The Diagnostic and Problem Area data offers a more detailed and concrete look into the specific impacts of therapy upon the relatedness group. The Diagnostic Areas include: anxiety; depression; and behavior. The category of relatedness itself is not included. The Problem Areas include: family relationships; school performance; social relationships; and community activity.
The definitions and data collection process were discussed in Post 21. As a quick review, the presence of any of these seven problems was usually determined during the three session assessment process. Infrequently, an additional problem(s) could and did surface during the course of the therapy. An interconnectedness of Diagnostic and Problem areas usually existed in terms of any given symptom, e.g. depressive symptoms connected to declining school performance, or a flagging school performance leading to defiance at home. The existence and impacts of relatedness traits specifically were based more on clinical observations during intake and therapy, and were usually not included as explicit elements of the family’s problem and clinical goals list.
The determination that a diagnostic or problem areas was no longer an issue was based primarily on client and family reports. Collateral observations from community professionals, mostly school counselors, helped refine the overall clinical picture of a case.
As a reminder when evaluating the above data, all the relatedness clients were males. How that fact skews the results is not clear, but some kind of skew can be assumed.
Consider dividing the seven DA/PA categories into three distinct sub-groups, including: anxiety and depression; behavior, school, and community; and family and social relationships. Anxiety and depression are internalizing symptoms. Behavior, school, and community problems tend to be the result of externalizing processes. Family and social relationships involve both.
The comparative results indicate that the non-relatedness groups tended to have internalizing problems more frequently, 73% compared to 50% for the non-relatedness group. The relatedness group similarly tended to have externalizing problems (76% to 50%). While relational issues are presumably driven by both internalizing and externalizing factors, the respective rates of their relational issues are almost identical to the externalizing data, perhaps suggesting, that the two relational status categories are more driven by externalizing processes. If so, this result may be more driven by the all-male cohort.
The relatedness group’s strongest area of improvement was anxiety. Their rate of resolution was above that of the non-relatedness group, as were the results in family relationships. The lessening of anxiety would appear to be related to the improvement of family relationships.
In contrast, the lowest improvement areas for the relatedness group were depression, school, and social relationships. This data is amplified further by the fact that all of the unresolved area problems within the relatedness group were those of the unresolved relatedness cases. The relationship between depression on the one hand, and school performance and social relationships on the other is probably one of mutual reinforcement. Again, these were the lingering problems of the unresolved relatedness group of thirteen at their terminations.
DA/PA Average Gain X 17/39, 13/43, 4/13
Note: In this chart, ‘Pre” refers to average number of the eight DA/PA categories each group has intake. ‘Post’ is the number remaining at termination, and ‘Gain’ is the difference. In Post 22, one resolved category was calculated to be the approximate equivalent of a 5 point CGAS gain.
The average unresolved relatedness case improved 2.0 DA/PA during therapy, evidence that youth having the misfortune of relatively intractable relatedness traits can nevertheless benefit from effective therapy. Being in the CGAS 50’s or 60’s is eminently more tolerable than being in the 40’s and 30’s, and offers a better opportunity for continued change and growth.
The vignette ending the previous post, #27, suggests that at least a few of the clients with relatedness problems that were unresolved at termination can continue to improve after termination. Two factors are almost certainly involved in determining which cases continue improvement and those that substantially do not.
First, as the number of traits in an individual rises, the possibility of full recovery appears to diminish. In the aftermath of asserting this, though, while the outpatient client may never resolve their relatedness tangles, they are still to be considered competent and capable of making improvements in at least some of the diagnostic and problem areas. The work could take a long while without much in the way of guaranteed gains. This clinical reality does pose a social policy conundrum.
Second, family support, particularly that of the parents individually and relationally, is of crucial importance. Part of the clinical task is to support and facilitate their roles. Capacity, tenacity, resilience, and reservoirs of energy are helpful attributes.
The statistical comparison above of the resolved group of four with the thirteen unresolved group highlights both the suppressive nature of a problematic trait system, and the almost kinetic recuperation when the traits fortunately dissipate.
The initial CGAS and DA/PA average scores of the resolved and unresolved relatedness cases are fairly close to each other: 49.8 CGAS for the resolved, and 44.8 for the unresolved; and 5.3 initial DA/PA for the resolved, and 5.8 for the unresolved. Both the clients who ultimately resolved their relatedness traits and those who did not began therapy functioning a decile or more lower than the non-relatedness group of thirty-nine.
The post scoring was dramatically different: 76.8 CGAS for the resolved, and 53.2 for the unresolved, and 5.3 DA/PA improvement for the resolved cases compared to 2.0 for the unresolved. The unresolved relatedness termination average was the lowest of any sub-group, and that of the resolved relatedness group was the highest.
The inference of the low Pre score for the entire relatedness group, from those with three traits to those with eight, may be having traits of any number is enough to disrupt one’s ability to relate, adapt, be accepted, and be trusted. How many traits may be a less significant factor than their mere presence.
The resolution of a relatedness problem, though, is definitely related to the number of traits existing at the outset of treatment. The resolved four cases had three and four traits while the unresolved cases had all the other scores, including the remaining four-trait cases and all else from fiver to eight.
The inferences of this data are that the presence of relatedness traits inhibit the development of normal relationships and mire the young person in situations of being distanced if not outright rejected as peers and others in their lives; and that once the traits begin to dissipate and disappear, the young person can climb into the normal strata of family, school, and social relationships.
The presence of traits are suppressive. Families, classes, and peer groups can be forgiving when the client starts to make changes. Speculatively, the combination of the conjoint identification of family problems early in the therapy, family relationship work using a socio-cognitive perspective exercise, and behavior management information for the parents helped lessen client anxiety. A good process and therapeutic relationship can provide modeling. Reinforcement both planned and spontaneous, anticipated and random can provide conditioning. The ability of children and adolescents to adjust and welcome the functionally improved into the social fold becomes an important feature of the client’s growth.
At least anecdotally, the experience with these four resolved cases suggests that trait resolution tended to follow improvements in other symptoms and problem areas. Notably, these traits were small in number. Perhaps, as suggested earlier, these low number trait systems are more the result of modeling and conditioning. Another viewpoint is that higher numbers of traits quickly develop a life of their own, mutually reinforcing each others’ existences and become much more difficult to resolve. Research on identical twins raised in separate environments suggests the genetics alone cannot explain why lower levels of traits tend to be more easily resolved, but genetics may account for the higher levels of traits that one have.
As the number of traits rose, the number of DA/PA at treatment’s outset rose as well. While some improvements, such as a lessening of anxiety and an improvement in family relationships, could be achieved, the higher numbers of the traits tended to make other gains difficult. Another factor with increased traits is a tendency to have other family dysfunctions that complicate the case and limit the capacity of the change process. Personality disorder-type defense mechanisms are potent treatment inhibitors as well.
The sad part of this schema is that many child and adolescent relatedness problems do not resolve. Positive changes can be made, and functionality can be improved, but existence at CGAS levels less than CGAS 71 continues. We do keep working our best until the case terminates.
The last point is a reiteration. These listed relatedness traits used here are culled from the eighty total traits listed in the personality disorder section of the DSM. Many of the cases had traits from more than one of the personality disorders. The same can be said for the DA/PA section in general. Most had two diagnostic area problems, a few had three. a couple had four. Most had more than one problem area, a few had three, and a couple had four. No one had all eight, but in a larger cohort, a small few could be reasonably anticipated.
A proposed dictum: the functional issue for therapy is not the diagnosis per se, but rather the number of extant DA/PA problem areas and relatedness traits.
Lastly, a system that identifies diagnostic and problem areas is graphically more indicative of change realities than a system based on diagnoses. This is said in some part because symptoms and problem areas are the prism through which line therapists have historically seen clients. A problem list is developed and a therapy proceeds from that point. An active mutual termination generally includes a review of what changed and what did not, for everyone’s reference.
Parenthetically, that style of treatment may be in the process of changing.