Stage 5 – The Pseudorealistic Stage, Age 9 – 11:  In previous stages, the process in making the visual art was great importance. In this stage, the product becomes most important to the child. This stage is marked by two psychological differences. In the first, called Visual, the individual’s artwork has the appearance of a looking at stage presentation. The work is inspired by visual stimuli. The second is based on subjective experience. This type of an individual’s Nonvisual artwork is based on subjective interpretations emphasizing emotional relationships to the external world as it relates to them.

Interpreting Meaning

Two parents came in with concerns about their two older boys, at that time aged 9 and 6. With them they brought their 2 week old baby girl, who laid quietly in her Moses basket at the Mom’s feet through out the first session. The family had moved from Europe a year earlier, and was now newly arrived in Seattle. The father was a working artist for a large tech firm and the mother remained the homemaker. The boys were both having social adjustment and academic performance problems at school as well as behavior issues at home. In particular, the mother was feeling overwhelmed. 

The process was 5 years long, entailing about 170 sessions all told. By the end, both boys were excelling in school in their particular areas of expertise, making friends, contributing to their classes, less defiant and disruptive at home, still with challenges, but their problems were now in the area of more ordinary. The baby-turned young girl was brought to most every meeting, She never sat in on sessions, per se. Once mobil and over time, she contentedly and imaginatively availed herself of most everything the waiting room play area had to offer. To her, coming to the office was just part of family life, and to her I must have been a family-like character of sorts. 

Around the age of 2 1/2, the girl began organized imaginary play, in this instance taking the few stuffed animals from the waiting room, bringing them to an office stuffed chair by a window away from the meeting area. The office itself was about 300 sq. ft., so she could play quietly and not be a distraction. But as a background, we could hear her talking to her little gathering, rearranging them on the chair, and continue talking just sweet, cute, sweet. She later began to draw on the dry erase board in the waiting room, and would make a point of showing us her work as the family left. I was impressed. She clearly had the father’s genes. And she was the nicest kid. 

She shifted from mothering her little clan to the building blocks on the waiting room carpet, fashioning a circular perimeter housing two and three block-high structures, presumably houses in her little world. We could hear her talk to imaginary family or neighbors or whoever they might be in her world, and she went through the same routine of showing us her work, this time as her family was leaving, session after session. Best background ever. 

Some time during the last year of the family’s therapy and now about 4 1/2, she came into the office from the waiting room where she had been busily drawing, and for the first time I could recall, she interrupted the session. She came up to my chair and proudly handed me a crayon drawing on a white page she had just finished, and with this lilting accent of her homeland said, ”This is for you!”, accenting the ‘you” with a rising intonation.
 

I looked at her work and was stunned, then looked at the father. He obviously didn’t know exactly what she’d drawn, or maybe he did but never gave on. He faintly smiled with raised eyebrows and a barely discernible nod, inferring a “See?” She had drawn the basics of a smiling girl with long yellow hair in a short dress, all with a degree of form and accuracy that could have come from an artistic 9 or10 year, but with her own indelible stamp. The legs were charicatured to more than twice the length of upper body, perfectly straight and parallel within shoes identically turned to the left. This was not drawing. This was art. She could tell I was impressed as I thanked her, and went back to the open-doored waiting room.

For the next maybe 10 sessions, over four or five months,  she repeated the routine like theater. “This is for you!” Her picture continued to improve though, the legs even longer, the clothing now colored, the facial expression a bit more detailed, the hair tied with a big red bow toward the end. If you re-read the descriptions of the 3 – 4 year old preschematic and the 5 – 6 year old schematic, she was so far beyond.

In ways, understanding meaning in a child’s art is a melding of several factors, to include: 

their particular developmental stage of art skills relative to their age; their own self-perception; their experiences, particularly as they relate to their being in a therapy office; their family history; the environment in which they are nurtured and live; when in the course of their therapy the art is being done; and, more broadly, what was going on in their world at the time. Events matter.

While all these points are largely abstractions, aided by an expertise, some things reasonably close to truths about the child can be learned and translated into the helping process.

Particular aspects of the child’s work come under scrutiny, for example the use of a color, facial expressions, who is or is not in the family picture, their portrayed sizes relative to each other, completeness of the body, the activity being depicted, and the composition of the surrounding environment. Particular mental health issues are said to be associated with specific aspects of a child’s drawing, ranging from depression, anxiety, and relational disturbances to what are contemporarily considered more brain-related disorders like PTSD and OCD. One unbeknownst and fascinating, to me anyway, correlation of drawing by those involved with the latter class of disorder cropped up in the context of research in preparing for this post, and will appear in Part 2.

In going through some of the on-line literature about assessing children’s drawing for the clinical purposes, a gleaning tendency toward conclusive certainty emerges, which taken literally can be troublesome. Like the global components of art appreciation listed above, clinical correlations with aspects of drawings are broadly based on observation, knowledge, and experience, and narrowly applied to the  case itself. They are opinions, and not the result of empirically-based research, at least insofar as I’ve seen over the years of perusing articles where the meaning of drawings is the topic. This does make a difference in how the information gained from the drawings is conveyed to the parents and subsequently processed by them.

Taking the vignette above and applying some of the assertions about the meaning as seen in a child’s work, the drawn character’s yellow hair, by one account read, represents the girl’s anxiousness, the red bow a representation of anger, and the exaggerated legs a fear of impending disaster and the ability to get away quick. None of those remotely apply to this child that I learned about from the parents and watched as she developed. 

Understanding the child’s drawings or specific aspects of the work like color, composition, likeness, or activity is a matter of the suggestive rather than the assertive.The correlation can be  reasonably linked, but quite possibly overwrought if fused. More importantly, sharing thoughts about possibilities based on experience and knowledge with both the child and the parents leads to interactive discussions and disclosures, which hopefully and eventually lead toward a mutual understanding and purpose. That process that stands in contrast to a professional declarative with diagnostic and treatment implications. To understand the child, particularly one who is troubled in some way or another, ’it takes a village’.

Managing The Drawing

The directive was simply, “I’d like you to make three drawings, one of your family together, one of yourself doing something, and last a picture of whatever you’d like draw. Here are the crayons, and you can use the table here (small rectangular coffee table between client couch and  the ancient stuffed rocker; crayon marks would come off the table with a little work, occasionally needed). 

I was generally quiet as they worked, may make a comment about something interesting or different that had been drawn, more along the lines of relationship building than gaining clinical knowledge. After they completed each picture, I would have them identify the characters and what was happening. Any further questions were casual rather than done with an intent to confer insight. At this point, the clinical relationship was more the forethought. Before they finished the assignment, I looked for something that stood out in an interesting way that could be brought out to bear and praised.

As I understand their role, art therapists will start doing overt clinical work with the individual from the beginning. They know what they’re doing, and usually in great depth. For me, doing overt clinical work during the drawing exercise was out of the question, which for many art therapists would likely be a planned part of their process. In some part, my interest was what kind of impact the experience of this first sit-down had with the client in and of itself, that being the most conservative kind of treatment. Suggesting a different way to feel about a particular situation, get along better with a sib, do something active to deal with anxiety, seek companionship when depressed, go to a safe place when angered, and so on with a thousand possibilities of suggestion could come after the next session with the parents and a treatment agreement reached. 

The child had known me now for all of maybe 10 -12 minutes, and I wanted to know more, facilitate the clinical relationship, and gain the parents’ confidence first. The support of that approach is that no case terminated after the child and adolescent interview, 56/56. What I did do during the drawing was keep notes on elements of the particular drawing that may have clinical significance as per the body of knowledge I had, done to review later, dictate notes, and prepare for the summary and recommendation session with the parents.

Noted Elements Of Client Drawings

Perhaps the major value of child drawings is in the discussions they can generate between the clinician and the parents in the subsequent session and thereafter. Diagnostic or interpretive declarations by the clinician of what one thing or another means in a child’s drawing can scuttle what could be an educative moment for both therapist and parents. The language used in this particular aspect of the overall assessment and treatment plan development is one of couching, i.e.: this often means…; this could possibly say…; what’s your take on this; have you seen this before; and in general working off each others thoughts.

Over time and with sufficient sampling, the following points are likely to arise in the drawing and become a note of mention:

Who is in the family drawing: For the most part, the drawings included the client, parents and other children. In cases of divorced or separated parents, the choice of the child is something of a dilemma, and several variations occur, including: the original family, as if nothing happened or if the parenting arrangement is evenly split; the home of the primary parent without the step parent, if one exists, or with the step-parent with their children, or at the other parent’s home and with their new partner and children to boot, etc. etc. etc.: I hesitated to explore with the child why they chose what they did during this particular question during the introduction session. The tendency was to accept the depiction as face value, and ask the involved parent what significance they may see. 

Who is left out: One can assume some kind of tension with the missing factor that could theoretically be explored with about why age the 8-and-under, brand new client left that person or people out, but again in this first session with the child, now perhaps fifteen to twenty minutes in, the strong inclination was to explore this with the parent(s). Some kind of history exists that is worth understanding, bu the parent is most probably in the better position to initially discuss. The therapist could aways get back to the child at a later time.

Extra, non-family  people in the family picture – This result was not common, and I believe often a manifestation of an already known cognitive issue, i.e. spectrum or other boundary-laden mental health issue, and reasonable to ask the client about the presences as well as addressing the question with the parent(s).

Presence of a yellow sun – Over time, I became more and more impressed with high-90%  frequency that a yellow sun would appear somewhere in the child’s drawing, usually in the drawing of themselves, but sometimes in the family picture. One not appearing at all was worth noting and leading to some kind of plan to explore the significance directly. In terms of the child I viewed the sun as an expression of being nurtured. I usually made note of the sun’s presence in the meeting with parents, providing that little bit of unanticipated reinforcement that doesn’t hurt.

Yellow streaked with orange – As per Lowenfeld, the presence of the sun is a personal extension of the child. Based on the uncommon happenstance, I believe a correlation between an orange streaked sun and a prevailing tension between mother and child existed. The tensions were likely already covered during the intake with the parents, and may or may not be needing mention. Discretion is a fixture on the therapist’s shoulder during these initial sessions.

Red and black  –  Predominant or significant use of red is widely considered to represent anger. Similarly, black is seen as representing depression. These two assertions seem have the most concurrence within the field of understanding children’s drawings, or at least the most commonly cited. When either or both of these appear in drawings, I did point them out during the following parents session. If anger and/or depression was part of the presenting problems, the parents would basically just nod, and we went ahead. If not, though, the question for them was what were their thoughts were about the suggested correlations, or were there other ways to view their child, and follow that track to some kind of working hypothesis between us. In other words, red being anger and black being depression were not presented as statements of fact, but rather an observation worth exploring and see where the discussion leads.

Baselining: A word for using the entire page, top to bottom and side to side. I heard or read  somewhere long ago that baselining was an indicator of a clinically significant anxiety, and found the correlation usually fit. Whether and how to address this with the parents is basically the same as that with dominating use of red and black above.

Relative size of characters: The pre-schematic 5 – 6 year old group are those most likely to have relative distortions of size. They did not occur often at all. When done at that age these were usually overlooked as far as the discussions the parents was concerned, unless one of the parents wanted to talk about their child’s perceptions, or when the distortion was gross. I can’t remember a specific example, that having occurred some time ago. The reaction was  more likely one of mild humor toward age normalcy than a knotted concern. The discussions that did occur must have had to do with fairly relationships, particularly as they impacted the client child.

Noted Elements – Missing Pieces and Constricted Coloring  –  to be continued on next post…

Thanks to Kimberly McMartin, MA, LMHC

Helped organize website, etc.

Clinical Colleague and Friend

#46 – HEINZ DILEMMA, ANSWERS, APPLICATIONS

Heinz Dilemma story as presented in this practice:

Once upon a time, a long time ago, there was an old couple, a man and a woman who had been married for many, many years and lived in a small town in Europe – (to the younger kids “you know where that is, right?). One morning they got up and the woman was feeling sick, which was unusual because she was always a pretty healthy lady. So, she and her husband went to see the town doctor. The doctor took her back into his office for a long time, examined her and ran a lot of tests. 

Some time later, he came out to talk with the husband. He said “I’m very sorry, but your wife has a rare form of cancer”. The old man was shocked, and he said “Well, is there anything we can do?” 

The doctor said, “Well, there’s only one cure for the cancer, and that’s a drug that’s been developed by the pharmacist in the town next door, so I’d suggest you go there and get the drug from him.” The old man said “OK, I’ll do that as soon as I can.”

The next morning he got in his horse-and-buggy and took the long drive down the mountainside to the next town. When he got there, he located the pharmacy and went in, introduced himself to the pharmacist, and explained to him that his wife had just been diagnosed with this rare form of cancer and the doctor told him that the pharmacist had a drug that could cure her and was that true?

The pharmacist said “Yes, that’s true. I do.”

And the old man said, “Well then, I’d like to buy it from you.”

And the pharmacist said “Alright. I sell it for $2000 dollars.”

The old man was surprised and he said “Gee, that’s a lot of money.”

The pharmacist said, “Well, I know it is, but the drug was expensive to develop, and I’m entitled to get some kind of profit out of it, so I only sell it for $2000.”

So, the old man  said “Well, I don’t have anywhere near that much money. Can I pay you as much as I can now and pay the rest as I can?”

The pharmacist said “No, I’m sorry, I only sell it for the $2000.”

The old man said “Well, I guess there’s nothing I can do.”

And the pharmacist said “Well, I’m really very sorry.”

And with that, the old man walked out, got in his horse and buggy and took the long drive back up the mountainside to his home, thinking all the way about what to do. That night, he drove back down to the town, and he broke into the pharmacy and stole the drug.

Now, the question is, should he or should he not have stolen the drug, and why?

Example Answers

Boy, 13 – “No, he could have done it another way” Stage 4

Boy, 12 – “Yes, it was wrong, so he should have stolen the drug because his wife might die”  Stage 2/3    

Boy 10 – “He should have because I wouldn’t let her die”. Stage 2/3

Girl, 9 – “No, the police would be arresting him and then he would go to jail and his wife would be alone.”  Stage 3

Boy, 12 – “Yes, he really cares for his wife and wanted to save her and didn’t care what was right or wrong.”  Stage 4

Girl, 15 – “No, he shouldn’t because he’ll get arrested and he’s not going to win in the end” – Stage 2

Boy, 14 – “Yes, it was OK to take the medicine because he cared more for what would happen to his wife than what would happen to him.”  Stage 4

Girl, 16 – “He probably shouldn’t steal it because if he gets caught it won’t do his wife any good and then she wouldn’t have him around, but if it’s the only way to get the drug, then it was OK”. Stage 4

And the winner is: Boy, 11 – “He should have stolen the drug because his wife had cancer and he wants to show that he really loves her and cares for her and that it was OK to steal even though others may have the cancer. He thought he had to because he doesn’t want his wife to die and he loved her. He may have a high price to pay for the theft because he may have to go to jail, but jail is only temporary.”  Scoring is  3 + 4  =   5++

Assigning a level value to Heinz Dilemma responses was often less than straight forward. With the child and young adolescent population, distinguishing between level 2 and 3 could be difficult, introducing a degree of subjectivity if the rater was required to score a specific number. Older adolescents were less problematic. As far as adults and higher functioning adolescents are concerned, one common type of answer is that ‘stealing the drug was appropriate because life is more valuable than property (or profit), a response that could fit either stage 4 or 6, but not really 5. That is something of a trifle when compared to the benefits of the exercise.

Kohlberg’s system paired the six stages into three broader groups, the first two stages being Pre-Conventional, the second two Conventional, and the last two Post-Conventional. My own interpretation coming from a developmental framework for the three groups is that: stages 1 and 2 focus on the needs of the individual, the first being a very concrete choice of good or bad, and the second exclusively focusing on the individual’s own needs; the Conventional third and fourth stages focus on self-and-other relationships, or how to act in ways that at least considers the needs and rights others, and the importance of obeying the rules that lead toward social order; and the last two stages of the Post-Conventional refer to moral decision making that was based on broader principals that stressed the importance of societal needs and conventions, and universal principles of justice. 

As with Erikson, Piaget, Hy, et.al., and other developmental theorists, Kohlberg’s view is that an individual’s moral development goes through an identifiable and sequential series of steps or stages that do not reverse, except as a result of cognitive diseases or disorders. The pertinent question here is whether effective mental health treatment, particularly of the young, can foster the growth of moral developmental.

The stages of psychosocial and cognitive growth as per Erikson and Piaget, resp., seem more biologically than experientially rooted, metaphorically being rivers that ‘can’t be pushed’. The effect of therapy is more one of enhancing one’s thoughts and behavior to make the experience of the particular stage in which the client is living more robust and satisfying to self and others. On the other hand, in doing post-testing on a small few long-term clients – three to six years in treatment – I did see concrete evidence of accelerated stage movement in Hy’s ego development, certainly in Piers, Harris’s self-esteem and self-concept, and at least a couple of memorable cases where re-test answers to the Heinz Dilemma had jumped two/three stages. These developmental areas can be impacted, not as a primary goal of treatment, which would have to be behaviorally and relationally rooted, but as a side benefit.

Using this overall Conventional construct, teaching and inculcating “useful principles of right conduct… and the distinction between right and wrong” (the definition of moral development via dictionary.com), can be seen in basic developmental terms. The individual first begins to develop increasingly sophisticated personal governors of conduct taught and shaped by parents, other family, teachers, and other caretakers. Then comes learning to recognize the needs of others and the ability to both accommodate and assimilate to solve differences, first through family and then out into the community, e.g neighbors, schools, social activities, teams, jobs, skill building, etc. Via education, experience, and general observance, the person comes to appreciate broader community needs and standards of conduct, and eventually develop a sense of universal principles of personal liberty, fairness, and standards of justice. At least in the abstract…as said earlier, some adults do not fully emerge from the pre-conventional state. A tarheted, programmatic intervention to improve or accelerate moral development, per se, is probably not necessary to achieve desired changes. 

Family therapy has a certain place insofar as ego, self-concept, self-esteem, and moral development processes are concerned, being the setting of first impact and the primary recourse, along with marriage or adult life partnership, for most people through life when in doubt about being or handling other’s moralities. The therapist becomes a guide of sorts just by doing the work well.

At the least, a family therapy would likely facilitate discussions about client issues bearing on ego development, including self-concept and self-esteem, and moral development, as defined above, personal self-care, responsibility, initiative, effort, honesty, trust, and other aspects of being. Getting along with others, recognizing another’s perspective and needs, learning to give-and-take, respect boundaries, being a classmate or a member, etc., can and usually will appear as sub-themes in therapies for children and young adolescents. As a young client’s social world develops, discussions involving their own thinking about how they are being perceived by someone else, and then by a group of others, and then a community of others occur with some frequency. These are also fertile grounds for therapies of many kinds. Post-conventional Stage concerns such as the social contract and the greatest good for most people and the universal principles involving justice and the ethics of obeying were generally not a source of discussion in a child and family therapy, but every once in a while….

The most direct impact of the moral development construct and the Heinz Dilemma task was the reinforcement value that was bring offered. That appeared in three basic ways. 

If the child is operating at a level that is two or more stages higher than their age would predict, that offered a great opportunity for me to praise and reinforce. Again, think of Johari’s Window. The parents get informed about the accomplishment in the next session, and they almost inevitably experience some kind or level of reinforcement themselves as parents. Presumably, the parents convey those feeling once again to the child when they get home. To be sure, this did not occur often, but could be powerful when evident. 

If the child is operating at two stages below, that situation also gets reviewed with the parents in the following session. More likely than not, that information at least reinforces their perceptions of their child’s strengths and weaknesses, and lends credence to their decision to seek help. Shoring up that area of cognition can be incorporated into the treatment plan as developed during that session. 

Possibly the best reinforcement to come out of the exercise is the parents’ awareness that their child took the Heinz Dilemma seriously. As parents, they are in the best position to read their child’s involvement just from the circumstance and quality of answer, and usually indicated so in one way or another. And they appreciated this entirely unanticipated display on their child’s part.

In hindsight, the Kohlberg’s Moral Development construct could have been used more frequently. Taking the specific elements of each stage as outlined in the paragraph above (beginning with “…using this overall Conventional….”), they could have been used as a template for a more detailed and comprehensive list covering the first five stages that could help focus discussion profitably and provide basis for suggestions and recommendations. An instrument like that may not have been used very often, but for a client that did seem to be struggling with socio-moral issues in age-appropriate manners, that could well have been a key for a few select cases that otherwise did not do as well as hoped. 

 

The girl whose Heinz reply was “no, he shouldn’t steal the drug because he’ll get arrested, and he’s not going to win in the end”, was a 15 year-old going on 30 going on 3, driven by id and impulse, seen for a couple of session stretches in between which she managed to close down a mid-major airport for an hour after racing away from security guards. She was living with a sincere father beside himself, minimal contact with mother who by description sounded like an immature Axis II-type. But the girl would talk, as much a release as anything else, likable to me, could make sense, and could demonstrate some insights in the right circumstance. Seeing me, at least for the time being, was sort of one of those circumstances. And then she’d be gone.

What could have been done, and wasn’t, would be to take that Heinz answer, have her identify with the old man, share an equivalent experience of disappointment, or two, or three, that she had had, help her take the ‘assimilate and accommodate’ tack playing the old man toward the pharmacist, work with that until she arrives at a reasonable place, and then have her apply the same approach to the one, two, or three circumstances she had found similar. That would be an example of using a developmental skill that is useful for stage 3 answers, and maybe help her stage 3 growth just a bit.

Instead, I just took the information and relayed it to the father in the next session. Too bad about being in hindsight. I did see the father three or four times over the next few years as she struggled, but seemed to have tenacity at the right times.

The 11 year-old “winner” was entirely different. When relayed verbatim to the parents during the summary session, his ‘answer’ became pivotal in understanding the family and the particular impacts on the client. He was the youngest of four boys, the other three being 14 -18 years old. His retired father had day-to-day household responsibility as the mother was a high level corporate exec. She did attend the intake and the summary, as well as two regular sessions. The parents were somewhat floored by the their son’s elaborate response to the Dilemma, he being usually quiet at home. His presenting problems at school of poor focus and concentration, disruptiveness, and a couple of tic-like mannerisms brought him into the office, but what became apparent during the debriefing in this summary session was that the client was getting lost in the midst of this toxic triangle formed by his three brothers. Those three were at each other with a certain constancy just below the line of unbearable.The father was a serious consumer of erudite writers from Dostoyevski to William F. Buckley, from whom he could recite passages, so the turmoil could grow from three to four fairly quickly, leaving the client to his basement bedroom. At least the “problem” was identified. Discussing the format options and in his innately conservative nature, the father insisted that the treatment be brief.

I said “10 sessions, then stop”, which may sound like hubris, but during my MSW practicum I learned how to do a time-limited brief therapy technique developed by Otto Rank (an ex-valet of Freud’s) in the 30’s, and used the approach in some 30 cases while working at the NPO counseling clinic in Everett. The method was of uncanny effectiveness. Still, though, this limit was a reach.

The cathartic event in this time-limited process is a reenactment of the presenting problem after the sixth session – most commonly before the seventh session – by the client. Such occurred here, as per the norm. My role was commenting to the client that the end of the ten weeks is coming and how did they feel about that. The boy was going to miss it and felt kind of bad, and was then asked if anything else that’s making him feel the same way. I’d like to say he wanted more attention from his father but that would be a maudlin script. He did talk in essence of concerns about the mother’s stress and welfare, and the father enthusiastically involved himself in a serious discussion about all three of them, father, mother, and son, what each of them needed, wanted, etc. reassuring his son but also making a couple of suggestions. And the client, who had been improving, continued to do so until termination. I’d like to say they lived happily ever, but follow-ups are verboten in Rank’s view, and my practice was not to do so anyway without some specific purpose to concern. The Heinz dilemma did become the catapult, though. And the father was happy.

Again, the personal concentration and thought the young clients almost universally gave to the Heinz task was impressive in and of itself regardless of the answer’s particular quality or stage.

#45 – CHILD ASSESSMENT SESSION

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.

Johari’s Window

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.

The Data

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.

Introduction

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.

Part 1

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)

Comments

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.

#44 – PARENT INTAKE SESSION

#44  –  Parent Intake Session

The Data

Out of the 58 parent intakes in the study group, 56 continued to the child assessment session. The two cases that dropped out called to let me know. Both were doing so for administrative reasons, one due to an insurance coverage issue and the other due to job loss. The fact they  took the time to call would suggest the problem was not the quality of their first meeting.

Calls of that sort did have a certain awkwardness. A reduced self-pay rate could have been offered. With space available on their calendar, many private clinicians would so so. The problem arises when the clinician also bills insurances for payments. Charging private pay clients at rates lower than those charged to insurances is technically committing fraud. 

The issue arose in a meeting of the state’s NASW Private Practice Commission in the early 90’s where a representative of Regence Blue Shield came to talk with us about insurance billing in general. All dozen or so clinicians present were relatively new to the business of independent practices. The session was going along smoothly until the topic of private pay charges being less than insurance billings arose. He said that doing so could result in required reimbursement to the company involved and possible dis-paneling. Social workers viewed the right to charge less to those in need bordered on the religious.

As one might imagine, a hue and cry arose, but the Regence rep was adamant. To his credit, he went back to check the policy at his office, and later wrote us to say that under limited circumstances a reduced fee could be overlooked. Taking that to heart, one reduced case at  time was my practice. A year or two later, I did hear of one clinician whose billing practices were part of an audit due to an unrelated consumer complaint. The outcome was not favorable, and he was required to reimburse well into the four figures, quite a sum in 1992.

On Engagement

Please consider the following list of therapist qualities that serve to aid and assure parents who are coming into the office to meet for the first time. Presume they are feeling both eager and  nervous. 

Tempered excitement:  about meeting someone new to your practice and introducing them to your own version of this therapeutic world in which you have certain faith.

Likes people, relates well:  Why someone who doesn’t like or relate well chooses this field is difficult to comprehend, but they are out there. 

Enjoys stories:  Obviously, every family is authoring a life story. As a clinician comes to know a family’s particular narrative or drama and becomes a contributor to help toward some happier, foretelling shift in direction.

Curiosity:  knowing more, digging deeper into the who, what, when, where, how, and why of the child-and-family’s dynamics, following both educated and intuitive leads, in doing so reflecting the clients back to themselves in ways that aid their growths.

Humility: If being invited into the intimacies of a family is not humbling, you might be in the wrong field. Compassion is every bit as important as knowledge. The first is validating and the second is instructive. Both are therapeutic.

Patience: Clients react more favorably toward recommendations when ready to do so. Tosome degree, change has its own schedule. Knowing what to do is important; knowing when to do is key. 

Equanimity: Evenness of reactivity toward the almost impossibly wide range of potential client thoughts, behaviors, and emotions is an ideal. Very few can universally handle anything and everything with calm presence and thoughtful response. How many times, particularly early in one’s career, do we re-think and re-think more some stressful situation to come up with an ideal perfect response. We do learn that way. Sometimes silence is best, even necessary, until the effective response comes to mind. In prolonged moments of head-down concentration, more often than not the client will fill the void. At first, taking and waiting that time takes courage. Then that becomes equanimity.

Boundaries: Keeping the relationship professional, meeting professional obligations, and avoiding making judgements about others.

Seek self-Improvement:  through the last day….

On Preparation

For my practice, not much in the way of preparation for the first session was necessary short of getting out copies of the disclosure and privacy policy statements and straightening out the waiting room. Times, though, were changing and have continued to do so quite a bit since.

Most clinicians now send out a disclosure statement and a privacy policy for the prospective client to date, sign, and bring to the first appointment, replacing the traditional read-and-sign in the waiting room before the first session began. Many practitioners now go further by including a form for general family information such as names, ages, occupations, schools, grades, parentage, others in the home, insurance company, and referents. 

Some proportion of the latter group send forms pertaining the presenting problem and history including past treatment, with whom, how successful, other outstanding problems and their treatment if any, etc. And yet some proportion of those, no doubt a distinct minority of therapists but equally no doubt getting larger, will send additional diagnostic inventories of symptoms and other clinically evaluative forms of their liking, everything to to be completed by the soon-to-be client, some returned in advance of he first session, and some all to be reviewed during the first meeting. 

As with most any other American business type of the past few decades, mental health practitioners too have been seeking efficiencies. The utility of having the information prepared in advance and in hand as the new client takes a seat seems obvious. However, the solution to a problem. Take that axion as an article of faith. To wit, the following is a rough analogy and thoroughly grandiose in scope, but nevertheless makes a point: 

Nicole Perlroth, the cybersecurity and digital espionage reporter for the New York Times, recently related a story she investigated in an MSNBC interview. An engineer for a small American city’s water department was sitting at the computer screen one morning, as per usual monitoring the town’s water flow. Suddenly, the cursor started roaming on its own. The engineer quickly discovered he had no control over the movement. The cursor moved to the site that controls additives to the water supply, and he watched in quite some horror as the release of lye into the system was increased from 11 parts per million to 111 parts, essentially making poisonous what was meant to be enhanced water quality. The engineer quickly took manual control of the system and reversed the command. Had he not been watching, a disaster could have easily occurred.

The culprit had not yet been firmly identified at the time of Perlroh’s interview, but was clearly a hostile force. Her most pertinent observation, though, was that in the midst of the overall national economic push toward digitization, most all water supplies had become managed on-line. Through that particular modernization, though, the water supply industry as a whole had not taken the necessary steps to secure the systems from digital assaults. This important safety feature had received little attention. The corollary here is that the solution to the problem of clinical time consumed while gathering core client information in session by having the client fill out forms beforehand does not take into account the underside of doing so, however incidental that may seem.

How clients, including the parents in this instance, relate with others is an integral part of the treatment process in child and adolescent work, almost regardless of the particular therapeutic modality employed. Some would say improving and repairing one’s relatedness is the most important component.The tenet being offered here is that the clinical relationship is enhanced when the clinician and the client are finding out about each other at the same time while together. Because relatedness itself is part of the treatment, the outpatient mental health clinician-client relationship is somewhat unique in the broad field of medical care.

At the start of the initial session in a traditional format, neither client nor clinician know much about the other. Regardless of how preternaturally composed the client may be, anxiety is present. The session starts easily enough with name, address, and so forth. The story then begins, sometimes detailing the uncomfortable, even the wrenching as the client watches the information being received while relating. You, as the therapist, like meeting new people, getting absorbed in the story, curious, and respecting the humanity involved as professional and client are each doing their part and learning about each other at the same time, all these elements being seeds of trust. 

What the client did not have was an additional worry – in a few cases frank suspicion – about what the therapist’s incontrovertibly preconceived impression of them had been. In most circumstances with these pre-intake forms, the sense of “I can work with this person” unfolds unabated. For an estimated 80% – 90% of new cases, all the form completion and document signing is innocuous and the different paces in which therapist and client come to know each other resolve in favor of trust. 

The other 10% to 20% would be the concern, those who have lower degrees of basic trust toward others with higher degrees of underlying insecurities, defensiveness, or even manipulativeness that shapes answers and thereby commits to a degree of false narrative, right from the beginning. Generically, these would be the Axis II – type troubles or their difficult-to-discern equivalents of the potentially difficult client. The start may be in trouble before the monitor is active, even before the inner office door is opened. Watching the therapist react in the here-an-now is more convincing that reliance on imagination. 

Just a suggestion – you might try doing this both ways, having some complete the clinically oriented form first, and then others complete them after the first interview. See what differences become notable down the road.

First Part – Basic Information 

As indicated above, the only information about the child and family came from the initial phone contact, and that was generally limited to the nature of the problem. Relative to knowing each other – usually not much – the parent(s) may have had more information had they researched this referral to me.

Whether one or both parents came to the intake was left up to the parents. Seeing how the family managed the first appointment was good information in and of itself. Also, I generally followed the notion that being directive when not really necessary could create more problems than not.

I had the parent(s) read the disclosure statement and privacy policies in the waiting room. The session itself began with asking if they had any questions about either form, and addressing any that arose.

All the family’s demographic information was covered in the first few minutes of the initial session, some times a bit longer in complicated family situations. The nature and content of the presenting problem and history usually took 30 – 35 minutes. The summary and business end of the session took the last few minutes. Once experienced at doing so, all could be done with relative ease over the course of that first 45 – 50 minutes.

Once addressing the occasional question about the disclosure and privacy policy statements, the session proper began with “So, let me get a little bit of information.”

What followed was gathering basic information, including names, address, jobs, referral source, and insurance coverage, which included the Pleistocene photocopying of the card. That was followed by information about the child of concern including, birthday, school, and grade. If a disparity between age and grade existed, that would be queried as to how and why. Next was about whoever else lived in the home, usually just sibs, if any.

Unless already established, the final basic information question was “And s/he is your natural child”?  If the answer was yes, the interview would move on to what was bringing them here.

Different family configurations generated their own specific inquiries at this point. They included families with step-parents, mostly step-fathers but occasionally step-mothers; single parents, almost always mothers; adoptive parents; the infrequent occasion of a family members as guardian/caretakers (a few including grandparents, aunts, or uncles, i.e. not many. Foster parents would have been interesting, but they tended to be funneled to agencies with state service contracts.

With a history of marital separation or divorce, right after the basic family and child information collections were completed, the question was posed to the natural parent present, again almost always mothers, “Could you tell me briefly what led to the divorce”? This is a pregnant question, happening in the first few minutes of interaction, likely unanticipated in the moment, and not to be underestimated. 

The answer most commonly involved one or more of adultery, alcohol, addiction, abuse, or abandonment. As irrational as the feeling may have been in the moment, a sense of shame anywhere from minutely and quickly passing to an unresolved omnipresence commonly seemed to get activated. Hence, the next interchange can generate something of value. 

The surface purpose of this interviewing at that particular junction was to get information about the ex’s formal and informal relationship with the child. The break-up itself could well take the rest of the session if becoming the focus, but this is simply the intake. Assuming the difficulty of the disclosure, the parent often paused before answering, poignantly always true if the precipitating events included physical abuse, only a small few over the years, but each gripping each in their own way.

When violent or particularly atrocious behavior was involved, the interview at the moment became unavoidably more complicated. The next question was how much the child witnessed directly, was within earshot, or afterward viewed the physical and/or emotional damage, and the impacts. One reason for doing so was an initial exploration of possible PTSD, still knowing little about the child. The second purpose was to engage with the abused, because the topic could be so hard. 

The next series of questions were more neutral, and one that was used for all cases involving separation or divorce. The focus was on the current relationship between child and the”ex”, including: where he lived; what he did for work; what his own relational status was at the time; what the custody or visitation arrangement was; how often he saw the child(ren); how often the child and father contacted each other; who initiated these calls or on-line communications; the general nature of the father – child(ren) relationship; and the current relationship between the two parents, at least from the participating parent’s perspective. 

When the mother’s initial reactions to the question of “what led to…” had been palpably distressed, particularly with a history of being physically abused, at the end of the discussion an acknowledgement, something along the lines of “that must have been a very difficult situation” was offered, and invariably got an assertive nod in return. For a small few occasions, that particular interchange often became a “moment”, an eye-to-eye, unspoken appreciation by the client of their own strength in the moment, the acknowledgement, and the relieving brevity of the interchange; and an almost visceral appreciation on my behalf of the client’s honesty, sincerity, extension of trust, and at the same time doing so without making overt and negative pronouncements about the abuser, as tempting as that might be, keeping his nature out of the interchange. To do so would a boundary problem, in this instance placing judgements onto someone about whom I know next to nothing about, a toxic breach of equanimity in and of itself.

‘I can work with this person’ can quietly go both ways.

After exploring the aftermath of the original family’s split, the attention switched to the step-parent, if present. A relevant notion, either an aphorism or the result of a study, was introduced: a child’s attachment to the step-father develops when they have been together as many years as the child was old when the step-parent entered the family. In this case, the term ‘attachment’ refers is a child’s sense of security that the step-parent will remain in their life.

The concept gained immediate attention, offering a new perspective from which the couple could view their particular situation, whatever it may be. In the instance of physical abuse, the step-father is immediately drawn back into the discussion in a specific, positive light, reducing the tension, something which he may have been doing all along. The subsequent examination of this step-parent – child relationship had the two adults interacting in a way that was usually helpful to their co-parenting, to my clinical understanding, and to the counseling’s viability itself. As well as providing good clinical information, the shift away from the disclosures of “what led to…” was a relief often approached with some relish.

Adopted Children 

The only questions during the intake were in regards to the circumstances of the adoption. They would generally include: what led to the decision to adopt, from where the child came; how old at adoption; to the best of anyone’s knowledge, what that led to the child being adopted; and any contact with either or both of the birth parents. Cases of adopted children were not that common. They represented 10% of this study group, or 6 of 56 cases, but that seemed abnormally high for a two year period. While the average number of adopted cases over time was never calculated,1 – 1.5  per year, or say, maybe 35 cases out of 900 – 1000 over the years seems more probable, maybe less. 

Without a concerted effort over time to track outcomes for adopted children, recognizing specific difficulties with case management for the group as a whole could be seen as difficult. Anecdotally, I had no particular impressions going into this study, i.e. they must have been like the general others. To add to the impression void, after licensed masters level clinicians were mandated to attend 18 hours of continuing education per annum following 1989’s licensing law, very few, if any courses concerning outpatient mental health treatment for adopted children were advertised by the major continuing education outlets. I have a certain faith that at least one such workshop would have been attended had they been advertised.

The problem here is that the work with this particular group of six turned out to be less than acceptable. For certain, three of the six cases were difficult from the outset. The outcome results of this group compared to the four other parenting configurations of the study as designed (Post 14), were unexpectedly low. Single mother cases were similarly low, but those were affected by a lower degrees of resources available to sustain a treatment process and a much higher number of Axis II – related issues among the ten fathers. Such was less the case with the adoption group. At least these parents had plus-adequate resources. The new thought about the work with adopted youth-and-family is that some core element was missing in the conception of treatments processes. Issues with attachment and detachment, or idealization and devaluation, or some other impactful shift or development within the basic mother-father-child triangle come to mind as possibilities.

The overall writing plan is to discuss a few sub-groups following the publication of the therapy process as a whole, one of which would be this group. The current intent is to enlist one or two outpatient therapists who are adoption specialists to help create the post. Hopefully the comments will be more salient than could be the case now.

One last group to mention, of which only one was in the study group, are those youth who are in the custody of family members other than the biological parents, again a very small but distinct group. The one in the study was a latter adolescent male in the custody of the grandmother. The father himself was deceased and the mother in prison. Most all of these cases involved significant parental disturbances and sometimes chaotic relationships between the caretakers and biological parent(s), a couple of which included extraordinarily bitter custody disputes. Therapy can definitely be of at least supportive help, but the external circumstances can make the sanctity of the treatment process tenuous, even in spite of good clinical relationships and demonstrable progresses with the client.

During the assessment summary and recommendations session where the treatment contract would be developed, the one stipulation regarding these sometimes legally complicate custody disputes was that I would do everything possible to would avoid becoming directly involved in any legal process. My input could be funneled through the guardian ad litem. The rationale was that becoming directly involved ran the risk of damaging the therapy process itself. The cases did not stop because of that stance, nor do I think played a factor in termination. Suffice to say, getting ensnared in messy or vituperative legal processes did not occur.

Part 2 –  Problem Evaluation

Two types of content simultaneously unfold in this portion of the interview. One is gathering information about the child and family issues, notably the symptoms, problem areas, and relational conflicts and abandonments. The second is the family narrative. While the formal function of diagnosing is generally done in a question-and-answer format, the story is more listening and providing prompting questions that would have the narrative continue. A third type of interaction would be doing clinical work itself, but in this intake session with this particular style that would occur only if driven by issues of safety.

Because time would run out long before both evaluative and narrative streams would run their course, given a choice between the clinical and narrative streams, my own inclination was to support the narrative. Covering a few areas of diagnostic information is enough to create a rudimentary intervention plan at session’s end, which is the central goal of the meeting. The narrative tends to get the family members involved into the flow, and helps establish a desired clinical environment for the on-going process that follows. One could argue with wide concurrence that the interview itself is therapeutic, but the deliberate pursuit of change except regarding issues of safety can be seen as premature and even disengaging if the client is not sanguine with the “help”. 

Not necessarily in order, the clinical information sought could include any few of the following:

The precipitating event leading to the search for help

Current symptoms of depression, anxiety, behavior, and other less common diagnostic categories 

Current problem areas of the client, including family relationships, school performance and behavior, social relationships, and community issues such as patterns of misbehavior, mischief, disturbance, police/legal attentions, etc.

Past client history of clinical and other personal problems

Previous treatment(s), results, reasons for termination

The youth’s reaction to this new attempt to obtain help

Other problems, stresses within the home including sib relationships

Impact on marriage or, for the single parent, impact on mental health

A necessary addition to this list developed over the past few years is specifically asking about possible trauma in the client’s history that might help explain their current status. If any benefit came out of the post-9/11 mideast wars, that might be the transfiguring increase in our cultural awareness and professional understanding of trauma and the difficulties of recovery.

Most importantly, deal with anything dangerous or critical and beyond the scope of clinical advice at the moment. This situation hardly ever appeared in my practice, which itself was likely tame compared to others in less resourced communities. In that event of an on-going crisis, the immediate goal is to suggest or refer to the appropriate community service for more immediate attention.

Given the task at hand is to assess, part of the intake process was observing the parents as well. My tendency was to simply follow their customary way of managing a situation, in this instance with an inquiring third party, and not attempt to manage their mutual communication process or style

Every once in a while, the parent who responded to “what can I do for you” would continue to answer everything and continue to do so until the imbalance had become almost dreadfully apparent. With uncommon exceptions, the other parent included themselves within a short time after the opening. But with the monologically-inclined, at some point after maybe 5 or 7 minutes that feels like 20 – and I can think of one that took more than 10 minutes that felt like 40 – I’d give a friendly look toward the quiet one and say something like “would you care to comment?”  At that point they would start, maybe a bit abashed, maybe smiling at the mild effrontery. 

Exactly why the precipitating pattern existed remain an unknown at the time, and under these circumstances one can assume the in-office behavior was not unique. The imbalance was certainly noted and at some point in a later therapy session would likely get addressed. By then, the silent partner was usually talking and initiating more normally. The pattern had been noted, underscored thrice on the note sheet. Why the difference between the quiet beginning and being more involved later would become the topic of inquiry that I would inject. The question initiated a look at an evident positive change that would likely serve as a reinforcement. In essence, this became a CBT-like approach – wait for the opposite behavior to manifest, examine the before and after, and reinforce the emergent behavior.

This is going into too much detail, but the notes were patterned as well. The clinical notations took center page, which made the dictation easier and more fluid. The relational and other narrative aspects of the interview tended to be kept on the side margins, and usually formed the outline of the treatment plan above and beyond the clinical objectives.

Part 3 of Intake Session

The transitional question from the problem description phase to this conclusion time was “Is there anything else you think I need to know”? Usually, that receives a shake of the head, but occasionally that ”one more thing” is expressed following a few seconds of deliberative consideration. Whatever the question may be, some kind of clinical meaning that may surface later in the process may make a sideline note worthwhile. 

“OK, so what kinds of questions do you have at this point?”

In a sense, the question foreshadows the regular session routine. At the beginning of a therapy session, the opening question was “What can I do for you today?” and the signal to wrap up was “Are there any other questions you have today?” This was true for at least the first few sessions. Processes often transmuted into their own form, as each has differences or uniquenesses, but this is how they began.

One good reason most disclosure forms include a 5 minute elastic clause to the length of sessions, e.g. 45 – 50 minutes, is that how many questions the parent(s) may have toward the end is almost impossible to predict, and the least desirable type of conclusion is hastening a new client out the door. After a while, the therapist has a clock in their head, intuitively knowing when to move from section to section, whether to anticipate a couple or a litany of questions, and how to expediently wrap up. 

A fair proportion of new cases don’t have any particular questions at this point, and ask or in some way indicate the question “what’s next”? The short answer is confirming the assessment session with the youth, answering what questions or concerns they may have about that, and then move on to remaining administrative details.

Among the frequent questions at this juncture are the following, in no particular order as to frequency: 

The occasional boomerang was “What do you think?”, almost always the father when the question infrequently appeared. The real question is whether their particular situation belongs in this practice, and was answered in that vein, i.e. along the lines of, ‘these kinds of problems have been seen here before (or are common here), but I’d need to see your (child, adolescent, boy, girl) to confirm that.’ I don’t recall anyone asking about success rates. At least in my practice, the assessment session usually demonstrated some kind of effectiveness in and of itself that made the question moot.

“How do we prepare Joey for his session next week?”, mostly raised by the mother when it, also infrequently, came up. The response was to ‘share with him/her what your own experience was here, field any concerns or worries he or she may have, and assure that you’ll be in the waiting room while they’re in the office’. If the youth is a balky adolescent, what I said was “I can’t do anything to get him into the waiting room, and it doesn’t matter what his demeanor is, but once here, things will be fine”, and that was true. For a younger child, “you might want to bring him in a few minutes early to play with things here or draw”.

Particularly for children but generally applicable to adolescents, if they build with the blocks or draw on the dry erase board, I ask them to leave their work, and ask parents to do the same while leaving the office. Sometimes others add to their little work of art, which is kind of fun fo all concerned.

The most frequent question was probably “what do we do about X problem.”As stated earlier, my tendency was to avoid clinical work per se until after a treatment agreement was reached toward the end of the third, summary and recommendations session with the parents, meaning that clinical work per se would begin more formally in the fourth session. However, they are asking and the clinician has to respond, so I would start with “What would you normally do?”, and riff off of that, making suggestions that would alter here or there their own tendencies. That approach included cases where suicidal ideation was extant. 

With that particular issue, this broad brush approach may not longer be professionally feasible. When a particular mental health disorder gains attention as an epidemic or national hardship generating intensive psychological research and treatment development, clinical approaches can evolve into community standards of care that unofficially need be met by the practitioner. Such may be the developing case with S.I. As a clinical professional, staying up to date on these community standards through on-gong collegial relationships, consultations, continuing education, and independent reading is helpful.

“What if medications are needed”? That question rarely came up during the intake, and in those uncommon circumstances when it did, the answer was deferred to the third session, after the youth had been seen. I will say that the question of medications in the first session almost 

never came up 35 years ago, but was surfacing, say, 1out of 20 or 30 new cases by 2010. That kind of percentage has likely increased since.

Lastly on this list is “How do you treat this kind of problem”. This was almost always answered in terms of format rather than school of therapy or detailing a process. The question was whether to pursue a therapy with parents and client together, parents and all children together, split sessions seeing client and parents separately during the same hour, or seeing the youth individually with occasional parent meetings That response sufficed.

Administrative issues such as fee payment and releases were usually held off until the end of he summary session. 

Scheduling was reviewed and altered if necessary and possible. 

The parents were also alerted that a second assessment session with the youth may be requested before the summary session in the event that the full assessment could not be completed, and that this  was not an indicator of severity or difficulty. In fact, that happened maybe once a year, but did occur. 

Does the parent(s) feel comfortable managing their youth between now and the next session? If not, are they aware of community resources that they can rely upon in case of emergency? Do they know you may not  be available on a 24/7 basis, might not be able to field a call for hours or even one business day? Personally, my disclosure statement indicated where to get emergency help, and that return calls may take up to  business day. I got maybe 3 or 4 emergency calls in those 30 years, and the practice was none the worse for the wear.

“Are there any other questions you have for today”. If any are asked, they get answered and then:

 “I’m looking forward to meeting your boy/girl.”

#43 – ORIENTATION AND INITIAL CONTACTS

On The Theoretics

My first professional role model was one Mary Rygg, MSW, among other roles in her life a volunteer counselor at Karma Clinic. The service arm of Everett, Washington’s non-profit Drug Abuse Council in the early 70’s, Karma was a takeoff on the Haight-Ashbury Free Clinic, providing help aimed primarily at “street youth”. In reality, the NPO was a subsidized community service that provided counseling, medical services, an off-hours crisis phone, and the occasional “flying squads” of young volunteers that went to a home situation screened by the clinic’s 24 hour  phone service. I went on occasional flying squads. As assistant director but like most everybody else working and volunteering in the place, I was in on-the-job training.  Later in my career, I came to understand the flying squad service to be borderline crazy, given a couple of really sketchy situations encountered. But we were young during an expansive era, and we were a part of the broader ‘movement’, so to speak. On the whole, we did good work.

Mary, on the other hand, was as straight as could be. At that time in her late 50’s, she was a faculty member of the UW Hospital’s Division of Child Psychiatry field training unit, Clinic 10. Beginning in the late 50’s, she was an early student of Satir’s, and became a field instructor for her, becoming one of Satir’s so-called ‘Beautiful People’. Mary was also particularly concerned about the drug abuse problem at the time, something that had struck her family, hence her involvement at Karma. We as staff were particularly fortunate.

In one of those impromptu, free-hour lessons, Mary talked about the different way Satir viewed the etiology of mental health problems. Now referred to as circular reasoning (see Wikipedia entry on Family Therapy), the belief was that dysfunctional patterns of family interactions were pedominantly responsible for the creation of most mental health problems, this in contrast to the professional standard then and now that problems were the result of individual psychology and experience, a.k.a. linear causation. To the circular causation way of thinking, family therapy was the most logical approach to mental health treatment – change the dynamics of family interactions in a guided setting, facilitate healthier interactions, improve the mental health, and diminish the “problem” behavior, mood, and/or thoughts.

For us boomers, the era of the sixties through the mid-seventies was the pursuit of a social reformation on a grand scale, now viewed by many if not most as quixotic, but at the time we were dealing with a thoroughly ghastly war in addition to wide discriminations and gaps in social well being, so something deep must have been amiss nationally. Many of us working in mental health were drawn to the alternative. 

As an extreme example, popular Scottish psychiatrist R.D. Laing, who at some point touted the healing properties of LSD and thus evolved into something of an icon to the counter-culturalists, postulated that an individual’s schizophrenia resulted from seven consecutive generations of double-binding within a family tree. At Karma, we doubted this based on our experience with a couple of local schizophrenic kids who hung around the clinic’s living room. So did Mary, but the more general notion of family communication issues as the major contributor to mental health problems struck a chord and we absorbed to be better at what we did.

Mary conducted a few planned in-house trainings on Satir’s methods and her own extrapolations. We took on Mary’s beliefs. I began to dabble. In her role as a UW faculty member, Mary also conducted trainings for child psychiatry fellows and residents but included us MSW practicum students placed at Clinic 10 as well. I began to incorporate family work into my regular caseload maintained at Counterpoint Clinic (a staff break-off from Karma more dedicated to counseling per se). Like for most practitioners, an individualized method started to grow. 

In fact, clinical thinking based on linear causation theory remained the mainstay. The symptoms get identified, the diagnosis comes next, followed by a clinical formulation about what went wrong in the past, what might go wrong in the future, and a skeletal intervention plan. Then the interventions begin. Given that formulations are essentially hypotheses, re-formulation and adjustments naturally occur as more information emerges and more treatment has its impacts. Take the case as far as possible, learn, finish, and move on. 

Mary taught that the circular-type therapist gathers the family together and is “treating” at the very outset. Communication problems become evident and get addressed by mostly using experiential techniques. Change and Improvements are processed between the family members with the clinician’s assistance and guidance. The family stops or phases out when ready. 

I didn’t use that model in its full scope. Most every other training, supervision, consultation, and class taken were rooted more in linear methods of problem formulation and resolution. My own work used a family format to the degree possible and feasible, exhibited both linear and circular concepts approaches. Formulate, calibrate, treat the symptoms, address the diagnosis, facilitate more functional and closer relationships, recalibrate, and so on to what hopefully is a healing end. The circular reasoning approach is clearly evident in the on-going therapy.

Orientation To The Content

After leaving Children’s Hospital, the creation of a therapy process for private practice began. Without any specific intent other than continuing to do what I knew how to do from a half dozen years earlier, the task was to create something that worked for the clients and make a living. Maybe 90 – 95% was in place by ten years. The process was essentially organic – “a systematic arrangement of parts; organized; elements fitting together into a unifiedwhole” (dictionary.com).

To reiterate, all outpatient mental health therapy processes get individualized by the practitioner to one degree or another, particularly important because of the assumption that the clinical relationship is an intrinsic element of clinical work. The presumption is that a clinician functions best with techniques that have a demonstrable effectiveness, and perhaps just as importantly, something in which they have an abiding belief, something that feels good. The reader will hopefully take away information and techniques that can be incorporated into their own work.

As discussed a bit in the last post, repetition can be seen as a clinical aid or tool itself. If a clinician uses one tool or ploy often enough, how people react to the use becomes an evaluative element in and of itself. If the tool is used repetitively over time, the clinician can observe how the client changes their responses over time. Simply noticing that improvement to the client is providing random, unanticipated reinforcement, which itself is the most impactful type of reinforcement. And if a decline is noticed, the therapist can explore that in one way or another and help turn the direction around.  

This repetition quality is also a facet of a personalized approach. Not everyone is so inclined, The experience here has been one of appreciable effectiveness, not universal by any stretch but that’s for the geniuses in the field amongst us, and that I’m not.

First Phase Process Outline

The purpose here is to offer ideas and tools that have worked effectively, and not a comprehensive template of treatment process. Pick and choose.

The first four sessions evolved into a structured problem formulation process itself, along the lines of the linear model. In the first conjoint sessions, which include the fourth session, themes out of the circular model begin to emerge. Most of the intervention techniques came out of the behavioral school, as differentiated from dynamic insight or experiential models.

In this practice, the initial contact with someone seeking help was always by phone. Rarely would someone email or text about availability and other questions, although that may have changed substantially just in the past five years. Those who did so were asked to phone. Whether they did or not is an unknown since the situation hardly ever arose.  That first contact establishes the need and confirms that the problem(s) are within the range of my casework.

The first meeting is with the parent(s), and provides a global view of the family composition and history, the current problems, reckoning with administrative and logistical matters, and discussion of the overall process that would be anticipated. With the rare exception, the result is a verbal agreement to continue the work. The exception is when the parent decides not to continue, either based on the experience, a coverage issue, or some other clinical expectation that could not be met. 

The second meeting is with the youth individually, age 4 to 18+, for an assessment. What emerges is a picture of symptoms, a tentative diagnostic hypothesis, their perspectives, evident strengths, and an initial reaction to relational skills. The meeting establishes the problem baseline, and aims to facilitate a sense of calm and confidence for the new client who was usually nervous or wary at the outset.  

The third meeting is a summary and recommendations session with the parents. This meeting completes the initial problem formulation and establishes a consensual treatment plan. Some elements of treatment are quietly implemented during the discussions.

The fourth meeting is with the client, the parents, and other children in the family who will be participating, and is broken into two sections. The first elicits what each person wants to see “get better”. This activity provides the initial clinical baseline. In the second half, the family plays a game. I observe, may ask unrelated questions, get to know them a bit less formally, and perhaps coach a bit vis-a-vis the game itself. Based on the in vivo observations, the game activity also helps establish a direction in terms of relational work to be incorporated into my clinical baseline.

Except in the broadest of terms, the formulaic session structure ends at this point. The fifth (or occasionally the sixth) session begins the regular family therapy process. 

Helpful Prerequisites

In my opinion, four basic clinical skills and one educational experience are prerequisites to doing family therapy. First is the ability to establish a clinical relationship. The second is doing an individual assessment and formulating the problem for treatment. The third is comfortably managing a clinical session from beginning to end. The fourth is recognizing the need for consultive help. The educational experience would be sufficient training and/or observational opportunities to develop an assuring conception of one’s own case process.

Once comfortable in the family therapy setting, one will likely find that the format is easier and less taxing than individual work. In one-to-one, the therapist is ‘on’ all the time. Marital therapy involves a threesome, and any triangle has its own encompassing dynamic. There the therapist is also ‘on’, although to a lesser degree than in individual work. With families of three or more, the therapist eventually can sit back and just watch while the others interact, coming in when necessary to share observations, suggestions, or reinforcement. As the process develops, they often do so for longer and longer periods in session. That’s easier work, certainly less taxing. The side benefit of the conjoint approach is that kids will randomly laugh during the family time, and that can be infectious to everyone else in the room. Nothing else in therapy has quite the same effect, especially if the therapist somehow gets drawn in.

On The Initial Contact

Responding to a prospective client’s request for an appointment may seems like a routine and even mundane task. To those clinicians who have done so hundreds of times, that is most certainly the case. But no one really offers a script. So, this section is largely oriented toward the new practitioner in the world of private practice. Doing well from the beginning helps. Two considerations arise. 

Most new cases for licensed practitioners come from referral sources, a practitioner’s most valued assets beyond their own skills and attributes. Particularly for professionals, referents in general have their own clientele or audience to consider. One of their expectations is that something as routine as a phone call with a prospective client would be handled flawlessly, or at least beyond generating negative feedback from the referred.

The second consideration is the evolution of a clinical relationship. The first interaction, however brief and elemental, is the beginning of an orientation for the prospective client to your own way of working and who you may be. A new caller usually does so with uncertainty to one degree or another as they ring you up. Beneath the brief greetings and movement toward an agreement, the clinician is introducing her or himself. In doing so, they hopefully provide a sense of confidence and security that registers in some way with the client. How were they feeling at call’s end? If a person is calling a therapist for the first time, one can presume they do so with anxiety. 

After a comfortable and confirmative call, however brief, the prospective client’s attitude likely changes from uncertain to a genuine curiosity about who this new person may be, in a way sewing a seed of a trust. Trust itself sometimes arrives quickly, sometimes not for a while, for a small handful of adult clients not for years, but they can at least enter the office less anxious than had been the case when they rang up the number. 

Some aspects of private practice appreciate with on-the-job training. I was somewhat unprepared from the outset, not aware that the initial five years or so of part-time agency clinical work was insufficient in the way of orientation. Add to that under-experience an interim six years of medical social work that did not involve much in the way of on-going counseling at all and one could anticipate early on that an initial call would occasionally go awry. I hadn’t even thought about this, felt a bit humbled when the problem emerged, eventually chastened and then sat down to work something out. During that first year, a basic framework or routine emerged. After another year or so, as I recall, with more honing, a settled process  was in place. I don’t think any problem occurred again. The call may not necessarily have ended in an appointment made, but for reasons that were more functional rather than reactive. Understanding the pitfalls helps.

Offered here is how I handled first calls, in level of detail that would likely be of little interest to those who have their own way established. For anybody though, if in going through this relatively short text, some thing or things – anything, really – could be found useful – then the time spent may be of worth.

Returning calls to potential clients within 24 hours or by the end of the next business day is a preferable habit for two reasons, those being as a demonstration of commitment,  and supporting your referent. Unless factors of fame make this diligence impractical, expeditiousness is courteous and earns credit. Do so even with a full caseload, or have your phone message indicate that you’re not taking new cases. If you do return a call and full, have a name or two in mind to give the client, should they ask. This can be seen as professional courtesy. Try not to leave someone hanging. Particularly in the spring when child and adolescent practices are most likely to be full, I would field the occasional  complaint from inquiring parents that “no one’s returning calls”. If nothing else, returning calls not as a matter of business but rather as one of courtesy is good karma. The referent also does not appreciate “ X didn’t (or wouldn’t) return my call.”

After the caller’s opening “I’d like to make an appointment for my child”, a certain set of questions followed. In order, they included: 

“Could I ask where you got my name from?”  –   Knowing the referent may make a difference in accepting or scheduling a new case, and the tack with the new caller is a nice, neutral way of starting the conversation. 

“Could you tell me a little bit (or a bit more) about the problem?”  –   Basic information about the presenting problem obviously determines whether the case is within your scope. An adroit couple of clarifying questions may be necessary to make certain. A brief confirmation that what the caller described is within your scope may be given. I avoided the practice of getting into substantive clinical discussion that verged into the clinical assessment itself, and even into treatment interventions during these calls. This is only a screening.

“And is this covered by insurance?”  –   The insurance question opens the topic of charges and payment, and panel status if insurance in involved. The caller may be advised to double-check their coverage, co-pays, service limitations, etc. I didn’t make that call myself unless some broader question or concern existed about the insurance company, and then get back to the caller. That was rare.

Once those three questions are addressed, and so far this would take a couple of minutes at most, a description of the assessment process is shared, to wit:  “So what I usually do is see the parent(s) first to do the intake, then see the child in the second session to do an assessment and get their point of view about things, and then see the parents again to share impressions and recommendations. And then see where we go from there.” 

Infrequently, a caller would have questions about that three session process, most commonly  wanting an individual format for a latter adolescent. While that would certainly be possibility, the practice policy for a minor client was to see the parent(s)or guardian first. I could see an insistent parent pushing back with “why?”, but can’t recall any parent actually stopping at that point for that reason. I wonder, though, that in these past five years since retirement a reality has changed – that with the more individualized latter adolescents in combination with more stressed parents, pushback on that first session may occur. That being the case and discretion being the better part of valor, I likely would have adapted.

When the parent has accepted the general process, e.g. ’that sounds OK…” , etc., the next step was scheduling. While the process of scheduling is mostly a non-issue, the problem can be  when the practice is close to full. Most practitioners leave a couple of slots open for returning clients – the return rate in my practice was around 8 – 10% – that could be used for an intake in a crunch, but sooner or later most practitioners face the dilemma of no more room on the calendar.

The practitioner either lets callers know their practice to be full, uses a waiting list, or, with some frequency, won’t answer the call at all. That’s a problem, and you never know what you’re missing. 

During a typically cloudy November afternoon three years before retiring, I returned a call to a mother looking for a therapist concerning her depressed 12 year old son. I was full at the time, but inquiring calls were nevertheless returned. Before I could move beyond “Hi, I’m returning your call…’, the mom went into a two minute outline of the boy’s problem, which was of moderate concern, and a family situation of Gordian dimensions, all said with a certain degree of irony and drama that might inwardly crack a tiny fissure of humor within the most stalwart. When my turn came, I told her “I’m sorry, but I’m not taking any new cases. Her frustration erupted, not directly toward me but more upward toward fate, and with pique, “No one’s returning any calls! No one!! I’ve called a lot, and they don’t get back!!! None of them!!!! And then the first one who calls back isn’t taking any new cases???? (shrilly) W… t.. f…!!!!!!!.”  And she heard my futile effort to stifle a laugh at the routine, I couldn’t help it, just couldn’t. But now I was stuck.You can’t laugh at a client you’re turning away. She was listening, quietly. She knew it. She was smiling. I knew it.”OK, OK, I’ll get you in.” I came in an hour early a couple of days afterward. Three years later, she was one of the last clients I saw before retiring. The bright kid was more socially active and getting much better grades her husband/step-parent got worse and moved out but by no means left the picture, the high achieving younger sister, who had a mouth, demonstrated more self-control and gained more friends, her long-ailing dependent 85 year-old mother living 90 miles away still somehow survived with attention by her only daughter, and the family members were all still living on the edge financially, like broke, a challenging morass and the reader can’t be told the half of it. There was more. She herself wasn’t much different from beginning to end. All in all, one of my very favorite cases/people. That was one way to get in.

Once the practice recovered some ten years after the massive influx of newly licensed providers into the area beginning in 1990, my practice remained near full from mid-October through June of each year. Periods did occur where I had no spaces available for child and adolescent work. Complicating matters were school districts that became increasingly reluctant-then-forbidding to let students out early for regular appointments, this as curriculum management became increasingly structured and expectations of student learning attainments that dominated teacher’s annual reviews were more rigorous. Thus, therapy appointments had to be at 3PM and later. I could make time for 18 slots, working until 9PM two nights a week. During the busy nine month period,  appointment times were all taken maybe 50% of the time, new cases averaging about 1.3 new cases a week. Hence, a couple of times a month I’d get a call and all was full.

I tried using a waiting list during the late 80’s, Aside from being one more administrative function to track, managing the list created as many problems as it solved. The lack of closures was disconcerting, what with people not returning calls when something opened, etc.  Keeping a waiting list for a large group practice or institution is less problematic, if for no other reason than someone other than the practitioner manages the list and deals with their inherent dilemmas, disappearances, and discontents of the seekers. I did come up with an approach that worked, thanks to the overall regularity of the practice’s business cycles.

In this scheduling part of the initial call, I would first find out what would suit the parent best. With nothing available within that parameter, I suggested that they take the earlier or less convenient time for the first two or three weeks with the assurance that something more convenient would show up. While the average numbers of sessions per case was 29.3, the mean was around 15. Turnover was reliably close to one per week during the heavy nine month period, meaning that something was likely to turn up for the new caller, and I said as much. The unshared fact was that If something did not clear, I would extend one of the two shorter days in the office to 7PM, and accommodate them until something in the regular schedule did appear. I would also keep track of who on the regular calendar had the latitude in scheduling to switch themselves to a different time slot if I asked. This system worked well for the purpose, and did not take much time to manage. Plus I had the flexibility and my own family’s support, for which I have a certain indebtedness. 

The last element is dealing with any remaining administrative matters, in those few instances mostly clarifying billing and payment processes. Increasingly toward the time when the practice closed, sending forms, histories, and clinical inventories for the prospective client to complete or fill out prior to the first appointment inched toward becoming the standard of practice. I was never so inclined, for reasons that can be addressed in the next post on the initial parent intake.

The last question was “Do you have any questions you’d like to ask me now?” This was clinical foreshadowing, always encouraging their questions. For the most part, the caller said ‘no’. Occasionally, someone might ask a simple question about experience, particularly in the area of the child’s presenting problems, or clarifying some other administrative concern. The guiding light here was to be both gracious and brief. The important purpose was to establish an openness and my interest in their thoughts.

And then closed with “I’ll look forward to seeing you.” More often than not, the response was along the lines of “Thank you, me (or us) too.”

Two additional points.. …

If issues of safety become apparent during the portion about the client’s problem. The large majority of those situations involved suicidal ideation. The assurance of safety became the central concern at the moment. A discussion about resources, i.e. emergency rooms and crisis line numbers, needed to occur whether an appointment with me was made or not. Almost all those cases did not require those services, both then and during their time in therapy.

A distinction can be made between the caller wanting to make an appointment and one who wants to interview the clinician about their services, histories, and clinical orientations as part of a decisional process of their own. I can’t remember the latter occurring, so this may be rare. My inclination would have been to inquire if they were considering me to help them, and if so, ask for a bit of information about what kind of problem the potential client’s may have. That may help the therapist to decide whether to be interviewed at that moment or at some other more convenient time to be set. I suppose the clinician could decline altogether, but doing so helps one hone their own line at the least.

Attributes, Purposes, and Intents

I usually returned these calls between sessions. Virtually all of them took less than those 10 minutes, maybe averaging 5 – 6. Brevity was a benefit.

Being friendly and focused in sessions carried over to these calls. Parents and even clients notice. As postulated earlier, the interaction is the seed of the clinical relationship. My belief is that the parent(s) is are likely to be a bit more relaxed to talk about what is precious and intimate, those being of the family and progeny, as the intake session begins having already had a favorable experience. The therapist being comfortable in doing the work, in all its minutia-to-sublimity, is a model for conjoint work toward resolutions.

Thinking again about the value of repetition, going through the necessary questions, fielding the answers, knowing what to do with the material, and coming to a mutual understanding, all in a manner of competence, helps develop meaningful confidence.

Staying on point, in this instance creating an initial agreement about proceeding, serves two functions. The first is the economic use of time, which is in the clinician’s interest, and in 2021’s world, ever more likely for the inquirer as well. The second is staying clear of doing clinical work, per se. Three reason exists for that stance. 

First, the therapist does not have a clinical agreement until the disclosure statement or similar document is signed. Some therapists certainly view this as a trifling, and that may be so. The concern in this limited arena of the initial call is not so much legal as giving the new client pause about who they are planning on seeing. The therapist knows nothing substantive about them until they meet face to face (in reality or virtually, as covid-19 has taught). The third is that delving further into the problems the family is experiencing and suggesting what might or could be done about the issues can end up with one of three outcomes: the caller could be impressed; the caller could be unimpressed, make an appointment and never show, or be more forthright and say they have ‘a couple of ‘other calls to make’ and never be seen; or they could take all the information they have collected during the discussion for free, and proceed with their own treatment. One out of three is not great odds.

So, what about just chatting? The only concern here is that the prospective relationship is about a professional helping a client, so the orientation is always toward the client and not toward the self. Might doing so be a temptation of fate? They are evaluating everything you say and do, with intent.

Stay on point. Watching change is the entertainment.

#42 – REVIEW – PREVIEW #3

The purpose of this blog is to describe a method of outpatient child and adolescent mental health work that uses family therapy as the primary treatment format. The project began six months before closing my 30+ year full time private practice and retiring. As events unfolded, the first step was devising an outcome study of what turned out to be 58 cases that terminated during a of period two calendar years. That decision came out of an intrinsic interest in numbers and a simple curiosity about how effective the work had been. The practice had been more than personally satisfying, but just what had the work accomplished and for whom?

The initial pre-test post-test calculations of clinical change led to one elaboration after another over the course of three months or so. During that time the consideration of writing arose. As has been noted a couple of times in previous posts, private practice is a ‘lean-forward’ life with the focus being ‘what’s next?’ Retrospection about process occurred mostly in the context of consultation and in sorting out what went awry in those cases that did. Doing so added added to the informal body of guidelines and cautions that formed a part of the processes’s vernacular, the do’s and don’t’s of day-to-day clinical work. Concentrated thought about the process as an entity had not occurred before, let alone organizing a layout. When thinking about the whole as the study developed, the notion that the process was fairly recursive and replicative became clear. At that point, I think, writing took on a life as well.

Whither Goest Family Therapy?

Child mental health as an institution in the 70’s was still sorting through the therapies primarily developed in the post-WW II era. Family therapy was one of several. The technique was developed, taught, and proselytized by Virginia Satir, Don Jackson, and others, and became a frequently utilized format, particularly in the Northeast states and on the West Coast. Family therapy was probably at its zenith in the late 70’s and early 80’s. For example, family therapy was the primary psychotherapeutic treatment taught to child psychiatry residents and fellows at the University of Washington Hospital’s field training program during that time. Those of us master’s level therapists who were using the approach in training programs and doing therapy in NPO clinics were convinced that this was the wave of the future, based on the results that were occurring.

The paradox at the time this study began was that family therapy had already been on the wane for more than a couple of decades. The north Eastside community, among other things the original heart of the Seattle metropolitan area’s renowned tech industry, is a kind of family halcyon that one would think a receptive area for a family therapy practice. However, from the mid-80’s onward and to the best of my knowledge, mine was the only practice that had organized all child and adolescent case processes through the family prism. Other youth therapists in the area would have occasional family sessions, but their work was predominantly oriented toward individual treatment.

Over time, I came to have working relationships with elementary, junior high, and high school counselors from three school districts. From time to time, I would ask one of them if they knew of anyone else doing primarily family therapy, thinking that clinicians who were doing so would also be in contact with the schools. The counselors know of what I spoke because the effectiveness of the family orientation was the reason they would use me as a referral source, but they’d all shake their heads, no one of which they heard or knew. That remained true through the significant infusion of outpatient therapists into the area after state licensing occurred in 1988.

Why the wane is complicated, at least from this perspective. Bear with the view, or skip to the more immediately germane material.

At least part of family therapy’s decreased presence was a result of a change in how the treatments of mental health symptoms had been conceptualized and hence implemented. Specifically, techniques such as CBT that were used for a client’s emotional and behavioral problems shifted away from an embedment in relational and growth orientations toward more programmatic applications.

 A major underlying economic thrust of national origins was an increased emphasis on efficiency. Like any other national industry, mental health treatment is impacted by the prevailing economic philosophy of the moment. Beginning in the late 70’s, the national economic policies turned away from an emphasis on government expenditures and controls that sought relative equality for all, generically termed Keynesian after Depression era economist John Maynard Keynes, to free markets that emphasized efficiency, production, and profit, e.g. Milton Friedman, et. al.* 

By the late 80’s, insurance companies were more aggressively controlling the provision of therapy services through devices like managed care, per person annual service limits, re-authorization procedures, preferred provider rates, etc. The average of 29.3 sessions per case in this outcome study here was not what insurance business managers had in mind. At what global cost or benefit the change generated is not clear. Barry Stevens would have suggested that ‘you can’t push the river.’

  • Read “The Economist’s Hour”, 2018, by Binyamin Applebaum, lead economics and business writer for the New York Times editorial board; additionally, Capital In The 21sr Century, 2014, Tomas Piketty esp. last chapter; The Deficit Myth, 2018, Stephanie Kelton, esp. Chapter 7; Good Economics in Hard Times, 2019, Banerjee and Duflo (2019 Nobel Prize for Economics); and/or maybe Debt: A 5000 Year History, 2011, David Graeber, esp. last chapter;

In 1990, Value Behavior Health (later known as Value Options and now part of Beacon Health) won a carve-out contract from Boeing’s health insurer, Regence Blue Shield, to manage the corporation’s mental health benefit. Representing by far the largest employer in the area, probably hundreds of therapists signed up for panel status. “Managed care” was a novelty for all of us. VBH organized an introductory workshop at the Seattle Center on a very warm May weekday in the center’s conference hall. About a hundred of us attended. The main speaker was an earnest young woman who ran through the basics. You get an automatic 10 sessions. MSWs and masters counselor types would be paid 55$ per session, some 20 – 25% lower than what masters level clinicians were charging for sessions at the time, but with the status of a ‘preferred provider’. The therapist could fill out a somewhat long re-authorization request for another 10 sessions that included diagnostic and progress data. Depending on VBH’s determination of need, you may or may not get it. If not, the client would have to pay out-of-pocket thereafter. The intimation of the presenter’s delivery suggested that private pay was sort of frowned upon, but OK because they had no formal way to check. However, clinician billing and re-authorization records could be “reviewed”. Murmurs started to surface. Then the challenging questions by Seattle’s leftist lot began, and the presenter calmly and smilingly answered as best she could, which she would do, but the thrill was clearly gone. Her small support staff started gathering together papers of their own, like this was the expected routine at all their venues. The young woman, who truly seemed to be a pleasant soul, stood silent for a few seconds with her hands clasped beneath her chin, and then said, as earnestly as ever, “What we’re looking for are professionals who share our philosophy.” There was silence, almost chilly. No one knew quite how to respond, but the message was clear – keep the processes short. 

Mental health as an institution of professionals is adaptive. Moving in the direction of efficient modalities like time-limited, solution focused, behavioral programs and even some EBT-type models has been relatively seamless. Therapists are referring child and adolescent clients more often to psychiatrists, pediatricians, and family doctors for medications as an adjunct to standard talk and/or behavioral therapies. Processes that are more structured and on the whole shorter that the 20+ session therapy were gaining favor. The insurance companies have been doing well. 

Since 2015, that top line has gone more toward vertical, the bottom line has probably dipped, and the middle line flattened. At least that’s the inference from public information available. Piketty researched back centuries about economic trends, and at the end of “Capital….”, he warned that if the skew in the distribution of wealth became too severe, the society would face revolution or war or depression. This was in 2013. Given 1/6/21, the warning has merit.

Efficiency produces vast amounts of wealth, but the pernicious side is that “free” competition clearly leads to greater economic disparity. The relative decline in living conditions for more than half of the population contributed to the significant increase in child and adolescent mental health problems, mostly in terms of anxiety. Unrelenting anxiety then leads to depression and behavior disorders. Where the generally accepted rates of diagnosable mental health disorders for youth at any given time was 15% a half century ago, that figure has been quoted contemporaneously at 25+%. We need to employ all the viable modalities, including family therapy, and the social means to support processes that demonstrate the capacity for effectiveness and to have the time necessary to achieve for the client. 

A last point, allegorically about efficiency and its impacts:

In the summer of 1972, the song “Does Anybody Really Know What Time It Is?” was getting a lot of attention. The title line began the refrain, and was followed by “Does anybody really care”. By the band Chicago, the tune could be seen as a kind of inferential ode to the title character of another song of the day, Lather, for whom time was a non-consideration. However irrational, such was one of the tenets among the young at that time. Now fifty years later and a vastly different circumstance of life, time for most people, time is a commodity for which there seems never quite enough, creating a reality of “Does anybody really not know what time it is, does anybody really not care…anymore”?

Increased anxiety has lots of mental health workers and school counselors very, very busy, god bless them…us.

Lots of mental health workers and school counselors are very, very busy, god bless them…us.

And then came the pandemic, and as the virus swept across the country, family therapy fell off the table that was already leaning in that direction due to matters that have little to do with its efficacy. In-office family therapy must have completely disappeared amidst all the needed safety precautions Family therapy by Zoom rudimentarily provides for multiple verbal inputs, but the therapist is deprived of most non-verbal behavior observation and all the real life communications that get quietly relayed. And then you have the factor of kids on Zoom…sitting still… for counseling.

To be adamant, in the midst of both good times and bad, family therapy still will be here. Family therapy in vivo has unique, timeless, serviceable qualities that preserve utility through the inevitable vicissitudes of social conditions and practice standards. As an intervention, the approach will always have a willing and wanting portion of the population. Like most socio-cultural staples, the demand for  the service may wax and wane with economic and political change, but will always be there to one degree or another as long as families have distressing and irresolvable difficulty.

Basic Advantages

The child’s problem(s) are also those of the family. Family members are present to help define the problem(s), explain the problem’s history, and describe the impacts. The family helps plot the course of intervention, and by doing so become more invested. They themselves are increasing their awarenesses and sensitivities, and altering their own relatedness patterns as may be helpful. They become involved in reinforcing the changes as they are occurring, and learn to work together through the inevitable relapses.

The therapist can witness random family functioning in detail. Much is happening non-verbally in a family gathering that helps the therapist understand in greater depth factors like: how the problems developed; what behavioral and relational reactions they generate; how they get reinforced; how do positive efforts get extinguished; where the antagonisms are, and so too the trusts. In the family, the therapist gains a collective opinion about the effects of clinical input and suggestions, helping to determine which show promise, which do not, what direction to take,  where the resistances may be, and who tracks what. 

Assuming: the whole is greater than the sum of its parts; positive change is usually infectious; resilience is more likely when the quality of relationships is higher. 

Keeping Up

The licensing that occurred in the late 80’s did help in a couple of ways. Master’s level therapists now could independently bill insurances, thus be freed of reliances on MDs and PhDs who ‘supervised’  the work of master’s level therapists and signed for insurance payments. At the same time, business found an open back door as insurances developed and exerted new expense controls, which in turn impacted therapy and psychiatry alike.

Along with the freedom of independent clinical functioning came required Certified Education Units for bi-annual recertification. Washington State’s biannual requirement is for 36 hours. This translated into six six-hour trainings, one every four months on the average. In reality, this became a rushed four workshops in the last six months of every two years. The units could be also gained just by reading training texts commercialized for the purpose, and answering a few questions on a “test” at the end, all taking less than an hour, sometimes fifteen minutes. I took the in-person training route, occasionally muttering but on the whole finding the workshops helpful.

A way to evaluate the benefit of any given training became apparent. If out of any CEU training came one material concept, or one specific tool that could be incorporated into the therapy process’s methods, something that could reliably produce the intended effect, the effort was worth the while. The same would be true here. Material concepts and specific tools are what is being offered here in the upcoming posts on the methods themselves.

Review 

Quickly, the first three posts covered the basic who, what, when, where, and why of the overall   project. Posts 4 – 23 detailed the outcome study along with a couple of elaborative vignettes. #24 was the first Review – Preview.

#25 – #41 covered the Relatedness/Axis 11 Sub-Group, seventeen posts in all. The term ‘personality disorder ‘ was not used for reasons covered in #25. For children and adolescents,  the use of term is premature and would be misconstrued in a way that could be a blow to their identity development. The chosen designation was ’Relatedness’, inasmuch as a labile set of relational thoughts, feelings, and behaviors were the primary manifestations of their difficulties. The term ‘Axis II’, a relativistic identifier used in the DSMs up to and including the IV-R, was used for adults with personality-type disorders. The category was bracketed by common mental health disorders on one side, and psychotic disorders on the other. 

With an N of 17 (of 56), these youth were the second largest sub-group of the study population. Those with suicidal ideation were the largest. In regards to the relatedness and Axis II group, Posts 25 – 33 focused on the incidence and treatments of the relatedness youth. #34 – #41 focused on those cases where the client youth had one or both parents or significant caretakers who were likely Axis II problems themselves. As a whole, these 17 cases provided an opportunity to present an integrated combination of data and casework considerations. 

The same could have been done with the suicidal ideation group. Not to diminish the seriousness of SI at all, the cases involving the relatedness group were more challenging from the clinical management perspective. They presented a ripe opportunity for delving into complicated clinical thinking concerning the intricate and potentially precarious situations they often develop. As such, they represented an alternate truth about casework. We envision positive outcomes with the development of good clinical relationships and the adroit  applications of method. In most instances, that happens. Alternately, normal clinical relationship work and normal case management encounter paradoxical responses that are difficult to re-direct. Stuff happens.

Compared to relatedness cases as a whole, those presenting with SI generally had more straight forward processes, better outcomes, and more traditional terminations. Still, the average CGAS gain for both groups as a whole were equivalent. The difference was that successful work within the relatedness group had high average gains, the less successful were very low, and they averaged out. When they were hard, they were very hard.

Preview

Four sections are planned, including: the therapy process; suicidal ideation and other notable sub-groups; a summary of outcome study findings; and the conclusion.

The therapy process section will be divided into 11 areas, most of them shorter posts than has been the case thus far. They include: the initial contact; the three- session assessment process consisting of the intake with the parents, the child interview, and the summary and recommendation session with the parents again; the first three conjoint  therapy sessions (usually # 4 – 6); a long section on ‘middle work’; termination process; retirement as the transition impacts clients; and setting up a private practice;

The only sub-group large enough to include some statistical analysis is those having suicidal ideation (N=21). All others are less than10. They include; single mothers (no single fathers in the study group); BIPOC/ESL; sexual identity issues; spectrum clients; referred out for medication evaluations; referred for other treatments; those with fathers completely out of the picture (no O.O.P. mothers in the group); those who received only individual counseling (format 4); clinical gains above 25 CGAS points; gains under 5 CGAS points; statistical outliers (three cases whose clinical gains were particularly low for the number of sessions used); and a  comparative look those who at those clients who terminated with a CGAS over 70 with those doing so at 70 and under. A few illustrative case vignettes throughout the sub-section are also planned.

The conclusion section is still a concept in progress. The larger context in which mental health work operates is the current consideration. Looking from a practitioners viewpoint at how child and adolescent mental health work impacts the community on the one hand, and how the larger forces of socio-politico-economic change impact how mental health work is practiced may have a certain value. Clinicians often face the impacts of external change on how they practice, which in turn may effect what kind of work they choose to do. Part of that exploration of moving toward the family approach when the predominant treatment philosophies have been trending inc other directions. 

For Whom

The therapy process information is largely instrumental. Most of the described interviewing techniques, tools, sequences, and approaches can be taken into most any therapy format on an experimental basis, by therapists anywhere from being in academic training to those with years of experience just to see what the particular effects of a particular method or technique may be. Nothing therein is inherently risky or dissuading from therapy.

Two target audiences come to mind. The first would be younger and newer therapists, those coming out of grad school or entering the field from other endeavors and searching to see what fits their interests, styles, and goals. The other would be established clinicians who have been working for public and/or private organizations providing community mental health services and are taking steps to build private practices. Given a specialty interest in child and adolescent work, family therapy as a potentially effective and useful format would be among the explorations and the presentation in the following posts would constitute an elemental introduction to the format. 

Recursiveness and Mastery

As stated earlier, the process as a whole is fairly recursive, i.e. repeatable. The structure and progression of treatment from the first contact to the terminating session has a certain sameness from step to step, often from question to question. This kind of approach has two advantages to providing care. 

One asset of recursiveness is that elements of the therapy process itself become another measuring device or evaluative tool. For example, in the first meeting with the child or adolescent, the assessment session, a five-tiered set of questions was developed to comfortably move from the initial greeting into the reasons why the young person is in the office, was employed with every case. Where in the sequence the new client begins to openly talk is an indicator of overall willingness and need vs. self-protection and wariness. That is helpful diagnostic information in and of itself, but also provides an important data point to discuss with the parents in the following assessment and summary session. Parents almost universally appreciated that kind of normative feedback, in this instance where their child fits in the range of comfort. In turn, that can also provide a base from which the child’s comfort may have grown during their first meeting, and that was usually the case. Parents like that, and the generation of trust is abetted. That tiered opening will be discussed in the sub-section of the client assessment session.

More generally, the recursiveness helps identify how people commonly react to certain steps or suggestions or phases that are part and parcel of the process. And then, what to make of someone who reacts differently from the norm and why do they do that, a question that may be overtly pursued but just as often registered internally as one more bit of information that helps to understand why that particular client is in the office, what they may need, and what direction to take. Examples will be given along the way. Some have already been given in earlier case vignettes.

Repetition also aids in gaining mastery, and mastery of skill is certainly one goal of the professional. Mastery entails considerable effort over time. Clarity of method matters.

On Mastery:  On a spring afternoon in1995, I’m at my desk during an open hour, clear of anything needing attention at the moment. For whatever random reason, I got into a holistic overview about the work. This was now ten years into the practice, a notable marker in and of itself. What dawned on me was that the process itself had reached a certain marker. Whatever came through the door, I knew what to do and basically how to go about doing it, and if I didn’t know what to do, I’d know what to do about that, help re-direct the individual in some way. I’d developed a process that worked most all the time. 

Acting like a developmentalist, I pulled over the notepad and devised a stage analysis. By the end of the first year, the basic nuts-and-bolts of running the practice were learned.  After three years, the work had encountered most of the serious problems and crises that would normally arise. After five years, the effects were beginning to have impact on the environment surrounding the practice, in a manner communalizing it. At ten years, the process had been mastered. That doesn’t mean growth and change had in some way stopped. Some level as yet to be experienced at that moment was still to come.

So, now how to test it? At the time, one activity of mine was playing Sunday morning basketball at a local Jewish community center. I played on the seniors court, mostly men 40 to 60. We played 4-on-4 on a 70 ft. cross court. First team to score 10 baskets wins and keeps the floor; those from the losing side head to the chairs behind the baseline and await their turn. While doing so, we’d usually talk amongst us while watching. The 20 or so regulars were a mix of professionals, corporates, small business owners, service people, etc.

I wondered what their experiences were like as they grew into their work specialties. Over the next three Sundays, I posed this question to around 15 of them – “In your work, how long did it take to to get to the point where you knew what to do with whatever kind of problem walked through, or you knew where to send them?”

They all took the question seriously, think five or ten seconds, and then give a specific number. Close to half of them said ’10 years’, by far the most quoted. The others ranged from 6 months to 3 or 4 years, as I recall.  One odd sidelight is that none of them ever asked me why I was asking. For even for us “old guys” , Sunday morning was all about the ball. 

This bit of informal field research demonstrated that piecing together a viable process takes continued learning, observation, experimentation, and, most of all, time. Using an effective approach, technique, or tool with consistency and in a similar manner from instance to instance is a mastery facilitator itself.

Having some kind of method to increase professional knowledge and skill base is as important as any other part of mental health’s endeavor. Being alert to new information and concepts, trying them out, doing anything that might help the development of one’s effective work is part and parcel of proficiency, and one definition of professionalism.

On Personalized Process

All treatment processes are personalized, regardless of the particular school of therapy or clientele or formats that shape one’s practice.The inherent distinction between medical and mental health treatments is the factor of relatedness. Mental health treatment addresses symptoms and disorders in the first order, but most any approach also impacts how the participant(s) relate. The therapy process is a shaper and conditioner of change, and the therapeutic relationship becomes a model of relatedness itself.

Interactional problems will gain some form of attention. That includes those interactions between family members, and those between the client(s) and the therapist. On occasion, the client-therapist communication is to resolve some problem that directly involves the therapist. How the therapist handles him or herself becomes yet one more model, and likely one that has an impact. At its base, the good relationship between client and clinician is a generator of trust.

Clients bring in their problems. The therapist brings in a panoply of interventions great and small. The comfort and belief in the interventions the therapist administers emanates from themselves. The tools the therapist uses are best those with which the therapist feels at home. As such, they represent some aspect of what the therapist believes. Just as the client wants to be better, the therapist wants to be effective. All treatment processes are personalized, regardless of the particular school of therapy or clientele or formats that shape one’s practice.The search for process enhancements that can be comfortably added to a professionals repertoire hopefully does not stop until that office door is closed for the last time.

Try what seems in your judgement to hold promise. Build your process. Trust yourself.

One more note – this post marks the beginning of describing the therapy process in considerable and digestible detail. If the material thus far strikes you as helpful and holding some promise, let others know. Thanks.

#41 – WHO’S WATCHING

At some point an increasing insecurity can merge into the realm of terror. James Garbarino’s definition of terrorizing a child includes “making the world seem capricious and hostile”. Prolonged separation and divorce are universally seen as major stressors for youth. This is tension. Add to the child’s experience an unabated dissension or differences between the parents, particularly when anger is common for one or both, and the stressors will often merge into clinical symptoms of anxiety, depression, and behavior problems. Add to that the specter of losing significant time or contact with one of the parents, or a step-parent becoming emotionally abusive, the child’s experience can become one of terror. Their world is capricious and hostile.

While the therapy process is pursuing symptom relief, higher functioning, improved relationships, all toward more hope, meaning, joy, and love, another concurrent and overarching process is simultaneously operating. Generally, one of the two parents is keeping track of every relationship within a family. These dyads are intrinsic elements of family cohesiveness in the short term, for duration over generations, of survival in the long run. That person is usually the mother. At least in terms of this practice’s population, fathers will often serve this function under the (2% – 5%?) circumstance when the mothers are otherwise occupied with their own particular issues. Two such fathers stand out in this regard within the 56 cases of the study, none of them involved with the cases of this section. Another (2%?) have neither in the role.

A certain natural limit in the scope of tracking is set by the number of children in the group. A family of four has six dyadic relationships; with three children the number is ten; one of four has fifteen with four; five (a family of seven total) has twenty-one. For the observing parent, almost regardless of devotion, to know all the dyads is probably tapped out at fifteen, maybe twenty-one, and certainly with the twenty-eight dyadic relationships within a family of eight. At some point beyond dyadic ability, the tracking parent’s concerns are rather those of interactional flows among all, and the specific attentions are on those relationships that are particularly strong, therein lie the leaders, or particularly conflictual, therein lying the threats. 

The tracking function survives separations and divorces. Noah’s, Owen’s, and Patrick’s mothers were all keenly interested in the relationships of their child(ren) with the formal or informal step- parent figure in their child’s life, and their children, if any. Or do their best they can within the limits of observation and reporting coming from both children and the ex. In my judgement, they earnestly tried.

A small few number of families do come into the office with neither parent really fulfilling the tracking role. A classic example would be a depressed atmosphere with an anxious mother and a preoccupied father. The children’s basic needs are met, but the interactions are otherwise limited. Typically, the boys would be acting out and the girls would inwardly be experiencing significant anxiety. In white suburban 1950s and 60s America when and where I grew up, this pattern was common. The initial treatment objectives of aiding family engagement were obvious, and family therapy a fortunate service where and when available. Invariably, the family therapy process itself models and teaches tracking. 

In the unfortunate circumstance of pathologically centrifugal families, people who generally do not seek out family therapy, probably no one fills the role. In the one seriously centrifugal family that can be recalled here, unfortunately occurring during the first year of private practice, the eighty year-old paternal grandmother at least tried to help and, retributively via her son, ended up with the thirteen year-old, acting out boy living with her. This was a remarkably complicated case made worse by questionable supervisory advice/directive, but the grandmother kept him in therapy as the father and mother/not-the-mother retreated from responsibility. The boy actually did much better with Granny, but “family” probably disappeared when the grandmother passed away, whenever that was. The boy was unforgettable. Crucial information I passed on to him concerning AIDS, this being 1985, quite possibly saved his life, given his nascent proclivities. I’m no sure where else he would have gotten the necessary information in time.

The six mothers in these last two groups tracked, no question. That can save lives.

The Tracker’s Realities

The successfully completed cases of Posts 36 and 37 were not devoid of inter-parenting struggle. Some of the pre-divorce issues and events could have terrified some of the children particularly at early ages. Post-divorce, all three cases involved challenges coming from the fathers either to the established custody arrangements, or to the therapy processes, or both. The divorce decrees had placed the three mothers with primary care responsibility, including key factors such as location, school placement, and healthcare. 

Each of the three mothers also had natural executive skills honed by workplace leadership responsibilities. These factors probably helped stabilize the nature of the parenting relationships with their exes, almost regardless of the paternal complaints. Achieving these states nevertheless entailed a more or less continuous attention on the part of the mothers, and watching by the children

One contrasting factor between the two groups of cases involved the initiation of the separation and divorce processes. In the first group, the mothers had initiated the processes. One mother was physically abused and forced the husband out. Difficulties with faithfulness led to another spouse’s eviction from the home. The third mother had to deal with her own moderately impactful anxiety – depression as the marriage failed to mature and the father became more erratic and oppositional following his job loss. For the wellbeing of herself and the two children, the decision to separate had to be made.

In addition to realigning their original families, the three had to resolve their own issues resulting from the marital difficulties and resultant separations. The physical abuse that the one mother experienced was perhaps on the lower end of that particular and horrific severity scale, but  anything on that range must take serious resolve to overcome and heal. She dealt with symptomatic issues of anger and guilt,  the anxiety about her capacity to manage a household, and the strength to re-engage with the world of relationships, all of which she did.  All three mothers were well along the way to resolutions, or at least in mitigating the damages done within the marriages by the time a family therapy process began for them. The practical problems following their divorces were of less impact than the emotional residues. They nevertheless kept those core family threads intact.

The three difficult cases of Posts 38 & 39 differed from the first group in several ways. The separations were initiated by the fathers, to one degree or another done at the surprise of the mothers. One father overtly left for another relationship. The second left for reasons that were more difficult to understand but included losses of affection and eventually of affiliation, in that order. The third appeared to have significantly devalued his wife and engaged in an emotional disunion. Whether another relationship was involved was not clear, but another family that included his new partner and her two children moved in to his new home within months of his departure.

The fathers in the second group were more aggressive, two of them being overtly so and the third likely being passive-aggressive. In addition, the fathers appeared to exploit certain vulnerabilities within each maternal home to achieve their own desired outcomes. The patterns of suddenly emerging hostility to therapy by the ODD boys, who by definition were prone to resistance but had been generally compliant, were clearly related to times spent with those fathers. The third father used superior resources to maintain custodial control and likely diminished the mother in ways that the young boy observed. His sister had just entered toddlerhood, so while she could not understand the words, she unquestionably experienced the anger in ways that could foment a sense of foreboding. In following the family evolution and patterns, the inferences were that all three fathers engaged in disruptive and misdirecting defense mechanisms, e.g. demanding, splitting, ego-syntonic postures, etc., and while that could also be inferred of the fathers from the successful group, their own particular defenses were less intrusive and for the most part subsided.

All six mothers in the two groups tracked the various dyadic relationships in which their child(ren) were involved. For the three difficult cases, the homes of the exes were more opaque, as the fathers tended to be non-disclosive. Those three mothers were trying to cope with the inadequate information coming from the exes, and the antipathetic attitudes of the exes toward their own parenting that ultimately included the therapies.

The mothers from the difficult cases also had to work through the emotional traumas of their marriages. Given that their exes were likely more difficult and entrenched in their own perspectives than were their counterparts from the more successful three cases, the mothers were more actively working through their own personal issues as their children’s therapies began. Two had their own therapists. The sense given by the third was that her male relationship conducted away from the home was a primary source of personal support.

So, presuming degrees of the fathers’ spousal devaluations, diminishment of the therapies, and their own underlying insecurities they steadfastly disavowed, and the mothers’ concerns about child mental health and the functioning of the original family unit regardless of their spread, what do the mothers do?

Care for self-and child  

Two were in therapy themselves, and the third was in a reliable, long term, confidant relationship independent of the rest of the family. Each client child demonstrated the ability to change during their therapy, two with the mothers and the third individually. The hard part was that two of the three lost significant ground after the impressive gains, and the third was prevented from the opportunity to build on his growth by the father’s unilateral termination of services, twice.

Track and nurture as possible the family relationships 

One mother had only the three relationships between herself, the ex, and the client to consider.  The other two had the fathers’ second families of four, including himself, to follow. Importantly, they were literate about the dyads within the original family grouping and observant of the relationships within the stepfamilies in which their children partially lived. Part of the family therapy is emphasizing the importance of reinforcing changed behaviors and patterns of relating, and they could be seen doing so.

Relate More Effectively With  Axis II-like Exes?

The task for both mother (in these cases) and therapist in these types of cases may seem Sisyphean, particularly so when the defenses are activated in the midst of extraordinary stakes. One’s child can be a stake greater than any other. Perhaps look at language first.

A few years ago, a day-long workshop tour on treatment with personality disorders came to Seattle. The presenter was probably Gregory Lester, but the excellent workshop booklet that was intended to be saved somehow disappeared in one transition or loan or somehow. Based on his experiences, within the handout was a page that paired which personality disorder married which personality disorder. Probably a dozen times over the last few years of practice, I would be disconcerted about some particular couple. Consulting that list invariably provided a helpful perspective. If one were available, that kind of quickie tool could be an aid while working with activated Axis II defenses. what works with what defense. The basic concept is to tailor the language and clinical objective to the particular issues that, say, pertains to these fathers.

The following is offered as a template, and not necessarily a working document. The qualifier is that the suggested content for working with particular Axis II defenses come from a non-expert, that being me. The writing is from the clinician’s working perspective. In helping an ’other’ parent improve the relationship with their co-parent, the clinician would have to extrapolate the relevant content for a given defense and adjust the recommended language toward a common parent to parent interchange.  The other caveat is that helping the client’s mother directly with their coparent relationship was not a significant focus in these six cases, in large part because four of them were reasonably comfortable with how they did so, and the other two were in individual therapies.

Deny a problem exists  

Describing the situation to the point of an even vague concurrence of reality, follow with the question “When would this actually become a problem, in your view?”  Go from there to “what would you like to see done about it?”,  and then work toward some kind of positive movement, reinforcing their acknowledgements, adjustments, and/or accommodations.

Vulnerabilities hidden by apparent strength

Insistence on being correct can be seen as an accompanying problem. In the context of a talk therapy process “Is it possible they may be a little right about this?”, “Is it possible you might feel a little anxious or worried about what’s being said?” Be more light than dark hearted when doing so. Reinforce any recognition of vulnerabilities that others experience, follow up with “Do you sometimes feel (or think) that way?”

Ego-Syntonic (that’s just who I am, e.g. nothing I can do about it)

Two issues: one is difficulty with the perspective of others close to the person, including how they think, what they feel, and how they may react to a given situation; and one can assume that anxiety beneath the commonly smiling patina of self-assuredness is present. Accessing the thoughts and feelings beyond the defense will likely take considerable time. Noting and reinforcing any observable change can soften the resistances.

Demanding 

Ideally, work on an instance or example of demands upon you, work it through, and eventually “does this same thing happen with others”? Also, “what is it you’d like from me here?”, followed by a discussion about what can and can’t be done in therapy, i.e. what are the boundaries of the clinical contract. Reinforce any switch on the client’s part from demand to request. To quote my long passed Wyoming-bred practicum supervisor Carlah Lytle, “Don’t get into a pissing match with a skunk – you’ll lose.”

Stigma of having a problem

Often will refuse to get help. Consider a focus on complicated loss issues, going back to family-of-origin’s attitudes toward having problems work, Feeling identification work, particularly anxiety. Reinforce sense of accomplishments, particularly those in therapy, and explicated senes of pride.

Rejecting

Assume degrees of projection. Integrate family narrative work into the therapeutic lexicon of the case, working toward an acknowledgement of anxiety, particularly about being seen critically. Reinforce any new type of acceptance. Gentle, as they have likely experienced blowback with some frequency.

Lying, manipulative, splitting

When all three operate within a person simultaneously, these defenses are the troika for family infighters with touches of sociopathy. As such, the traits are difficult to change. Those who engage in employing them are unlikely to be involved in a therapy, family or otherwise. At the same time, the afflicted – for they are, indeed, afflicted with a serious, tumultuous disorder- can be very devoted to their children and they stay much in the picture. For the adult involved in the therapy, again usually the mother but not always, the parenting task can be inordinately complicated. Difficult choices between the more aggressive and the more judicious, observant-supportive postures are presented. 

Some situations within their control can be addressed by the involved parent to the challenging co-parent with a firm “this is the way we’re going to do this”. Other situations don’t offer a window of decisional clarity. The parent can do something either this way or that, including a solution that accommodates the wishes or demands of the non-involved parent, or one that assimilates him more into the involved parent’s style of parenting. Compromise does occur, often with therapeutic input. The underlying motivation of the involved parent is usually to keep the original family unit, such as it is, as close as possible and still meet the child’s particular emotional and behavioral needs at the time. The therapist’s role is guiding the process toward a fruitful conclusion, as always, but these are among the most challenging cases to do so, sometimes leading to that difficult spot of “do I push this, or do I let go.” Most all child and adolescent clinicians have experienced the dilemma of letting a heretofore effective therapy go in deference to the family’s need of avoiding an unraveling. A guiding mantra here is “keep the door open.”

Addictive, substance abusing

Obviously, if a problem cannot be safely managed in an outpatient practice, the first act is recommending specialist treatment for the problem parent. Help the ‘clean’ parent, so to speak, toward spousal education, advice, and support as part of the problem parent’s treatment, unless that also is within the clinician’s expertise. Be careful. If the problem parent is not in treatment, look into referring the client’s parent to a specialist or program offering services for their particular educational or intervention needs. Assuming the plan is for the client youth and their parent to remain in treatment with you, coordinate with an involved substance abuse specialist, particularly if their typical practice is to work with all available and suitable family members, minors included. Two concurrent processes working on the same basic problem could possibly make matters worse, hence the need to determine who will be doing what.

Suicidal

Suicidal behaviors that are standing patterns and one of multiple personality disorder defenses are presumed here to be etiologically separate from SI that is a result of depression, anxiety, trauma and other issues formerly known as Axis I disorders. If the pattern is not a hidden problem, known to family, acquaintances, medical professionals, and/or safety personnel, the problem is not very likely to randomly appear in an outpatient child and adolescent treatment practice facility. This would be even more so if the privately practicing clinician or community clinic were a masters-level professional concern. If the case remains with you for one reason or another, the involvement of a psychiatrist or MD with 24 hour coverage and admitting privileges would seem to be a must. Being the clinician of last resort, that person is effectively the lead professional and would expect to be kept informed.

Suspicious of warmth and positivity

By the nature that led into this profession, most of us emanate warmth and positivity to one degree or another. Even if the first sentence of the first session is done with some amount of reservation, within the next 45 minutes that underlying aspect of the ` therapist’s self becomes apparent. Thoughts that the client has suspiciousness about warmth and positivity don’t normally surface for the average clinician, and the client is probably skilled at disguise since adolescence. 

One exercise may be helpful for future reference in regards to this characteristic. Go through the cases in the past that were unilaterally ended by the client for reasons that in hindsight are not apparent, particularly between the third to seventh sessions. Serious, life-impacting suspiciousness of warmth and positivity likely does not appear early on in talk therapies, but looking through those early, precipitous terminations may unearth examples. From those the therapist can learn. If they stay in treatment and a basic trust has been established, logic would suggest that patience is required. This is a serious Axis II problem. Change may be halting and slow. As a 60’s – 70’s priestess of conscious awareness, Barry Stevens asserted, “You can’t push the river.” Affirm and reinforce clear, observable demonstrations of increased trust.

Chaotic life management

Friedrich Nietzsche once intoned “You must carry chaos within you to give birth to a dancing star.” Dancing stars are of questionable value in a therapy office. This trait in a  family adult necessarily becomes a clinical management problem if the problem parent. They would need sufficient organization to make and keep the intake appointment. The effective therapy process then has to survive the chaos of daily activities and decisions at least through the first half dozen sessions. The parent’s problem is likely to become apparent in the history of the afflicted parent, including the areas of relationships, residences, work, finances, health, and education. With that history and a stable first six sessions, adroit reinforcement of organized behavior on the part of the parent may solidify the viability of the therapy and increase the commitment within the family. My first professional role model, Mary Rygg, MSW, a UW School of Medicine faculty member and original member of Virginia Satir’s Beautiful People acolytes, once presented a case of hers that involved a chaotic life management mother of five children that survived the first few family therapy sessions, became a habit for the mother, and lasted more than three years. The older two daughters made sure the appointments were kept, worked with their mother, and she emerged from the therapy a tracker, to use the term. If you ` `are blessed with one of these people that can keep the process going, reinforce changed approaches to situations and patterns.

Self Destructive Behavior

Separate from persistent suicidal ideation/behaviors/attempts, patterns of self destructive behavior will be discussed in a separate post.

Expand Use of Other Formats?

None of the three mothers were seen for individual work during the processes with me. Again, two were in their own therapies, and the third in a helpful relationship. The meetings with them alone were essentially short side bars to the conjoint processes with Nathan and Owen, and the individual process for Patrick. They were intended mostly for administrative issues and limited clinical concerns such as helping them shape their specific approaches to issues involving the fathers, although Patrick’s mother used the opportunity to do some venting in the midst.

Specific events occurred during each process that could have warranted a switch in format. At some point for both Nathan and Owen, negative changes in their affect and behavior aimed at the mothers following time at the fathers’s homes were repeated more than once. The highly antagonistic parking lot confrontation between Patrick’s parents combined with the mother’s positive reactions to her brief update discussions before his individual session could also have led to a consideration of a switch.

What could have evolved in all three cases were split processes. For Nathan and Owen, the process could alternate between conjoint sessions one week and split hours where the client and mother are seen individually during the next, or some arrangement along those lines. Both Nathan and Owen had demonstrated nice changes, and testing out the feasibility of individual work with them would be a reasonable step to take. Simultaneously, the mothers could then deal with individual, post-marital, and parenting work in greater depths. For Patrick, the split hour could be either every week or on alternating weeks. To some degree that was already happening, but formalizing and extending the mother’s session time might facilitate more disclosure, increase the understanding of the family and marital dynamics, and perhaps help her develop a more viable post-divorce parenting relationship. Coordination with the therapist’s for Owen and Patrick’s mother would become more important if the switch to split formats were made.

The problem with switching formats was that the upward gain curves had not plateaued before the rather steep declines. One could argue that an individual therapy for both may have provided some insulation from the paternal enmities, but an attempt to do so may also have led to an earlier termination, one that preceded the gains. Maybe. These are difficult decisions. Having the mothers involved in conjoint processes at least buys the time to facilitate noticeable and hopefully meaningful change. Perhaps a guiding principle would be ‘Do what you can do best.’

Enhance the effectiveness of communication with the fathers?

Remember again that the fathers had been invited to make appointments with me and, as was their perfect right by which one cannot judge, chose to not do so. 

The task of effective communication here may seem Sisyphean, particularly when the defenses are activated in the midst of extraordinary stakes. One’s child can be a stake greater than any other. 

The following is offered as a template, and not necessarily a working document. The suggested specifics to working with particular Axis II defenses come from a non-expert.

A few years ago and once again in need of a few more CEU’s, I signed up for a day-long workshop on treatment with personality disorders. I think the presenter was Gregory Lester, but the workshop handout booklet that was intended to be saved, because the information was really good, somehow disappeared in one transition or another. Within the work was a page that listed which personality disorder married which personality disorder, based on his experiences. Probably a half dozen times over the last few years of practice, I would be stumped about some particular couple, and pulled out the list. Doing so provided a few helpful “…so that’s what’s going on…” moments. If one were available, that kind of quickie tool can be an aid while working with activated Axis II defenses. The basic concept is to tailor the language and clinical objective to the particular defenses that the compromised parent may be utilizing.

The following is offered as a template, and not necessarily a working document. The suggested specifics to working with particular Axis II defenses come from a non-expert.

Deny a problem exists  

Describing the situation to the point of an even vague concurrence of reality, follow with the question “When would this actually become a problem, in your view?”  Go from there to “what would you like to see done about it?”,  and then work toward some kind of positive movement, reinforcing their acknowledgements, adjustments, and/or accommodations.

Vulnerabilities hidden by apparent strength

Insistence on being correct can be seen as an accompanying problem. In the context of a talk therapy process “Is it possible they may be a little right about this?”, “Is it possible you might feel a little anxious or worried about what’s being said?” Be more light than dark hearted when doing so. Reinforce any recognition of vulnerabilities that others experience, follow up with “Do you sometimes feel (or think) that way?”

Ego-Syntonic (that’s just who I am, e.g. nothing I can do about it)

Two issues: one is difficulty with the perspective of others close to the person, including how they think, what they feel, and how they may react to a given situation; and one can assume that anxiety beneath the commonly smiling patina of self-assuredness is present. Accessing the thoughts and feelings beyond the defense will likely take considerable time. Noting and reinforcing any observable change can soften the resistances.

Demanding 

Ideally, work on an instance or example of demands upon you, work it through, and eventually “does this same thing happen with others”? Also, “what is it you’d like from me here?”, followed by a discussion about what can and can’t be done in therapy, i.e. what are the boundaries of the clinical contract. Reinforce any switch on the client’s part from demand to request. To quote my long passed Wyoming-bred practicum supervisor Carlah Lytle, “Don’t get into a pissing match with a skunk – you’ll lose.”

Stigma of having a problem

Often will refuse to get help. Consider a focus on complicated loss issues, going back to family-of-origin’s attitudes toward having problems work, Feeling identification work, particularly anxiety. Reinforce sense of accomplishments, particularly those in therapy, and explicated senes of pride.

Rejecting

Assume degrees of projection. Integrate family narrative work into the therapeutic lexicon of the case, working toward an acknowledgement of anxiety, particularly about being seen critically. Reinforce any new type of acceptance. Gentle, as they have likely experienced blowback with some frequency.

Lying, manipulative, splitting

When all three operate within a person simultaneously, these defenses are the troika for family infighters with touches of sociopathy. As such, the traits are difficult to change. Those who engage in employing them are unlikely to be involved in a therapy, family or otherwise. At the same time, the afflicted – for they are, indeed, afflicted with a serious, tumultuous disorder- can be very devoted to their children and they stay much in the picture. For the adult involved in the therapy, again usually the mother but not always, the parenting task can be inordinately complicated. Difficult choices between the more aggressive and the more judicious, observant-supportive postures are presented. 

Some situations within their control can be addressed by the involved parent to the challenging co-parent with a firm “this is the way we’re going to do this”. Other situations don’t offer a window of decisional clarity. The parent can do something either this way or that, including a solution that accommodates the wishes or demands of the non-involved parent, or one that assimilates him more into the involved parent’s style of parenting. Compromise does occur, often with therapeutic input. The underlying motivation of the involved parent is usually to keep the original family unit, such as it is, as close as possible and still meet the child’s particular emotional and behavioral needs at the time. The therapist’s role is guiding the process toward a fruitful conclusion, as always, but these are among the most challenging cases to do so, sometimes leading to that difficult spot of “do I push this, or do I let go.” Most all child and adolescent clinicians have experienced the dilemma of letting a heretofore effective therapy go in deference to the family’s need of avoiding an unraveling. A guiding mantra here is “keep the door open.”

Addictive, substance abusing

Obviously, if a problem cannot be safely managed in an outpatient practice, the first act is recommending specialist treatment for the problem parent. Help the ‘clean’ parent, so to speak, toward spousal education, advice, and support as part of the problem parent’s treatment, unless that also is within the clinician’s expertise. Be careful. If the problem parent is not in treatment, look into referring the client’s parent to a specialist or program offering services for their particular educational or intervention needs. Assuming the plan is for the client youth and their parent to remain in treatment with you, coordinate with an involved substance abuse specialist, particularly if their typical practice is to work with all available and suitable family members, minors included. Two concurrent processes working on the same basic problem could possibly make matters worse, hence the need to determine who will be doing what.

Suicidal

Suicidal behaviors that are standing patterns and one of multiple personality disorder defenses are presumed here to be etiologically separate from SI that is a result of depression, anxiety, trauma and other issues formerly known as Axis I disorders. If the pattern is not a hidden problem, known to family, acquaintances, medical professionals, and/or safety personnel, the problem is not very likely to randomly appear in an outpatient child and adolescent treatment practice facility. This would be even more so if the privately practicing clinician or community clinic were a masters-level professional concern. If the case remains with you for one reason or another, the involvement of a psychiatrist or MD with 24 hour coverage and admitting privileges would seem to be a must. Being the clinician of last resort, that person is effectively the lead professional and would expect to be kept informed.

Suspicious of warmth and positivity

By the nature that led into this profession, most of us emanate warmth and positivity to one degree or another. Even if the first sentence of the first session is done with some amount of reservation, within the next 45 minutes that underlying aspect of the ` therapist’s self becomes apparent. Thoughts that the client has suspiciousness about warmth and positivity don’t normally surface for the average clinician, and the client is probably skilled at disguise since adolescence. 

One exercise may be helpful for future reference in regards to this characteristic. Go through the cases in the past that were unilaterally ended by the client for reasons that in hindsight are not apparent, particularly between the third to seventh sessions. Serious, life-impacting suspiciousness of warmth and positivity likely does not appear early on in talk therapies, but looking through those early, precipitous terminations may unearth examples. From those the therapist can learn. If they stay in treatment and a basic trust has been established, logic would suggest that patience is required. This is a serious Axis II problem. Change may be halting and slow. As a 60’s – 70’s priestess of conscious awareness, Barry Stevens asserted, “You can’t push the river.” Affirm and reinforce clear, observable demonstrations of increased trust.

Chaotic life management

Friedrich Nietzsche once intoned “You must carry chaos within you to give birth to a dancing star.” Dancing stars are of questionable value in a therapy office. This trait in a  family adult necessarily becomes a clinical management problem if the problem parent. They would need sufficient organization to make and keep the intake appointment. The effective therapy process then has to survive the chaos of daily activities and decisions at least through the first half dozen sessions. The parent’s problem is likely to become apparent in the history of the afflicted parent, including the areas of relationships, residences, work, finances, health, and education. With that history and a stable first six sessions, adroit reinforcement of organized behavior on the part of the parent may solidify the viability of the therapy and increase the commitment within the family. My first professional role model, Mary Rygg, MSW, a UW School of Medicine faculty member and original member of Virginia Satir’s Beautiful People acolytes, once presented a case of hers that involved a chaotic life management mother of five children that survived the first few family therapy sessions, became a habit for the mother, and lasted more than three years. The older two daughters made sure the appointments were kept, worked with their mother, and she emerged from the therapy a tracker, to use the term. If you ` `are blessed with one of these people that can keep the process going, reinforce changed approaches to situations and patterns.

Self Destructive Behavior

Separate from persistent suicidal ideation/behaviors/attempts, patterns of self destructive behavior will be discussed in an upcoming post.

Conclusion(s)

All three cases were essentially unilateral terminations. One bit of the study compared the three termination variables, including: those that were mutually determined by therapist and clients; unilaterally determined the client’s parents for most cases, or by the clients 16 and over (although latter adolescent clients rarely terminated unilaterally); and administratively driven terminations, e.g. moving away, insurance running out or changes, illness, referred out (also rare). Average outcomes were relatively high for the first group, and fair to poor within the second. The third group was too small to draw conclusions. The three cases of discussion here were among the unilateral group. 

Unilaterally terminating cases as a whole were presumed to be customers less than satisfied

with the treatment or levels of improvement. Most, if not all of these terminations were made by phone message, mail, or text. Determining exactly why each had stopped could only be inferred, but a level of discontent or concern was usually discernible. Something had gone wrong.

These three cases ended on a different kind of note, between the mutual and unilateral group. First, the terminations had been pressured in one way or another, or at least that was the best available explanation and was concurred by the mothers. Secondly, the women all wanted last session appointments that could review the processes, to hear a clinical perspective, get input and recommendations, and at best help chart a course for what was to come. This was typical of a mutually terminating process. While disappointed, these particular parnts did not seem resigned or unduly daunted. Their situations at the time of termination were largely unresolved, but they had developed better senses of how to proceed.

In mental health work, when you’re treating a child in the age range of 4 – 18, you’re also treating the family. That may be the furthest inkling from, say, the mind of a clinician administering a 12-session EBT for a 7 year old’s phobia of spiders in southeast Texas where the creatures threaten to take over human civilization along with snakes, mosquitoes as big as bats, and fourteen foot alligators, or of a counselor working in one setting or another, be it school, ecclesiastic, camp, or probation. The impact on the child does ripple, perceptibly or not onto the family, and the family’s reactions between each other, however subtle, have ripple effects back on the child, shaping however slightly the change inaugurated by the therapy. 

Take for granted that everyone in the families of Nathan, Owen, and Patrick were impacted in some way great or small by their changes. In fact, ‘better’ for one member may be ‘worse’ for another, such are more dysfunctional families. The fathers were certainly impacted, perhaps reacting antithetically in their separate ways, using overt, passive, or both types of aggressions to protect themselves from their own insecurities an fears, or so one could imagine. From the vantage of reality’s concerns, the ones who had more panoramic perspectives were the mothers, not to romanticize this because the extant issues were of deep personal meaning to all eleven members of these three families of origin. Trackers follow the ripples, be they imperceptible or tsunamic.

Coming into their last meetings, regardless of the difficult circumstances, the mothers had made several gains of their own. To the degree that they harbored doubts, the early phases of their processes reassured that them their child could get better. Each boy had shown more relational involvements within their families, which also helped improve their moods and self-perceptions. This was particularly true for Nathan.The power of reinforcement and praise to change targeted behavior patterns like joining more and improve self-perceptions was affirmed. The transformative process of the mothers turning anger in its various manifestations into worry’s concerns, and then on to creating directions of positive change had become a staple. That was particularly true for Owen’s mother. Their native abilities to both assimilate and accommodate were more consciously employ. All along they knew that growth is a process, but that’s basic mothering. Keep the faith.

An under appreciated clinical factor of talk therapies is the tempo of sessions. In the interactive session work, therapists tend to be attentive, calm and relatively quiet, contemplative an considerate. The dialogue is usually of measured and unbroken sentences and paragraphs that go back and forth, all toward a mutual clarity and meaning, and hopefully onto a translation into purposeful action or behavior. This manner is almost always at distinct odds with habitual, day-to-day realities of stressed, troubled, or in other ways difficult homes that end up seeking remedy. 

The communication process becomes a model in and of itself. Some clients, certainly not all, will absorb and replicate the experience during moments when the style itself can be a modulator, as much if not more so than the words, The child(ren) may begin to absorb as well. 

While exactly how they had been at home had neither been brought up or explored, the mothers of Nathan and Owen were at home with the office manner. The one person involved in these three cases whose pace, focus, and congruence of thought substantially changed was Patrick’s mother. The degree to which her experience in this family work helped with the growth is difficult to say. She had been in her own individual therapy throughout, and that was likely of greater impact. Regardless of how and why, her interchanges were calmer, more on point, more oriented toward the parenting, and less in expressed helplessness. Her sense of what mattered at the moment had grown. The changes were matters of evolution rather than feedback or spoken discovery, altho the change was part of the feedback given during the last meeting.

The last meetings with each of the three mothers had a certain congruence that went unrecognized all these years, private practice having this “lean forward” momentum that tends to move rather quickly past reflection. The circumstances of the cases at the time of their terminations were rather bleak. Two of the clients had regressed almost back to their baselines, and the third was enmeshed in what seemed to be an impervious, impenetrable new household that foretold possible trouble…maybe or maybe not, but the anxiety in both mother and child over this development were present for the same reasons. 

What was striking in these mothers in their last sessions, again in hindsight, was the composure, thoughtful determination, and continued trust in the clinical feedback they were receiving as they sat there and worked. And while dealing with these very similar process endings, these three pretty distinct personalities now seemed so similar in this regard. 

While clearly bothered by the circumstantial events leading to end of treatment, none came in looking for some kind of reclaiming action or resolving approach on my part.  They were accepting the current status, leaning toward a longer point of view. While I certainly gave each situation some thought. Nothing beyond simply waiting for opportune future moments to meet with each boy and see where that could lead came to mind, and even that might be a stretch.

They were there to work rather than review, which would have been more typical of a final meeting, and generally knew what they wanted from the session. Respecting them and the broader matter of their family’s evolutions, I followed their material and questions they brought up. If there were any clinical theme that characterized all three, it likely would have been the concept of assimilation and accommodation, trying to sort out what to accept an what to push in their child’s needs and in the interest of the family. Also, how keep the long term conversation going as much as possible. Cutting ties never entered any conversation.

Typical for a last session, affirming feedback about them was given toward the end of the hours. Observations about each child’s particular impressiveness were shared. Within the realities of each situation, at least a couple of reassurances that their approaches stood reasonable chances of working. And that they could always return. 

Historically in this practice, about one in ten to twelve cases returned, usually within a couple of years. Had any of these done so, that would have been heartening, but more so somewhat pleasantly surprising. And they did not.

The therapies may have been taken as for as possible, given the intrinsic headwinds. One certainty was that more trust existed between mother and child. Trust had been a basic issue for Nathan, and that would probably continue, but he began cooperating, helping, and on occasion even ardently playing with her. Whether Owen’s issues were trust or an embedded anxiety of some sort was never clear, and whichever probably remained a potential problem as he entered adolescence, but he and mother related much more effectively. Patrick never demonstrated a problem with basic trust, but more one of who would care for him in what way and degree. His mother became more other-focused, which did help reduce his anxiety. Remember that when he was telling stories about the small block constructions he made during sessions, the theme was war between two sides that, for quite a while, ended up in death, but toward the en, everybody made up an “everything was better.”

The mothers knew more about their exes, what they could and would and wouldn’t do, and about their vulnerabilities, how each could feel or be hurt. Those things all mattered to aid in avoiding implacable stalemates and disdain. For Nathan and Owen’s mothers, most of the thoughts snd suggestions reinforced their own thinking. For Patrick’s mother, the feedback was in the vein of continued change. She would be remaining in her own therapy.

From beginning to end, these cases transpired over a period of close to four years. The similarities that prompted this section of posts did not became apparent until studying the data some two years after closing shop. In particular, they stood out within the unilaterally terminating case group. In particular, the circumstances of their particular terminations and the difficulties the fathers seemed to have presented were in common. In the course of the writing itself, the notion of the family tracker emerged, or call the role a center of gravity, or simply the mother, but that’s not necessarily true because fathers can be this also, and in really strained circumstance, an oldest child or closest grandparent. Maybe the saddest of all is the centrifugal group that flings members out alone from each other and no one’s really watching. 

In these difficult cases of relatedness or Axis II issues, splits, custody contests, unrepentant hurt and hostility within people who are unavailable or destructive to the clinical process, and/or sometimes terror, keeping the process going is most always a challenge. Often they end in a minor key, and the interim task is to stay even as the work continues bit by bit. What became clearer here is that in such circumstances, the clinical focus can turn toward the one who’s keeping track of the relationships with the purpose of keeping the family together, even though sometimes split, as much as possible. This is an advantage of family therapy. Among the myriad of aids, the work can help foster the healing graces of gratitude and forgiveness.

Keep the door open.

Lastly, would the concept of the tracker have helped had the thinking been available years go? For the majority of family therapies involving child and adolescent mental health problems, probably not very much. For a few cases, the concept likely would have made significant differences, and I wish the opportunity had been there. But that kind of wist is part of a therapist’s reality.

#40 – LEARNING AND EXPERIENCE Re: #38, 39

Prelude

In spite of its novel and progressive origins during the mid-20th century, family therapy tends to be fairly conservative. Understanding that psychotherapy generally has very few absolutes, which themselves are hallmarks of conservatism, the school “tends toward” rather than “ is always”. Conceptually, the basic approach leans more toward the adaptivity model than the disease model; the work tends to be more “with” rather than “on” the clients; is more inclined to point out and reinforce observed change rather than channel toward a certain state; and  certainly operates more collectively than bilaterally. The focus is more on generating accommodation and assimilation, the parallel twins of adaption, within the family unit. The attainment of diagnostic objectives and specific symptomatic resolutions are important, but not the soul of the process.

Still, processes sometimes don’t go well, or right, and as much as our human instincts in difficult circumstance may generate impulses to take certain clients by their metaphorical shoulders and gently shake them into awareness, we can’t and we don’t. So, we get these cases such as the three in Post 39 above that make us pour over strategic and tactical decisions, looking for the understanding or clinical gem through which needed change might have been effected. We go through these exercises if for no other reason than the well being of the child.

Statistical Comparison of Completed (Post 37) vs. Discontinued Cases (Posts 38, 39)

All six cases tended to be more complicated than usual, presumably due the split family factor in combination with the likely presence of parental Axis II issues in all six cases, and pre-Axis II problems for three of the youth. These kinds of cases tend to take longer and use more sessions.

Several similarities between these two small groups are at least notable. The average initial CGAS for both groups were near the study group overall average of 55, as was the average age of the clients at intake. In those modest regards, the six as a group were indistinct from the general study population. Five of the marriages had ended in divorce and one was in the process. In essence, all families were separated. All six fathers were seen as probable Axis II involved. In a way, the overall combination of these disparate similarities can support the clinician’s maxim that at the beginning, ’you never quite know what’s walking through the door.’  

The differences between the two groups are more pronounced. Both the average numbers of sessions and lengths of treatment were 2.5 times greater for the more successful Post 38 group than for the those of more disappointing #39. #38’s CGAS gain was more than four times as high, and the average DA/PA resolutions three times higher. 

The average CGAS gain of 24.7, DA/PA resolution rate of 4.0, length of treatment, and number of sessions for the first group are as high as most any sub-group within the study itself. In contrast, the average CGAS gain for the Post 39 group of 6.1 and DAPA resolution rate of 1.3 are as low as most any other study subgroup

The family-based treatment approaches can result in substantial improvements for those cases involving the presence of Axis II issues, but these levels of gain will most likely take considerable time and sessions, and will also depend on the numbers and severities of the extant Axis II issues in each family.

Please note: a fair assertion is that any treatment approach, family and otherwise, with these particularly complex family issues will require higher levels of resources to positively impact not only the client but the rest of the family environment that is involved in raising the youth and hopefully reinforcing and maintaining client gains. The socio-political issue of inadequate or even no resources available to support such processes for an increasing percentage of families within the national population (circa 2020) is becoming more pronounced.

As another aside, comparing the average CGAS gains and DA/PA resolutions within each of these groups adds a bit of validity to the DA/PA scale in particular, it having been designed for the purposes of the study and never vetted.

Anomalies 

#1 – Double the problem…

All six cases had in common fathers with likely Axis II involvements. One of the mothers was also seen as probably Axis II involved. Three of the boys were assessed as having relatedness, or pre-Axis II issues. Two of the boys were in the Post 39 group while the other was among the clients in the successful group #38. Whether the latter youth was actually pre-Axis II became debatable by the time his therapy ended, he having resolved all four of the relatedness issues presented during his assessment some three years earlier.

Five of the nineteen overall youth in the study who were seen as having relatedness issues were scored with three or four symptoms (Post 26) during their assessments. Both clients with three symptoms largely resolved their relatedness issues, as did two of the three clients with four symptoms. None of the remaining fourteen, those with levels of five to eight relatedness traits at the beginning, achieved significant resolution. Just based on that finding, one could begin to surmise that those who resolved may not have been true relatedness problems from the outset, presuming that real Axis II issues in both youth and adult do not tend to resolve so easily. The boy from #38 who had four symptoms was much better at treatment’s end. The two in the second group, who had six and seven symptoms, resp., were more intransigent and remained to have most of their these issues at treatment’s end.

The major differentiating factor between the two groups was that each of the three cases in the #39 had two Axis II problems. Two included the fathers and their twelve and thirteen year-old sons, and the third included both father and mother but not the client. Thinking triangularly, these were cases in which all three sides were compromised, therefore more prone to conflict and irresolutions. 

When only one Axis II issue is within that triad, at least one side to the triangle can operate more or less normally, that being between the non-Axis II family members. Their work together can often keep at least one of the other two sides from failing, and sometimes both. In the best of circumstance, one which can and does occur, all three sides can evolve to persist on better and stronger terms without necessarily resolving the underlying Axis II problems. One could argue that this was the result in the cases of Hank and Jackson in the first group.

Interestingly, the most serious problem on the surface within the three family members is not necessarily between the two personality problems at any given period of time. In the second group, one was between the mother and the thirteen year old son as she strained to normalize his family, social, and school presences. The other was between the father and non-Axis II mother. The third was between the two Axis II challenged parents. Given the varied structural dynamics, an efficient, overarching clinical program with a prescribed step-by-step nature for the family is difficult to conceive. Each case may call for its own approach or method.

Another aside is that only a handful, maybe ten times during the overall thirty-five years of practice, situations involving likely Axis II issues for all three in the mother, father, and youth triad went through the family process as offered at the time. As recalled, they tended to be eccentric, prone to some of the less potentially malevolent defense mechanisms such as denial, externalizing, ego-syntonic, and/or ignoring boundaries (as opposed to being demanding, aggressive, rejecting, lying, manipulative, and/or splitting). A few tended to do remarkably well during therapy, albeit not necessarily in the Axis II area itself. Others certainly did not.

One such case was seen in four separate counseling sequences over a four year period of time, about seventy sessions in all, as the boy and parents navigated their idiosyncratic way through a tumultuous child-to-teen period of fourth to seventh grade. The boy was defiant at home, inured to grounding and loss of possessions, disruptive in class, often sent to the hallway or principal’s office, annoying and contemptuous toward peers, missing assignments altho passing tests sometimes with class high sores, destructive with items both at home and school, possibly filching small items from parents, peers, and classroom, and apparently prone to telling tall stories. The working parent was a data manager for the local hospital system. The other was a retired civilian military consultant who could be seen occasionally walking a tall, stately Scottish deerhound in the area. 

Some time in middle of the process, the boy matter of factly related a story about the family cat trying to jump over the kitchen sink and getting one hind leg caught in the running disposal, and lived, and I just sat there just looking over my glasses at him, pursing the beginning of an incredulous “what?”, wondering ‘could that have really….?’  as he moved on to something else and I continued to listen and decided this had to be nonsense and ignored it, at least for the time being. The image recurred, and really did kind of ruin the rest of the day. 

The therapy eventually ended for financial reasons, but throughout they remained different and likable. The boy’s more extreme concerns like stealing and destructiveness were reportedly resolved. At least the parents were dighted. Contemptuousness had also dissipated. To a degree, defiance improved at school but not so much at home. He transferred to a district arts and humanities program with its own school counselor. I coordinated the transfer insofar as the individual work was concerned. They were a much longer story, unforgettable but for the most part a positive experience. Not so much the image, sadly still sticking around.

In sum of these generalizations, those cases with one Axis II can be more easily managed and positively effected in a family therapy setting, the exceptions being the more disruptive and controlling types that can be difficult under any circumstance when on a roll. The most difficult cases here were when two people within the basic triad had Axis II involvements. Those situations were the anomalies. The very few cases where all three were Axis II involved either made limited progress in their odd, often friendly, and manageable ways, or left having made little gain during abbreviated processes, i.e. six sessions or less. A portion of the latter were referred to child psychiatrists for medication evaluation and further treatment. 

#2 – Steep falls following substantial gains…

The two adolescent cases in the second group both experienced precipitous declines of gain after a period or more or less steady improvements. In and of itself, that was an unusual pattern.  With ODD cases, as these two were, a degree of vacillation in their upward status line during the first few months of therapy was common, particularly as they go about the business of sorting out their respective autonomy and emotional regulation concerns.

Both demonstrating clinically difficulty ODD symptoms, Nathan and Owen had somewhat unusually quick and substantial gains over the first 10 – 15 sessions. However, they both precipitously declined back down close to their baseline status, Owen doing so while still actively in therapy, and Nathan during the period of time after his first therapy period had stopped (due to insurance coverage), and then abruptly stopped again just before the second period of therapy had the chance to gather momentum. 

These were uncommon drops and, I believe, anomalous losses following periods of gain. The hypothesis is that undue stress had entered the clinical picture. In both cases, the circumstances indicated a paternal antipathy to the processes involving their sons. That, in turn, presents clinical dilemmas of a high sort, i.e. what to do.

#3 – If something happens once…

In Patrick’s case, the father left the mother immediately after the first client interview with his then seven year old son. He was given primary care responsibility by the judge, having the boy nine out of every fourteen days. He then terminated the still productive process when the divorce was finalized some eighteen months later. The initiation and termination of the therapy had the appearance of being preconceived. The conditions of custody and authority were affirmed. The termination appeared to be irrespective of the boy’s particular needs at the time. The apparent faithlessness was somewhat breathtaking, but then, parts of the story were almost certainly unknown, and those could alter perspectives.

Almost exactly the same sequence occurred about a year later with another early elementary-aged boy. Between the client assessment session and the assessment summary session with both parents, a father initiated a separation. Of note, the client assessment session itself went quite well, as was also the case with Patrick. The consensual parenting plan established the father as the primary caretaker, the mother having the boy every other weekend. A nanny had already been hired and the mother was in the process of moving out.

The similarity between the two men was their certainty. This father was particularly assertive where Patrick’s father was further out on the right side of the passive – aggressive continuum. The terminations of the two fairly long processes were unilaterally determined by the fathers around the time of the divorce decree itself. The difference between the two, in hindsight, was in their individual focuses of self-and-other, the first father seemingly locked in on the ‘self’ part where the second had more orientation toward the ‘other’. 

The latter’s concern precipitating the termination was about school placement. Some well established research data was offered that questioned his plan, but the shift in schools went ahead. He simultaneously ended a process he thought had been of some utility, but apparently had also run its course. How much that had to do with the divorce finalization was unclear, but they were close in time. 

The boy had made surprisingly significant progress in his own sense of self-and-other that had been sorely lacking before treatment, but that was short of the father’s expectations re: academic improvement. The nanny brought the boy to sessions, spent some of the time aligning her own style with what was being done with the client, and the father had been peripherally involved. The mistake I had made was not keeping the father sufficiently abreast of the changes that were occurring within his boy, their meaning and implications, and preaching a bit of patience. But in both instances here, the fathers acted quite independently both in initiating the divorces and terminating the treatments.

This particular scenario of beginning a treatment process at the very beginning of a divorce process does make some empathic sense, but in actuality was uncommon. Having the father independently beginning the therapy process was rare. Taking these two cases as one’s “if something happens once, take note, and if something happens twice, you have a pattern”, the clinician may want to consider how to head off the third stanza of “if something happens three times, you have a problem”, because apparently the ‘problem’ can arrive foregone. Keeping the father apprised would appear to be key. 

#4 – Single mothers with ODD children 

Seeing a single mother with an ODD child was not exactly anomalous for this practice, although doing so was far less common than the broad statistics would suggest. Purely coincident and unrelated to each other, single parents and ODD cases both represented roughly 15% of the clientele. That fact would imply about 20 – 25 single mother – ODD cases over the years, but maybe as few as four or five were actually seen. Nathan and Owen’s single mother situations were almost unique, and that’s aside from the problems their fathers brought into the baseline.

Two factors may account for the fewer single mother – ODD cases seen in the practice. Single mothers probably have a more difficult time getting their sons into a therapist’s office at all, they being oppositional-defiant. Secondly and presumably, boys might also be more amenable to take a drug rather than engage in talk therapy, given the ultimatum of one or the other. Beginning around 1990, a watershed time for mental health practice, the burgeoning pediatric bi-polar disorder industry accommodated that preference as ODD was being regularly re-defined as PBD, and PBD was almost exclusively treated with multiple medication combinations that were vernacularly termed “cocktails” (read Your Child Does Not Have Pediatric Bi-Polar Disorder, Stanley Kaplan, MD, 2011).

The conjoint family process was employed in most every case, a shift following an initial four year period of individual counseling in the practice for ODD proved futile. What came to be understood is that having two parents working together with their child in a family setting was the essential element of a successful therapy. Defined by all three sides reflecting stable relationships, a functional triangle is a strong corrective measure, and can better sustain that necessary degree of stability through the inevitable fluctuations and permutations of family life. The nature of the parents’ relationship is foundational. At the very least, the tendency to blame each other for the problem, if present, needs to be resolved. That can be done either in the primary format of conjoint work, as a prelude, or during a short split session treatment period.

The speed with which Nathan and Owen made changes may have been deceptive. When both of them began balking and regressing in their own therapies, the assumption was made that the slides would be transient. The task remained the same, just work through the downturns in spite of their sudden onsets and precipitous regressions.

Not having much experience with the single mother – ODD child configuration, I was possibly slow to recognize that the some of the dynamics involved in both Nathan’s and Owen’s cases were not dyadic in nature, but rather one of a toxic triangle that included the therapeutically uninvolved Axis II fathers. The clinical relationships were meaningful for the mothers and and at least respectfully received by the boys until the course of their treatments went rapidly south. The strength of the clinical relationships and the progresses that had occurred proved to be was nowhere near enough to pull the boys back up to their improvement lines. Hence the clinical dilemma. That third corner of the triangle was impactful and unavailable.

If the fathers are present in the boy’s life, even if not involved in the processes, they best not be discounted.

But, what to do?

The Dark Matter

The first problem is the nature of Axis II impacts on behaviors, communications, and other relationships. A quick review:

Miriam-Webster presents a succinct civilian definition of ‘personality disorder’ that suitably characterizes the inherent dilemmas of clinical work within a family system that is potentially impacted.

“Any of various psychological disorders that are characterized by inflexible or impaired patterns of thoughts and behavior that usually cause difficulties in forming and maintaining interpersonal relationships and meeting the demands of one’s personal and work life.” …and add ‘the patterns are persistent over time and circumstance’.

Emphasize the terms ‘inflexible, impaired, persistent’

Predictability in clinical work is desired, particularly when contemplating between different approaches, strategies, or tactics for a given quandary in a given case. With Axis II individuals, the predictability of an action taken is reduced. While the intention may be the best, the result could be quite the opposite. The reaction to the clinical action can and will be shaped by any one or more defenses from the following list.

The Leider Dictum is also pertinent, that being:  ‘working with a family is like walking through a minefield – they know where the mines are, you don’t, and if you try to lead them through, you can get blown up’. Trying to make untoward Axis II behavior more toward can produce great results, but just as likely if not more so, unleash a torpedo. The sequelae of an activated defense may in some instances be predictable, re-directive, and therefore clinically manageable, but one can fairly assume that case may be among a significant minority.

Clinical Considerations

1. Confront the father problem?

Perhaps the most obvious critique of the clinical management for these three cases would involve the relative passivity toward the apparent paternal oppositions and obstructions to their sons’ therapy processes. Could anything be attempted that did not run a risk of worsening family functioning, a viable consideration in light of the probable determinations and impairments of judgement involved. The therapies had been fundamentally working and the potentials of change manifesting. Would those starts actually be enough for the mothers alone to maintain that upward incline of improvement over time? With the potential up-and-down vagaries of their behavior disorders? 

What would have been helpful was a process by which the fathers individually came to the office to weigh out their own needs versus those of their child, and join in collaborative reasoning toward a way to better meet both? That would be the therapeutic goal if, indeed, they cooperated. 

Two of fathers were aware from the beginning that they could make an appointment at any time, and the third could choose at any time to participate in the on-going family work. They all chose not to do so. 

As a rule in my practice, calling family members not involved with the therapy process of their child to suggest making an appointment for discussion about issues X, Y, and/or Z was not done.  The closest to doing so would be suggesting to a client either in the office or during a call they placed to me to, say, come in sooner than currently scheduled, or increase the frequency of sessions, etc. In this manner, we can talk about the feasibilities of my inputs in the context of their on-going therapy.

Some outpatient therapists do ask people to come make appointments. The social workers’ Code Of Ethics, a 29-page booklet once proclaimed by the NASW as the longest and most detailed ethics code among the health care professions – par for social work’s pursuit of due diligence – does not prohibit entreating someone to make an appointment. To me, the problem was the use of a professional position to persuade an appointment for a family member not involved in the treatment, one that would result in a payment or a use of a session benefit, more likely both, all of which are at their expense. That may not be unethical, but still feels like a misuse of professional authority. 

Another dissuader is that by asking someone to come in, the clinician is essentially responsible for the session’s content. Therapy sessions are designed to focus on the client’s presenting problems or content. 

Calling non-involved family members to argue convincingly the need to make changes also puts the clinician in the role of rescuer. If the session becomes upsetting to the beckoned interviewee, the subsequent objections to family members and maybe others involved shift the therapist from the rescuers role to that of the victim, the one being blamed for the problem(s). As stated in earlier posts, the ultimate victim of unbidden rescuing will likely be the young client if the therapy process itself is ended. Like any family, these operate by their own rules and customs. 

Lastly, If the call is made and a session does occur, the report out by the father to the mother, and/or to their child(ren), and/or to others in the family network may have no resemblance to what was actually said. The impression that the therapist strives to leave can get grossly mischaracterized as their self-protective defense mechanisms of are activated.

More broadly, asking someone to come in over the phone under these circumstances may produce wonderful results, or may completely backfire. One can view aggressive tactics as high risk gambits – they may really work, and they may really not, and accurately predicting when and how Axis II issues are involved is difficult unless the clinician is particularly expert with personalities and their particular, peculiar manifestations.

2. Interim Parental Reviews?

The fathers all knew they could make an appointment at some time, and chose not to do so. Regardless of their actions, that needs to be respected, at least from this point of view. Could they more indirectly be drawn in? 

Addressing the possibilities of paternal opposition was done mostly with the mothers in brief individual side sessions either at the beginning or end of a conjoint session, and the result was usually just a suggestion to talk with the father about some specified issue. To bring the topic of the father into a discussion for either Nathan or Owen had proved difficult, the two boys being avoidant and the mothers judicious. Avoiding a reinforcement of resistance was important, and both mothers were astute. 

The therapies were in early stages for ODD-type problems, still working mostly on the manifest behavior issues.The overall progress was moving along nicely before the issues of paternal opposition became more palpable. In hindsight, floating the idea of a parental review of the process seems reasonable. The mother’s would likely have been favorable. In general, mid-therapy conjoint reviews for separated or divorced parents in this practice general were far and few between, but nevertheless precedented. Including Patrick, all three cases may have benefitted. The mothers would have likely concurred. 

The risk is that manifested Axis II defenses may make matters worse in the aftermath of a review. The fathers could have silently experienced the directions that the therapy as threatening to their own needs or plans, and stopped or sabotaged the process even earlier than they did. Proposing interim parental reviews under these circumstances would need to be carefully considered with the involved parent, perhaps through a separate session with the mother. Protect the process.

3. Stuck on Format?

At the beginning of a particular kind of intake with the parents, the first to speak, usually the mother, would lean forward on the couch with hands clasped on her lap, look down for a moment of thought gathering, then earnestly look at me to utter, almost verbatim, “He’s really a good kid, but…”  

What inevitably proceeded was a description of the behaviors with which they’d been struggling that perfectly described ODD. These were difficult moments for the parents as they often felt shame, frustration, sadness, and lots of worry, anything but unbridled joy. Once started, though, they became comfortable and relatively easy interviewees. Someone knew of that which they spoke, was not taken aback, asked the right questions that helped them expound, nodded an “mm hmm” at their elaboration of their child’s behaviors that spoke to them ‘Right, I’ve heard that before….’ The therapy had already begun.

As said earlier, family approaches were categorically better with ODD than the individual therapy approach, at least as was practiced here. As a secondary benefit, the results of the family therapy work helped drive a reputation. Everyone knew these were difficult cases, A few may not have worked out, but most did. Conjoint had become my ‘standard operating procedure’, to use a military term in honor of the embattlement. Families most often persevered, did better, got happier.

The one recurring strategic error during the last twenty years of the practice, at least of which I am aware, were instances of staying in the conjoint format too long. Whatever the resistance or discomfort issue may be before me, the almost unconscious operative belief was that the family therapy process would facilitate necessary resolutions. Every once in a while, the onset of an inadequately addressed discontent of one kind or another lingered too long. Having had enough, the family would unilaterally stop, not really angrily but certainly disappointed. This did happen in one of the 58 study cases here, neither being Nathan and Owen. Those two could be seen as decisional question marks in this regard.

Regardless of their proximal causes, when family member resistances appear to rise and processing them proves discomforting, would recommending a change from the family format to one of split sessions have prevented unilateral and oppositional terminations? Again in hindsight, Identifiable moments occurred in each process which could have prompted at least the thought of recommending a change to seeing mother and client separately during the hour.

When Nathan wrote on the waiting room’s dry erase board “Run for your life out of this place”, he could have been seen as a candidate for an individual therapeutic process and relationship. Work with the mother would mostly concentrate on parenting Nathan, but also discuss the father and his historical and current family role at greater depth. Something there just did not add up. With Nathan, the initial purpose would be to create a space in which he could develop a dependable trust. An inherent degree of suspiciousness likely contributed to his social isolation, a common underlying dynamic in ODD. Family therapy could help with that, but maybe in individual even more.

When Owen inexplicably buried his head for a minute or two in his sweatshirt and shed tears for the second time after several productive sessions, a change in format could also have well been considered. Some specific issue was certain, but he was more stubborn about disclosure than most. With his demonstrated degree of regard toward me during the latter portions of sessions and when leaving the office, he may have been approachable. The Nash Equilibrium – a person decides what to do based on their perception of what others will do, not necessarily what may be in their own best interests, e.g. Dad will get mad so I won’t (do therapy)  – could have been used as a clinical structure with Owen, enable him to operate more in his own best interests.

For both boys, the purpose would be to establish meaningful individual relationships that may have survived the impacts of the random discontents, irritations, and/or disguised worries that presumably radiated from the fathers and ultimately ended the therapies. The split session format could have allowed for more in depth work with the mothers re: fathers. Doing both perhaps could have headed off these premature terminations.

Had the switch to split sessions for been considered, one prevailing concern applied to both young clients. They were oppositional-defiant, no doubt getting better, but as said, ODD generally takes a longer time to treat with more lability during treatment itself. Those are simply facts. For whatever specific reasons that would include simple stubborn impulse, each could abruptly say ‘no more’ to individual counseling, and getting them back to the conjoint process may prove impossible. They had been cooperative thus far. Under that circumstance, saving the split session process as an option if either refused to continue conjoint for one reason or another would be prudent but would continue individually. The conjoint format may also served as a salutary sanctuary and in that way actually preferable.

The individual concern about moving Owen into individual work was the reality of the father’s veto power over therapy processes. The father may have been threatened by his son developing an individual clinical relationship over which he could feel diminished, and preemptively exercised  his veto. 

While Nathan had also been cooperative being seen with his mother, he was much more hyper-autonomous than Owen and more than likely to ‘put his foot down and out the door’, so to speak, had something gone amiss or the father privately objected.

Both may also have been more manageable being seen with their mothers than individually. One view of ODD kids is that they have disturbances of autonomy. Almost by definition, they can be excessively independent as they act out, and then bewilderingly hyper-dependent when in a practical or emotional need. Hard to sat for a fact, but the process may be safer done as conjoint. 

A split session format would have been more viable for the mothers had they been in particular need. However, neither were at wit’s end in regards to the fathers, and the boys had been clearly making progress in an overall sense. The two or three times each had met with me for a few minutes before or after the conjoint session were at my request, mostly over something administrative. Suggestions they talk with their exes in regards to a specific issue or need for clarification of some sort occurred a couple of times with each. Owen’s mother had her own therapist with whom she was covering issues with the father. Nathan’s mother could generally talk with his father about her concerns and wishes, usually received cooperative responses, if occasionally not a genuine or full disclosure.

4. For future reference….

One mistake was not referring Patrick’s father and grandfather to an adult therapist. The father came in once for parenting help, and the grandfather came in with the father to get help essentially parenting his own son. They did not ask for another appointment. One was also not offered in order to avoid a conflict of interest with the process focusing on Patrick. A more complete closure of the session would be an offer to make a referral if they wanted further input. The father’s father may well have taken up on the offer.

A second oversight may have been not contacting Owen’s mother’s new individual therapist. The informal standard of practice is for the clinician new to a case to contact the current therapist just as a matter of introduction and coordination, if necessary. I did not see the need, but neither did I see the case terminating so prematurely and abruptly.

Also, pursuing the release that went unanswered with Patrick’s mother’s therapist to gain her insights may have helped, but one could also argue in that the contact may have made little difference anyway. The father’s abrupt termination of the process after the divorce was legally finalized would have been difficult for either one of us therapists to anticipate. 

Note: Next post is summary and conclusion of this section including posts 37 – 39

HARD CASES – VIGNETTE #39

Owen

Owen seriously did not want to enter the office from the waiting room. If he were younger and that resistant, the accompanying parent(s) would have been brought into the assessment session along with the youngster, a rare event in and of itself. But being twelve, volitional, and discreet about disobeying in public, he finally hung his head and trudged to the couch. Once he started talking, in his case after only the second question of ‘what brings you here’, he was cooperative, forthright, cautiously informative, well spoken, and a bit unconventional.

His view of the issues reasonably resembled his mother’s viewpoint as expressed during the initial parent interview, which is usually a good omen. What he straight forwardly listed were problems both at his mother’s home and at his father’s place. A voracious reader – he had read 750 pages of Game of Thrones in the two days prior to this appointment – in regards to his father’s home Owen said that his step-mother’s main complaint was that having any kind of discussion with him was very difficult. He immediately followed that with the unsought explanation “but a lot of women are like that”, he of twelve years old. The implicit question of modeling occurred to me. His jaded quality would continue to appear from time to time.

Along with three other symptoms of depression, he endorsed occasional suicidal thoughts. He had no intentions, no plan, no notion of method, and nor any research. The reasons why he would not make an attempt on his life involved significant concerns about how others would be hurt, and he would not want that to “ever occur”. He also denied having problems with sleep, headaches, or stomach aches, those three being the cursory indicators of child and adolescent generalized anxiety used in this evaluation format. If two or three of those were endorsed, the evaluation would move to a more comprehensive inventory (actually using the 18-symptom list out of Generalized Anxiety Disorder in the old DSM IIIR, in my judgement the best instrument for the purpose of an outpatient initial assessment). This was not necessary. The basic symptomatic problems were depression, behavior, and relatedness. But anxiety remained to be a hypothesis of mine. Something did not add up.

His self-esteem was over 5 (on the scale of 10) for five of the six categories. His self-perceived greatest strengths were his intellect and his school performance. Owen gave himself a score of 4 for peer status and social skills, an assessment that corresponded to his reclusiveness. Early life stress and loss have heightened reactions to perceptions of peer rejection (Peutz, et. al.; J. of Amer. Academy of Child and Adol. Psychiatry; Dec ’14). His hesitances to come into the office would suggest a problem with anxiety, but his self-rating in that category was 6. His overall self-esteem as gauged by this evaluative test was close to average for an early adolescent male living in the north Eastside area.

His ego-development evaluation came out at a mix of Stages 4 and 5, high normal for his age. The socio-moral eval came out at another high-normal stage 4, altho his answer to the question was unorthodox, to say the least. A version of the Heinz Dilemma was used as the problematic situation presented to the client, where an aged husband was faced with either stealing a pharmacist’s unaffordable life-saving cancer medication for his ailing wife or watch her die.  Given the question ‘Should he or should he not steal the drug?’, Owen paused for a few seconds, started off by saying “It’s against the law”. He then answered more directly, proffering a utilitarian point of view that the “old man should not steal the drug because they’re old and their time is up”. Categorically, his was a Stage 4. Utilitarian thinking for a 12 year old is good, to be sure, but I quickly worked to stifle what would have been an entirely inappropriate, hand-cover-you-eyes laughter. This response just could not have been anticipated, so what emerged was a bowed head “good answer” to this bright, brooding youngster, he being all of an age twelve. 

After asking him if he had any questions he wanted to ask me – and there were not – he was posed with the choices of being seen alone, with his mother, or with mother and brother all together. He quickly chose being seen with his mother, doing so without any umbrage. I concurred, and the session ended on the upside.

He walked out of the meeting more confidently than when he entered, and left with an eye-contact, spontaneous ”thank-you” as he walked out the office door. Right behind him, the mother querulously did a searching look at him-then-me-then-him-then-me, and gave a surprised nod of gratitude herself. 

In the summary-and-planning session with the mother, she concurred first with the overall assessment that suggested either a primary problem with depression or ODD, leaning toward depression. His anxiety portion of the symptomatic problems was based more on his own overall presentation rather than his self-descriptions or results of the evaluative exercises. The source of the anxiety was not clear, although the moodiness and more recent reclusiveness were also evident during toddlerhood. A harbored clinical hypothesis was that he now had either some identity issue, and/or was being impacted by the difficult struggles between his parents. The mother also concurred with the recommendation that the two of them be seen together. She also had relayed the information to the father that he could make an appointment for himself. 

The first meeting with both was productive in outlining the problems that needed to be addressed from the mother’s perspective, including moodiness, withdrawal, disrespect, chores, and non-compliant classroom behavior, all defined in terms of their opposites, to wit: more pleasant around the house; more time with family; more appreciation of others; more compliant with chores and requests; and meeting expectations in schoolwork and behavior. The only complaint of Owen’s was that the mother would often get angry with him. The mother’s hopes included generating better communications, develop a better understanding of how to help her son become “a healthy, happy, confident young man,” other challenges of parenting, and managing her own feelings. Having enough time to “do everything” was problematic. Owen remained attentive. He could or would not identify anything he would like to see get better other than his mother’s irritation, but the mother agreed with his observation and asserted that she would work on that. 

Both were involved and verbal. Some topics gained Owen’s genuine interest to the degree that almost the entire hour was used. That meant the promised game of Jenga, to which Owen had looked forward, would have to be postponed. He left contented and dropped another “thank-you”. This being progress, Mom was pleased.

The next session began with reviewing the progresses and changes that had occurred over the week. The mother reported him to be more talkative, picking up after himself, doing his chores, receiving no complaints from school, a couple of high quiz scores, and a more pleasant mood. Owen concurred with what his mother said, and added that she had not been irritated ‘very much’. He did participate, however minimally, about what led to the changes. Elucidating why he was ‘less stressed’  was difficult. Talking about himself seemed painful. The underlying anxiety remained unexplained.  Pursuing what led to that stress in and of itself provoked irritated silence, so we moved to the next step of ‘what can I do for you today?’. 

The mother brought up the amount of time reading in his room. In short order Owen became teary, and buried his head in clothing. When asked about his feelings at the time, he said he “didn’t know”, and then emerged from his sweatshirt. He slowly began to participate. The next step would normally be a return at some point to the question of what led to the tears earlier. The problem is that “I don’t know” usually means “I do know but I don’t want to tell you”. Given the client’s ambivalence and apparent lability, pushing the envelope carried unnecessary risk, so with 20 minutes left, we finally arrived at the step of playing the Jenga game. What emerged a vast difference.

The heretofore unseen side of Owen, the one that the mother declared existed during the intake, emerged as a happy, energetic, engaged competitor. The game could be played one of two ways – who would make the stack fall, thus creating a “winner”, or collaboratively build the stack together as high as possible. In this therapy, the decision or inclination about how to play the game was split about half and half. All I would do is observe, maybe give a tip here and there, but mostly take advantage of the opportunity to ask more informal questions, to get to know them better, and they me.

The two chose to see how tall they could create a tower, and animatedly worked their placements of the individual tiles up to 29 levels before the building crashed to the carpet. The mother applauded, Owen covered his ears, and leaned into her as she put her arm around his shoulders. 29 levels really was a very good result. Letting them know that, they beamed. At heart, this kid was really likable, emotionally young and idiosyncratic, but with a certain charisma. At the moment, and speaking uncritically,  he seemed about 8 or 9 years old.

The next five sessions had a certain pattern. Save for one session where his entry and exit were more normal, Owen was reluctant to move out of the waiting room and slowly entered the office. At some point he would become wordlessly teary for a short period to himself, then re-emerge and re-join. He was not in that much distress in the aftermath. His refusal to engage in the pursuit of understanding the pattern became presumed. Exploring if the pattern that began when the parents were upset with each other in his presence, before the separation when he was about 1, was a reasonable pursuit, but at this early point in the therapy the foray could be too provocative. In pure diagnostic terms, the problem was unclear as he did not rise to a clinical depression, nor to ODD, nor to PTSD. The overall clinical evaluation at this point of ten sessions or so was still on-going, common with the more difficult kids. The work was to address whatever presenting problem of the week that the client or parent(s) brought into sessions, and be patient. 

The work was a standard combination of behavioral, cognitive, and relational methods. Owen would become more involved, although not to the point of engaging much in the affective work that he had minimized and avoided. Simply noting that pattern in and of itself, which with a bright early adolescent male would normally work, did not result in a deepening of the substance. Still, by the end of the sessions he was generally more relaxed, and still said “Thanks” as he left the office – not every time, but enough.

Most of the presenting problems had been directly addressed over these meetings with both together. School performance and behavior were no longer problematic. Owen had begun to share more about his peer experience at school, both at home and once in session. Chores and help around the house were better, still resisting though if called from his room while reading. Resistances were more in the normal range. More interactions between the three of them, older brother included, were occurring. The irritability and touchiness could still dominate Owen’s mood around the house, but overall had lessened from the pre-therapy state of more often than not, more days than not, i.e. in a clinically depressed state. Social interactions outside of school were still infrequent. Book after book were completed. The father had not initiated contact, and I could only infer that he was not inquiring about the therapy after the occasional brief updates by the mother.

The experience of this practice with ODD cases, or ODD-like cases which seemed more and more the case over time with Owen, effective casework could easily take a year or longer. The clinical strategy was basically to press on with the family work as long as some kind of positive movement was being experienced. The slow but steady initial gains Owen made were common. Regressions occurred, but most would eventually reverse. Some did not, and those would be among the few ODD cases of lesser and occasionally no meaningful clinical gain. With difficult cases like these, success is a combination of primarily clinical skill and secondarily the good fortune of avoiding the land mines in the family’s field. The approach is to get as far down the improvement road as possible by maintaining creativity and enhancing relationships. Such was the case here. The good outcome is still no guarantee.

Following a week in his father’s family home, Owen had regressed, being particularly difficult for two days with his mother and brother both, uncharacteristically so with his older, mild mannered, and self-directed sib. For the first time, the defiance toward his mother included some physical intimidation. While school behavior and work quality continued to be better, at home he had regressed almost to the baseline. The session itself was marked by instances of aggressive  argumentativeness with his mother. The relational skills and socio-cognitive development tools which had been previously effective resulted only in a lessening of the overt contentiousness. The mood persisted. Rather than getting sharply corrective herself, which would be more reflective of her old pattern, the mother continued in a vein that was calmer and directing her interactions toward understanding what Owen was feeling and trying to guide him toward more accommodative behavior. The last ten or fifteen minutes were spent by the mother discussing a range of family concerns and events. Owen remained mostly silent. Gone, though, were the tears. He left in moderation, with eye contact and an approving nod, having once again emerged from the grizzly mood.

During the ensuing week, Owen found a middle ground, between his most ornery of the previous week, and the high point of his growth three weeks earlier. He was more withdrawn in his room, sporadically defiant, hesitant to cooperative, easily irritated. At the same time, he was not aggressive at home,  and school seemed to be going well as he brought home two high grade papers and quizzes each. Resistance to the therapy appointments continued, but he ultimately came, as per usual. More uncharacteristically, resistance to participating in session was higher and did not dissipate. He became mildly but irritatedly interruptive in the office. Still no pattern was discernible, at least to me, of what provoked the testing behaviors that announced his displeasure, like lying across the green overstuffed chair that he customarily used, feet dangling over the left side and head hanging backward over the right, which, when done in the office, was more typical of the eight year old. I suggested to the mother to ignore the provocation, only for the sake of the appointment if her rules at home were different. He later sat up. No tears again. The acting out seemed to supplant them.

I asked to talk with the mother alone for a few minutes at the end of the session. Owen stayed in the waiting room rather than taking the option of going down to their car. The pattern of these past two weeks suggested something relative to the process here was percolating with the father. The father remained aloof, as he had been all along, probably maintaining a dubious attitude toward the counseling. Owen’s only comments to her were that the tensions among the father’s second family of four were annoying, leading him to stay in his room while there, apparently even more so than at her place. She also shared a thought, taken from moments of greater candor from Owen, that the step-mother was pursuing a family-of-six atmosphere in which neither Owen nor his brother had much interest, his older brother being sixteen and into his social and athletic life and often not going to the father’s home at all. Owen distanced because he was Owen.

I asked her to check with the father about anything being different there. She was doubtful that he would be candid but would do so after Owen returned from his week there, reflecting her generally foresightful judgement. I walked the mother to the waiting room. Owen had his back turned away from the office door, building something in the way of a medieval enclosure with the ancient set of small wooden blocks. I asked him to leave the structure there, that others may want to add to what he’d done. Normally, kids will be excited to one degree or another when asked to preserve their work, but he nodded without turning around and wordlessly left.

If something happens once, take note. If something happens twice, you have a pattern.

Coming from the week with his father again, the next session was the most difficult. Owen’s refusal to engage continued for the second consecutive session. He had protested vehemently about coming, and was persistent in seeking an early ending session ending. Some work similar to that which had been done in the past was accomplished, but when a lull occurred in the interchanges, he began acting out. This time he engaged in a mimicking echolalia, repeating word for word what had just been said by either me or his mother.

Once again, Owen did begin to settle down, and left in a state just below that of equanumity, not polite, but not in derogation. In my running notes, part of the entry was  “the return to previous levels of resistance is verging on an on-going problem. As long as he’s in counseling, though, we can deal with it.”

If something happens three times, you have a problem.

Indeed. That was the last session. For the session following the week with his father, Owen refused to return. A day later, the father wrote a long email to the mother which was quite contemptuous about the therapy, about counseling in general, and presumably toward me personally. The mother didn’t venture those comments, and I didn’t ask. She had grace, the same form she exhibited during the intake when, in response to the question ‘what led to the divorce?’, she simply identified “incompatibility”. She always exhibited devotion, but something really deleterious must have happened in this marriage, and then to dissolution and his relatively swift re-marriage that must have hurt, something presumably being managed in her own therapy. At the same time, she is the matriarch of this family, divorce or no, and her most vested interest is in keeping the basic family bonds and six relationships between the four of them as intact as possible, a mother’s task of joy and curse. Owen had retained some of his gains through the last difficult weeks, important gains. Mother had made changes quickly and easily. 

Several recommendations were made to the mother relative to the management of Owen, and toward family relationships in general. The door was left open. She was disappointed but observed that the sessions had demonstrated her son could, indeed, get better, and she believed he would do so. I mentioned research that suggests the biological maturation process of youth continues until age 28. She had plenty of time, plenty of skill, and at heart a good kid.

In sum and in spite of Owen’s current tensions from his ‘exhausting struggle’, I had reasonably certainty that he would be fine in the long run.  Although assessed as a pre-adolescent with a moderate – serious pre-Axis II problem, he was one of only four (out of nineteen) who resolved most of those issues. His reactivity to the father’s clear, personalized antipathies toward the therapy process appeared to inaugurate a return of a defiance and disruptiveness that had largely dissipated for several months. Otherwise, the young man was more normal, had too many strengths and skills to become permanently troubled in his social relationships, and with the continued maternal guidance and modeling, stood a good chance of having a meaningful relationship and quite possibly a family of his own as an adult. The hard part is that the therapist doesn’t find these things out except by the odd and uncommon circumstance of a chance encounter. The door was left open. 

The cases of Owen, Nathan, and Patrick nevertheless all leave process questions, as these types of cases necessarily do. The experience of difficult endings is unsettling, but nevertheless provide rich learning opportunities that can lead to more effective case management.

Analyses and comments are in the next post.