#51 – BEGINNING FAMILY WORK – PART 2

#51 – Beginning Family Work – Part 2

Is This CBT?

Yes, by using cognitions to help change behavior in a therapeutic setting…were it so simple….

Part of my introductory training in mental health work, way back when, involved watching the Gloria Tapes three times along with a half dozen other young staffers of the Everett (Wa.) Drug Abuse Council’s clinical arm, named Karma Clinic. That name itself was about five years out of date, but in ways so was the small timber and industrial port city, one that was comfortable within itself.     

Gloria’s problems were conventional issues of anxiety, depression, relationships, and none with behavior. A pleasant and earnest woman in her 30’s, she would have been rated somewhere in the moderate to mild, 51 – 70 range on the CGAS scale. She had consented to be interviewed by three psychotherapy titans of the time, including Carl Rogers, Fritz Perls, and Albert Ellis.

Rogers was a manifestly kind and gentle man who represented the humanistic, “client-centered” approach that itself came to be known as Rogerian Therapy. That school’s clinical focus was on self-actualization, the realization toward fulfillment of one’s potentials. Perls was the somewhat theatric and more widely known proponent of GestaltTherapy, a school that focuses on one’s experience and insights as they emerge in the here-and-now, enhancing self-and-other awareness.  Ellis was the founder of Rational Emotive Therapy. That school’s clinical focus is on self-defeating thoughts and feelings, challenging their rationality, and helping the client replace them with healthier, more productive beliefs and behaviors. As a representation of the growing, coalescing clinical world at the time, the Gloria Tapes would have been more complete had they included Virginia Satir, both as a representative female therapist and as an advocate for the family approach to mental health, one that promotes mutually supportive and enhancing relationships for their clientele, in some part as a conduit toward behavior change.

The three professionals had very different approaches and left plenty of discussion material for us beginners. In her summary exit interview, Gloria said she felt most comfortable with Rogers, but would have chosen Perls. She got less from Ellis, but then again, his approach was less gravitational than those of his two magnetic peers (albeit those two were vastly different from each other) and would likely need more time to become fully engaged. Of the three, Ellis was the one toward whom I instinctively gravitated, not so much concerning his focus but for his more centrist approach to problem definition, clinical formulation, and creative solutions.

All through the 40 + years following those ‘Gloria’  staff sessions, et. al., identifying my work by a specific school of therapy never really occurred to me.  What got done is what got done, all along reasonably effective, the process grew and was best at the end, et.al.

Two years before retiring and in need of a few CEU credits before what turned out to be a last recertification, a flyer advertised a six-hour Friday workshop by Don Michenbaum on CBT. The topic itself was not of particular interest. At that time, my incorrect belief was that CBT entailed a collection of specific behavioral treatments from which clinician could choose. I didn’t do that.  The attraction was Michenbaum himself, a forerunning clinician and researcher in the field of behavioral therapies since the late 60’s, a cut below the more iconic three above. This would be like seeing Tony Bennet on a farewell tour.

Arriving at the hospital conference hall about 15 minutes late, I took a copy of the program manuscript and sat in one of the back seats. Michenbaum was well into his introductory remarks, walking back and forth across the stage. His delivery was an almost reverent overview of his specialty, then interspersed by a raspy, acerbic patter that for all the world sounded like a 1950’s Catskills comic, an odd, amusing, maybe even endearing combo that also raised questions about just what this day might possibly bring. A disappointing CEU conference could feel like an eternity, and then Friday evening travel out of the city could be long and jangly. But then, this would be the six credits needed. Maybe with a quizzical look, I continued to read through the manuscript. 

Some fifteen absorbing minutes later, I laid the document down, a bit stunned. What he outlined was what I did. I’d had virtually no idea. This 75-ish character, expertly knowledgable, maybe eccentric, out there roaming the stage, presenting his information and periodically veering into this vernacular was my role model…really? But then his show went into a live, Gloria-type interview. Buddy Hackett disappeared, and his inner therapist led his client, coincidently or not a 35-ish single female, through a beautifully done, compacted initial session replete with engagement, problem identification, tentative clinical formulation, conceptually broad suggestions, and a clear mutual appreciation to conclude. I walked out at the end with a clinical identity, supposing better late than never.

An excellent synopsis of CBT that closely resembles what Michenbaum presented is an article published by the American Psychiatric Association’s Psychological Tools section pertaining to PTSD treatment entitled “What Is Cognitive Behavior Therapy”, available via google.

Continuation on Language Shaping in Session

As stated in the last post, language shaping as a clinical tool involves two functional dynamics. The first is the intent to directly aid the client, in this instance here by facilitating clinical comfort, maintaining a clarity of roles, and preserving trust. The second function is to provide a model of interaction that can be experienced as more engaging, running less risk of being off-putting or  disengaging, and probably more of benefit to the parents.

In a way, psychotherapeutic style can be seen as being bipolar (the graphic type), one pole being directive and the other collegial. The directive style relies on unilateral expertise to develop a truth and apply their authority on remedy. The collegial style works more toward mutual discovery to understand, and include trial and error among recommended treatments. Typically, the inquiring style of the ‘expert’ is structured by the ‘who, what, when, where, why, or how’ questioning paradigm to uncover what one thinks, feels, and or does. The collegial approach is essentially “let’s explore this together”. While never much for extorting authority (despite having been a lieutenant in the army), the gravitation toward the peak of the collegial pole took time. Conduciveness to family therapy, if for no other reason than that the collegial style lends itself as a model for more effective resolution skills and solution processes within the family itself.

The following short compilation of phrases were accumulated over the first ten years or so of the practice. My first private practice clinical consultant, a conventional clinical psychiatrist and consultant with forty years experience, had an unusual combination of a personal austerity and a heightened sensitivity to other’s struggles. He modeled this humanist tone outlined here by using the first three phrases on this list as regular part of his repertoire. The rest were either adopted from hearing someone else or occurred spontaneously. Noticing a positive impact within a client, the new line was field tested, generally using the dictum ‘if something worked once, take note; if something worked twice, there’s a pattern; and if three times, the item is probably a keeper’… until proven otherwise.

Also take into account that the interpretation of spoken words can be seen as a combination of  given meanings and the personality of the conveyor. Particularly in the first half dozen sessions, clients young and old alike can find the atmosphere intrinsically intimidating to one degree or another. Beginning therapy can generate vulnerability when the delving person is essentially an unknown, even if highly recommended. Knowing the words to use is important. Knowing how you as the therapist come across using those words is equally as important if not more so. Particularly if being an unknown entity to the ‘other’, modulating some kinds of probes or critiques by a beckoning preface can reduce self-protective resistance on the part of the client, even dissipate it altogether, and help foster a growth of trust, both of the therapist and within oneself.

Cultivating The Clinician Role 

“I’m interested in understanding…..” rather than just “what…” or “how…” or the more potentially more vexing “why…”.

“I’m interested in learning more about (your feelings, thoughts, behavior, etc)” rather than ‘tell me why” or “…what”, or “…how”

“You did the work”, in response to ‘you’ve helped me so much’ when reviewing changes that have occurred

Clarifying Role Boundaries

“I work for you…”

“My job is to work myself out of a job.”

“I may have helped, but you did the work”.

Preserving Trust

When time allows toward the end of a session, on occasion randomly ask “Do you have any (other) questions you’d like to ask me?”

“How are you feeling about this process so far?.”   Some speaker years ago said that ‘super-clinicians’ are in part defined by the willingness to encourage honest feedback from clients about themselves. This line was used effectively, again on occasion, after the first few sessions of a case settling into the process and a certain comfort established in the room, particularly with complicated or evidently difficult cases.

Wading Into Difficult Waters

“I might be wrong here, but I think what’s happening here is….”

“There may be no answer to my question here, but…….”

“This will be a difficult question, but I’ll help you with it”.  Infrequent, but used particularly in a family setting, providing both direct clinical help and, in a way, parental modeling.

“Unsolicited advice is usually worse than no advice at all, so, this may be pushing things, but I’d like to suggest that…” or something along those lines. Parents in particular might remember this one, and thereafter perhaps be more judicious with their feedback to the children.

“I’m having a hard time making sense out of this, so please help me…”

Acknowledging differing opinions

“…but you understand what I’m saying – you may not agree, but you get my point of view, right?” Again used infrequently, this was usually employed with adolescents

“Right or wrong, good or bad….” When offering an arguable point of view….

Second Half of Session 4 – Family Game

Following the individual inputs and around-the-room discussions about what each participating family member wanted to see improved, the second half of the session was having the family play a game together. The game of choice was Jenga, chosen for its simplicity, being well under under thirty minutes to play, and options of approach. 

For the uninitiated, Jenga is a block construction activity that uses 54 wooden pieces,  

all 3” x  1” x  1/2”. The classic game is to build a 3” x 3” tower as tall as possible. A level is usually made of either one or two pieces, starting with two, then crossed in the middle by one, then another two, etc. The skill is to maintain balance as the tower grows. Imbalance leads the tower to crash, a cute paradigm in this clinical setting that remained unspoken.

An interesting facet of Jenga is that playing the game can be either a competition or a collaboration. As a competition, everyone is on their own. Each player works to avoid being the one who causes the stack to fall. A handful of times among the few families that chose this approach, one of the children, usually an elementary aged boy, may try to set up the following player, often a parent, to be the ‘loser’ with an odd placement that poses a balancing problem. If the parent then crashes the tower, the joy can be truly funny.

As a cooperative enterprise, the group’s interest is to see how high the stack can be built. The goal of this particular game is to use all the blocks and still have a standing tower. What I would tell all families at the beginning is that building a tower of thirty-six levels can theoretically be done but is very difficult to do. Most families gravitated toward that route and cooperated with suggestions and rooting for others.

Aside from that implicit nudge toward the cooperative approach, I remained a neutral observer insofar as the game was concerned. The clinical purpose of the family game was to gather more information about the individuals, their individual relationships, roles, habits, and demonstrated values. As the final part of the formal assessment, I also viewed the family game as an opportunity to interact more informally with them. The byproduct would hopefully be enhancing the engagement process by joining them a bit. While clinical suggestions based on evident problems could have been done, to me the rubric of ‘unsolicited advice being worse than no advice at all’ prevailed. The next session, which starts with “what can I do for you today” would begin the treatment per se and all suggestions thereafter in the session could be deemed as overtly solicited.

This family game exercise was done some 350 – 400 times over the years. Very early on, one family of four did accomplish the goal of a 36-level stack. The pride they had in doing so was palpable. The ten year old client himself laid down that final stick, ever so carefully because of the slight but potentially deadly teetering up top. Knowing this sounds like saccharine theatrics, the father had his arm around the kid’s shoulder on the way out. Given the family’s presenting issues, that father’s gesture was meaningful in and of itself.

At the time, I didn’t give credit due to this exercise. As a result, almost nothing in the way of descriptions or notes were written afterwards. And I have no record of who that family was, what were their presetting problems their family structure, or the clinical outcome. Only the accomplishment and the distinct memory remained.The difficulty of finishing with a standing tower is demonstrated by the fact that this success would never be replicated in the office by anyone. Thirty-six is a tough make. 

With very few excerptions, the families left the office relaxed, so this somewhat lengthy assessment process finished on a fitter note. 

Only one out of the 55 cases experiencing this fourth session dropped out at that point afterward. Going into session five, 54 of 58 continued.

One of the regrets in hindsight was not collecting data about how families chose to approach the game, family make-up, pre and post CGAS status, other characteristics, etc.

Lastly, the value of repetition is that norms get established over time. The positive abnormals can be confidently reinforced based on data, and the troubled abnormals can be addressed on a similar basis.

#50 – FIRST FAMILY MEETING, Part

The first family meeting is the last of the structured variety. The number of participants ranged from three to six, mostly of two parents and one to four children. More than four children would have certainly been welcomed, but in fact that only happened two or three times over the years. Oftentimes when the participants were a single mother and one child or adolescent, the process moved directly from the summary and recommendations session into straight clinical sessions, the two having been long accustomed to working together. 

Roughly a third of the families bypassed this session and moved directly into clinical work. In addition to the few mother-child dyads, cases involving multiple family-wide  issues that required immediate attention and recommendations was the primary reason for skipping the routines of the fourth session. These could include manifest conduct disorder types of aggression, delinquencies, suspensions, and resistances; self destructive behaviors; threats to safety and security; and lingering post-divorce issues that pull the child(ren) back and forth, creating a prevailing atmosphere of inhibiting anxiety and dread.

 Nietzsche once wrote that “out of chaos comes a dancing star”. These situations cited above were usually among the most difficult, with a higher percentage of early withdrawal. But those that stayed the course and really got somewhere new and healthier could be seen as the dancing stars. If the clinician can work them, meaningful degrees of peace and even beauty can emerge.

The purpose of the fourth overall session is threefold. The first is to accustom the group involved family members to working as a group in the office, for the most part an entirely new endeavor. The second is to establish a family-determined baseline of desired changes. The session is split into two separate sections, and one function of the second half is to observe the family playing a neutral and entertaining activity that also provides an opportunity to engage with the participants more informally.

After the induction of family members attending for the first time, the session begins with: “Is there anything of immediate importance that you need to discuss today?”  

An affirmative was uncommon, and most of those situations were deferred to the last few minutes of the session.

The follow-up was “What I’d like to do is to hear from each of you what it is that you’d like to see get better in your family, so whoever wants to start, go ahead.” After a few seconds of looking around at each other, nine times out of ten that person would be the mother. Staying in the role of interviewer rather than director, who came next was left up to them. 

The first process consideration concerned time. Minimally, twenty of the fifty minutes were going to be used for the session’s second half game, and preferably twenty-five. One intent was to use the same amount of time interviewing each family member present during this first section, so these mini-interviews had to be structured accordingly. If the group in the office numbered three, that would leave eight minutes or so for each; for six that would be five.

Before shifting to the game they were to play, a quick summary of what the group had identified as targets for improvement was given. I ask if anyone has anything they want to add or elaborate of change. 

The list forms the family baseline, different from the clinical. Together, they make an outline of reference points that will help shape the termination session review, whenever that occurs. 

For an experienced interviewer, this work is fairly easy, enlightening, and as so often with kids, sometimes pretty fun.

Language Shaping 

In addition to establishing baselines, much of the clinical work during these early sessions involved two kinds of language shaping. The first is a small body of suggestions for the participants as they related thoughts and pursued changes, all toward facilitating manners that are more descriptive, specific, and positive in nature. The other involves interviewer phraseology, modeling what can be viewed as a collegial style as differentiated from a directive one. 

Shaping Vis-a-vis The Participants

All of these following examples recurred over time, enough that a standard response was developed to intercede for most. Any of the first four could and would surface in this fourth session or early thereafter, and the others would arise more randomly.

“You should…”  or “should not”

‘Shoulds’  were actually not used very often during session, almost surprisingly so. Shoulds were usually used by a father reproving a son during this first family meeting. Before the youngster could answer, I would interject, “There are no shoulds” (highlighting the ‘are’ as a mild emphasis)”, so what I’d like you to do is restate your point without using the ‘should’. 

 Almost all the rephrasing parents created a better and less challenging restatement. That they did so unquestioningly was a kind of revelation. More importantly, the restatement itself could be highlighted as being more to the point and effective, thus  providing some unanticipated, random reinforcement, always the most potent kind. 

Only two fathers that I recall challenged the assertion. Both were lawyers, and they both used an example, like “Of course there are… ‘you should pay your taxes!’’ 

And I replied “A should is really just an opinion presented as an imperative.” 

And both shrugged, accepted this proposition, and went ahead with their revisions. With an exception or two, the use of ‘should’ by the adult being addressed fully stopped. The important part was that these parents, particularly the fathers, were likely putting more thought into their messages rather than bering reflexive. In the office, anyway, the children were more attentive at that moment of revision. In and of itself, the last point could be randomly reinforced as well.

Defining objectives in positive terms

To a parent who has just told the child he needed to, say, cut down on computer game time: “Now, could you phrase that in terms of what you want to see happen rather than what you want to see stop happening?”

For some parents the transition here is challenging, affording an early opportunity to be of straight clinical help in shaping their new message. Possibly that work might include how the parent could aid or facilitate what they’d like the child to be doing. Would the child like the parent to be of a bit more help with homework, that usually being what the parent wanted the kid to do in lieu of gaming at the outset. Basic CBT.

Beneath most anger is fear

This approach can be particularly effective in the office. From a clinician’s standpoint, switching the focus is a shortcut around what can be the laborious and time consuming task of unwinding the anger itself, and the parents now have a new and easy tool to use at home. 

“What might you be worrying about here?” 

“Can you say that in a quieter way? You’ll be heard better”

An alternative to the approach above. If the occurrence of anger was frequent, one could also use a family narrative approach, asking the parents if either of them or other family members of theirs had the same kind of anger pattern.

“Use “I”

In response to the parent talking about themselves in the third person, e.g. “Mommy’s is disappointed about (what you did)”. 

I interjected, “Use ‘I’.“ The belief here is that third person-ing induces more in the way of guilt, and produces less in the way of thought.

“I’m just lazy”

This statement appeared maybe only a half-dozen times over the years. The use is essentially a dodge of responsibility. Every one was by boys.

The response was: “I don’t believe in ‘lazy’. There’s no “lazy” gene. You may have problems with motivation or focus and concentration, but those are problems of mood and/or anxiety, not of who you are, and I can help with those.”

The following discussion was about which of these symptoms applied to the client, what might they be worried about, what actually happened when they tried to focus or concentrate, what could be done by the parents and even sibs to help an improvement along. Follow up in the next session is important to consolidate the gain, presuming one occurred.

Complaints by client of boredom

This sentiment usually took a bit of time to emerge and not to be ignored. As parents of apathetic, listless, or overwhelmed children would testify, tackling this problem with guidance, persuasion, or pure pleading, structure, reinforcers and consequences, tight reins on the one hand or ’s/he’ll grow up’ on the other, etc. etc. etc. can be draining. 

Eventually pieced together, the approach used here was reality-based, sharing a set of observations about other youth who complained or asserted this state of mind, to wit: 

“I spent some time thinking about the kids I’ve seen here who say they’re bored, and found they have some things in common. So, I’m going to share them with you. Some seemed to to be kind of young for their age: some may worry about how they’re being seen by others; some may have trouble initiating activities and interests; some may feel lonely; and some sometimes just feel sad, almost for no reason.” 

Because this is a lot of information to absorb, the delivery is slow. The question is whether the client experiences any of these themselves. The list was given mostly as information simply for them to consider. I avoided pushing any narrative about the pertinence of the list to the child, but rather just asked if any did pertain. If so, the discussion went toward that area, carefully, and in turn could lead into conversations about the young person’s realities in one or more the of cited areas and maybe others.

The particular emotional and behavioral problems the young person had been experiencing have already been defined during the assessment phase. The work had started and likely began to generate observable improvements in other areas like school performance or social activity. Some adroit reinforcement for effort is always in order. Gently exploring once again feelings of worry and sadness can marshal a sense of support for the client, and while not quite the same as acquiring a friend or getting an A on an assignment, the experience in the office can help reduce that sense of isolation. Seeking joy comes next. Least important but notable is that with these clients, the phrase “I’m bored” usually didn’t surface again. 

The use of “I don’t know”

Not knowing an established fact is one thing. Being unable to a have a semblance of how one feels, what one thinks, or what one did is quite another. 

The response would be one of two:

“You know, ’I don’t know’ in this office usually means ‘I do know but I don’t want to tell you’. So, assuming that’s not true, let’s try this again.” 

 “ ‘I don’t know’ just doesn’t work in here, so, let’s try this again.”

With either, the important part of the response is to actively help the client reformulate, then praise, For most of these cases, “I don’t know” has long been reinforced, so reinforcing the opposite behavior, one of knowing and responding, and making something positive out of the challenge through the subsequent exploration is constructive.  

Clarifying feelings from thoughts

Raising awareness about a client’s own feelings and and recognizing those within others is an intrinsic part of child and family therapy work.  As part of that mission, a majority of the children and adolescents who went through the assessment were given the feeling identification exercise (see Post 47 – Assessment). Those who did not would frequently be given this test during this session as part of his or her interview.  

The use of that tool continued into this first family meeting. As part of that 5 – 10 minute time interviewing the client youth, many of those who were not asked to go through the exercise did so here, i.e. “OK, there are five different basic feelings that everyone has. I’m going to ask you to name the five. Very few people can name all five, but I’ll help you. So, what are they?” 

Part of the purpose in doing so in the family session was to introduce the rest of the family to the concept of feelings as differentiated from thoughts.

The fun part was when one of the parents, again usually the mother but occasionally a dad, do the exercise themselves. These would be for instances where the child has already done it in the assessment. The first step was to carefully pick out the parent. The last thing needed was to embarrass one of them. Some were not that conformable yet, some still not persuaded about therapy itself, some naturally more introverted, inhibited, or inherently anxious. A parent who demonstrated equanimity, forbearance, and humor was ideal. Finding a prompt during their short interview was simple, and from there, “OK, there are five different feelings….”

Since the client child had already gone through this process during their assessment session, they always sat forward, usually with this big smile because they knew the answers. The younger the client, the more animated they would become just sitting there, they can’t was, and the parent knew their jig was up. Watching a child occupying the proverbial catbird seat is a real treat. Interestingly, the parents struggled in the same way as their child in identifying all five. They’d name three, a few four, and I don’t recall anyone getting all five. Every once in a while, I’d have the child help the parent identify the last one or two, and that was satisfying to watch. Fun helps.

Through all this attention on behavior, an accurate awareness of what others feel may be paramount. 

“But, I’m ADHD.”

In the first thirty years of doing child and family therapy, this line did not arise. Beginning around 2010 and for reasons I can’t explain, this utterance started appearing.

 An old axiom is: ‘If something happens once, take note; if something happens twice, you have a pattern; and if something happens three times, you have a problem.”

“But I’m ADHD” appeared more than three times. Like with the declarations of being lazy or bored, the use of the particular diagnosis was usually a dodge. 

Interestingly, all of the maybe four or five of these clients during those last five years of practice were adolescent girls. With the same basic intent, boys used  “lazy”or “bored”.  Also, the male use of being lazy or being bored always occurred in the context of conjoint work, as if to lay out a challenge to the parents. The ADHD declaration, on the other hand, usually occurred while the young women were being seen individually during split session processes. That point is significant because they likely never would have used the diagnosis as an explanation for deficits in front of their mothers and/or fathers. In this instance, one has to appreciate female discretion re: the family as a whole.

Charles Mann’s 500 page book “1491”, described by the NY Times as a “sweeping portrait of human life in the Americas before Columbus”, looked into the social structure of the Haudenosaunee nation of the U.S. northeast. He summarized that the leadership of the tribes were divided into two discreet roles. Women ran the politics and men provided the defense. And then one thinks about the contemporary U.S. Republican Party….

Creating a generic response to particular client avoidances and resistances requires a few episodes to develop, and four or five is probably not enough. Eventually, I used the following approach with the last one or possibly two of them, not enough to be validated, and in this instance certainly not to be recommended due to being a little over the bar. But for these two, this worked in the sense that the need for the excuse seemed to dissipate and the discussion matured. They stayed with the program, so to speak, by adjusting.The other difference was that with the lazy and bored declarations, the interviewing demeanor was definitely sober because of the feedback’s serious nature. This approach used an affable exaggeration, to wit:.

“Is there anyone else with whom you used that one…and it worked…it kind of got them off the trail…like they just throw up their hands… and turn away…and you say to yourself… in a surprised tone… ‘It worked?!….’

The discussions then tended to move toward what the experience with ADHD was like, what some of the problems were, how they coped, what worked to pass or even pass-plus, how they felt about themselves before and after, where they got their A’s and B’s and how did they do that? 

I think this approach to adolescent males would run the risk of generating a more smoldering sort of reaction that diminishes the clinical relationship. These millennial females seemed more responsible.

Abiding the notion that behaviors speak as well, two types occurred in the office that warrant some kind of attention, if for no other reason than they are distracting, they being yawning and fidgeting. 

Yawning

Again not particularly common, but a pattern of yawning by the client was noticeable and presumed to be meaningful in the office. Going through the relevant articles online about yawning, the cause and meaning has yet to be firmly identified, making the action one of the more mysterious human behaviors. Many associated yawning with the state of boredom, or lack of brain activity. The large intake of oxygen is proven to be energizing. Others postulate is that yawning “cools” an overheated brain, one that’s undergoing stress. From this perspective, the latter hypothesis is more to the point under the circumstance of a therapy session. The experience for a client and other family members working together in the office together is anything but “boring”. 

A pattern of yawning was presumed to be an indictor of a client’s specific anxiety related to the overall topic or tenor of the session, and likely needed some attention.The incident(s) were generally not cited at the time, but rather noted to be addressed later. That would usually be during the next session or two. 

Yawning did dissipate, and probably would have over time without attention. The behavior offers an entry point into work with anxiety and other discontents.

Fidgeting 

By one published study (not noted), fidgeting increases the amount of serotonin in the system, so the behavior pattern becomes a biological way of improving mood. 

Fidgeting can be either random and fleeting, or a significant condition. Instances of restlessness, nervousness, and/or impatience at the beginning of a therapy process can be expected for some plurality of children and adolescents, particularly so when in the presence of parents. When being seen individually, they refrain and tend to be more focused. Those early manifestations of situational anxiety would be overlooked as they evanesce fairly quickly.

On the other hand, fidgeting as a condition, meaning the afflicted just cannot refrain, is another matter altogether. The longest case in the 58 case study – 162 sessions over 6 1/2 years lasting from sixth thru twelfth grade – was also the epitome of persistent movement and fiddling with whatever nearby caught his attention. He’d be redirected, and within a few short minutes, he’s back at it, then redirected, then back…. 

Nate presented with multiple behavioral problems at home and school that amounted to an oppositional disorder, a depression with anxious features, social isolation and victimization, and obsessiveness beyond mere fidgeting. Perhaps superseding all was a socio-cognitive deficit that did not fall well into spectrum criteria, nor of a low IQ, nor any aspect of reality testing. Three diagnostic specialists in the area of socio-cognitive disorders who had evaluated the boy had differing opinions, but none that led either to a cogent understanding or an effective treatment. That included multiple attempts at medicating. The last medication was prescribed by referral of mine to a regarded child psychiatrist specializing in this general child and adolescent area. In a follow-up conversation, he agreed that the boy had a deficit, but one that defied categorization. He added that these more vague problems were not all that rare.

Fortunately for the client, his parents were Ohioans replete with midwestern values such as family-orientation, honesty, competence, belief in hard work, and persistence. Both were mid-level administrators, one in the private sector and the other in local government. The older daughter by three years was a high achieving student and athlete with an active social life, eventually getting accepted to a top-tier West Coast university. She participated during early sessions and was helpful filling in details about the younger brother’s strengths and difficulties.

From the very outset in my office, Nate was easily distracted by the minutia around him. He sought to examine and manipulate anything from the clock to a small potted plant to the couch buttons and even more than once to a dust bunny. Such behavior occurred even when being seen alone in the assessment session, and would require redirection more than once or twice during a session. 

This process was the first and only psychotherapy process the family used. The mental health work done prior was mostly evaluations and programmatic recommendations that could lead to modest improvements which then waned. Medications hadn’t seemed to help. The psychiatrist to whom I referred him prescribed an SSRI during his fourth year in treatment. Within three weeks he became suicidal, was taken off, returned to his old state, all providing us with a sharp startle. 

The therapy here was a standard combination of behavioral, relational, affect management, and personal growth or insight techniques. The fidgeting was not a central focus. Rather, the attention focused on re-direction, praise for maintaining attention, random unsolicited praise for his propriety during sessions, etc. The overall problem list was long and concerning, and the fiddling became a  secondary concern. Making the fiddling a central feature of the work felt like fiddling itself, given the extant of other issues.,

As the process proceeded into years length and he had presumably become accustomed and less anxious about being in the office, the fidgeting did decrease, but very slowly with considerable and sometimes steep ups and downs. That matched his school performance over time, where he would have periods of reasonably good work and then flag, and a social experience that would also wax and wane. All those areas of unstable life activities did not necessarily rise and fall in conjunction with each other, in a way demonstrating a modest but profound lack of integration. Particularly during junior high, his schoolmate experience could be emotionally brutal. But the overall plane of functioning as seen over months and ultimately years did rise, however slowly. The fidgeting per se was not tracked, but the sense here is that the activity lessened more quickly and more linearly, likely gone by his junior year in high school, if not sooner.

Reinforcing the opposite behavior was probably the most frequently employed tactic, certainly during sessions both conjoint and individual. Various home supervision and programmatic ideas were floated during sessions. A few were employed by the parents with success for a while and then waned. Being in therapy, the parents were less isolated in their parenting struggle. Never particularly punitive, their irritation levels could nevertheless rise and hang over the home atmosphere, a major incentive to try therapy again at the elementary school counselor’s recommendation. The clinical work itself helped reduce the isolation. The mother in particular was a relentless advocate, with the father’s allegiant support.

I worked with the three school counselors involved with Nate from elementary through high school, mostly during junior high. His eighth grade was probably the worst year of his life up to the time he terminated as the social machine ground up the litter. During that time, though, Nate developed an interest in origami, of all things and a perfect outlet for a fidgeter. He showed a skill level that probably eclipsed any of his other endeavors, excerpt online gaming. The idea of him doing an origami project for class credit came up in a family session, and he was unusually animated. The school counselor thought that a display of his work in the school’s rotunda was feasible and was similarly enthused. So Jenny and I agreed to approach the school’s up-and-coming vice principal, by reputation a ‘tough guy’, but the class credit idea just seemed so innocuous and potentially spiriting. She set up a meeting. 

He took a seat behind a large circular lunchroom table by the entryway, setting himself about nine or ten feet apart from where we sat. Jenny and I were both experienced, generally known and respected professionals, comfortably and ably involved with the student and family both. With thanks for meeting with us, I outlined the problems. She explained the proposed plan. 

Homework was only one of several problems in school, not the least of which was hallway bullying. On the other hand, his ability to produce something artistic had emerged, the first appearance of a tangible, abiding interest that could be relevant to school and community. Showing the work might help reduce the denigration and occasional victimization. The credits would matter and may encourage a better academic effort via the greater degree of confidence. 

The taciturn VP took all of this in with a question or two, sometimes with eye contact, mostly looking down at his pad on which he had made couple of notes, maybe fiddling, hard to say. When Jenny finished our input, he paused as if to think for a bit, then as he was rising and with a hint of disdain he declared “If my eight year old daughter can do her homework, he can do his too.”, got up, turned around, and strode out the door, clearly put out. Jenny and I had a wordless few seconds of eye contact, shaking the heads, and got up ourselves. Both of us realized on the way out to the parking lot that the meeting needed to be between the principal and the parents rather than the VP and two mental health people. That was a mistake, and in this business, clinical mistakes are not that easily countenanced.

This story is shared because the experience with this human intransigence was something of a metaphor for the therapy process itself. Nate had serious problems. He also had unflagging support from his parents and reasonably competent, diligent, and creative professional help. He’d been climbing a hilly road with steep inclines, declines, and patches of bumpy traveling surfaces to tread. He would make some progress, for example academically, recognize his efforts, and then tailspin like some cold, implacable, internal force inside thrusted a “Nope”,  only later to bring himself up just a bit further up that hill, again into new territory, and then “Nope”, only again later to.…

Some of his problems he created for himself but those such as a cognitive deficit were created to endure. Declines followed inclines, but successes could also follow setbacks. Finding that one key, know for a fact what he really thought and felt why he did what he did seemed to be the task of Sisyphus, but nevertheless he was getting better at interchange. The team of parents/therapist employed what felt like everything. Nate was slowly clueing in to the experience of others, slowly over six years, and the directions that the therapy had been taking seemed reasonable, providing direction, avoiding the punitive, and reinforcing the gains. He could acknowledge disappointment, recognize what needed to be done, but that too could quickly wane. The parents were struggling to find the narrow space between too much and too little involvement because that line’s placement in life readily shifted within Nate. As for behavioral action, his stimuluses and effects were quixotic, and not in the glamorous sense at all. Stuff happens, but still, growth can prevail, emphasize the word ‘can’ as opposed to ‘will’. Just as the VP’s response, the ‘stuff’’ this kid endured was not common, at all. That was just one more.

Our professional charge apparently shrugged about the result of the meeting, perhaps relieved in some way, kept up with the origami for a short while, then turned toward some other interest. His one advantage was the more enlightened version of fidgeting. He was always into something.

Nate carried on into 12th grade. He was now passing most everything, had a small coterie of friends, but still a distance from the normal social experience of latter teens. He had a part-time afternoon job at a farming supply store where he was doing reasonably well. And then he decided to quit high school and go to the school district’s award-winning voc tech. He also independently decided to conclude therapy. 

The termination session was more perfunctory than most long terms. His social relationships had developed some warmth for him, so the coolish demeanor didn’t really indicate a lack of capacity to care for those who value him. His parents were not particularly effusive all along, but always friendly, and appreciative when intervention successes and progress occurred. Right or wrong, I associated the reserve with their strain of midwestern personality.

I felt warmer during the termination session than he, the work having been reasonably effective and one always wanted to root for the kid. The mindless fidgeting had not appeared for a long while. I reminded him about that. He looked a bit puzzled, and then shrugged, underwhelmed. As per the custom, I told him any time he wanted met be of some help, I’d be glad to do so. This generated his more affirmative nod and smile. He left with a good, firm handshake. 

Via my own scoring using the CGAS scale, he had gone from being in the upper side of the severely disturbed decile, estimated to have been a 38, changed and grew through the serious decile, then through the moderate, and finally operating in the mildly disturbed area, estimated at a 62. He still had a level of disturbance, but momentum itself in a case like this can push the progress forward. At the same time, were it not for his parents, the therapy would never have gotten this far, so ultimately, he has also been lucky. 

More broadly, the process could also be seen as plodding. From certain contemporary perspectives emphasizing efficiency and cost minimization, that may be hard to dispute. Granted, the complex of problems was somewhat daunting, particularly driven by the cognitive deficit. A small congress of third parties with differing vested interests charged to evaluate a therapy for that length of time over that many sessions involving that many people would minimally have a contentious time. But the critiques that become valuable are those that are couched by the realities of early 21st century mental health practice in real life, out there in the community, away from brilliant lights.

Indulging in my own musings with an eye on both history and the concept of developmental growth by stages, the science of mental health treatment can arguably be in the prepubescent stage of development. We know enough to concretely understand the basics, but remain far from an overarching, formally, and scientifically reasoned understanding of the brain, the person, the community, the environment, life itself as an operative aggregation of all these variables. We’re what, 150 years old as a profession? That leaves a far and long way to grow. Talk therapy may become relatively primitive when thinking about just how far technology has yet to take the effective treatment implementation, likely will remain a mainstay because we are social at heart…most of us, anyway. 

Maybe where the profession is now?  If all extant outpatient treatment types were divided into, say, five discreet categories, talk therapy bring one, and a comparative outcome study including, say, 2500 cases all treated by chosen community-based practitioners that create an equal distribution among the five expertises, my guess is that the differences between four of the five would be empirically insignificant and the fifth would a bit fall short, and that none would empirically stand out from the others in standard deviation terms. One may turn out to be significantly lower, and that would not include this talk therapy. That’s an estimation of where we are. 

So, we choose how to work among the contemporary options, get the training, stay up to date, and do the best we can, and for the time being, that’s more than acceptable until we as a species know a lot more and something emerges as categorically better by some significant measure to resolve the problems that come through our doors. 

If there’s a message here, hard cases are certainly out there and you can get them anytime, and they will challenge in many ways, some that might be insuperable but many that provide an almost unique human satisfaction as did Nate and his folks..  So….  Stay the course. Be diligent. Trust your skills. Be Kind.

Note:  The following post will address in order: interviewing language; the family game; and the fifth session that essentially presents the basic structure of regular family and individual sessions.

#49 – SUMMARY AND RECOMMENDATIONS SESSION

Where the parent intake and child assessment were almost entirely information gathering, the more direct clinical work begins here. The nature of relationships and individuals roles within the family begin to take shape as the previous two weeks are reviewed. The discussion of problems focuses more on what happened within the family since the parents were seen rather than a continued exploration of prior history. In doing so, a more dynamic picture of the child and family emerges, and opportunities to be more directly helpful to the parents tends to arise.

The basic objectives of the session are twofold. First and foremost is developing a mutual understanding of the basic problems bringing the client and family into the office. The second is an agreement about the format to be used, or at least defer that decision until the best arrangement becomes apparent. In the latter instance, an interim process is usually a family format including as many of the family as feasible and possible, and then shift at an opportune time.

The structure of this appointment is fairly simple. First is a review of events pertaining to the child from the time he or she first entered the waiting room through the next week or two to this summary session. That segues into the second portion, a review of pertinent information gathered and observations noted as the child went through the assessment process. The discussion with the parents then gradually expands to include other information they have to share, adding to the intake session information. This third phase establishes a mutually understood baseline of problems to be addressed, followed by a format recommendation, and then an agreement about how to proceed in terms of session scheduling and frequency. 

The last phase of the summary session tends to administrative matters. Often just routine, matters like scheduling, obtaining releases of information, co-payments, and late cancellation policies are addressed, some of which were in the disclosure statement read before the session began and covered as a reminder. This time is also used to address issues like complicated or contentious issues between divorced parents and how they may effect the therapy itself, other legal matters including CPS involvement, coordination with other professionals involved with the child and parents, etc. etc.

Getting To Work

The session begins with “I’m interested in what questions you have, and I’m interested in how Tommy reacted to being here, and whether there have been any sort of changes you’ve noticed, for better or for worse, whether they seem to be related to coming here or not.” 

Parents generally began their response with the question about changes. In roughly half of the cases, the parents reported no particular change, and the interview went on to the assessment review.

The other half noted improvements to one degree or another. The direct clinical work begins here, largely because the changes being discussed are in the here-and-now. In particular, the review of change included a summary of events, thoughts about why the changes occurred, what role the parents may have played, and what their responses to the changes may have been. Underlying the interview here are the emphases on relationships, observation, and the use of reinforcement. As an aside, and one of those fleeting satisfactions for the clinician, the parents reporting improvements detailed what they had experienced in a way that was noticeably more animated than they had been during the intake.

Those instances where the child seemed to worsen after the assessment session were few and far between, but they did occur. A worsening following the assessment session is not a death knell to the process, but does require attention. In reviewing the week with the parents, some unrelated negative event or stressor was usually identified. Still, though, since the reaction to that something else may have been in some part exacerbated by the session, the situation was likely to be covered in depth. The downturn offers an opportunity to create a discussion about responses that occurred, and exploring possible alternatives. To the degree possible, the intent is helping the parents come to their own solutions, or at least to a recommendation through discussion rather than a therapist analysis-and-pronouncement. 

The clinical interest was in essence a series of questions. How did the child report the session to the accompanying parent, and was that similar or different than my impression; what was the child like driving home; what happened at home and elsewhere between then and now; what worked, what didn’t; anything the parents had tried that was different? 

As they spoke, portions which may have raised concerns about the parenting itself were usually just noted. Their actions on the child’s behalf that were effective, particularly those that were the result of a creative effort on their part, were reinforced. Looking for the opportunity to do just that was part of the clinical work. Generally and unless matters of safety and security are involved, the events of the previous week are part of an emerging picture. Important to remember is that a baseline is still being created. To the degree feasible, corrective measures could wait.

Even with a practice that was 90+% boys over the last ten or fifteen years, the level of overt resistance to their assessment session was surprisingly uncommon. As inferred in the Assessment post, once through the door and the interview begins, that attitude generally began to dissipate and the relevant information begins to flow. In and of itself, that transformation c bean medicinal. The parent is out there wondering. In the best of circumstance, and this did happen with some frequency, the boy would walk out of the session into the waiting room, open the suite door as the mother rose to accompany him, turn toward me and say “Thank you.” The mother’s head would snap straight, she looked at him and then toward me with a querying expression, and then break into a smile as they disappeared. I liked that one, and in an act of pure indulgence, brought it up at some point soon after the summary session began.During the course of the reviews, theirs and mine, discussions in and of themselves have a capacity to generate change, however small they may be. Organic change may be the most potent and lasting.

For that large majority of the youth who came cooperatively and for whom the session went reasonably well, the approach with the parents was less rigorous. The types of questions included: what the child reported on the way home; noticeable changes in behavior or mood; differences in how the client related to family members or others; how their particular situation evolved over the days; and what the parents did differently that may have enhanced the improvements were commonly used. A reinforcing observation or two would likely still be made. 

Patterns of the child’s mood and behavior are now based on up-to-date experience. Such was also the case with parenting. The impacts that the parents are having, both positive and otherwise, become more demonstrable. The discussions can generate at least some insight on their part about their respective roles and effects. Potential changes are taking shape. While clinical goals themselves get more concretely established during the next two sessions, the possibilities begin to take shape. The development of clinical trust is a fruitful byproduct.

Much remained to learn about the new case, particularly the inner dynamics of the parental relationship. Secondly, and this may seem picayune, a treatment contract per se had yet to be made. Presumably, that would occur at the end of the session, maybe just minutes away, but a certain reticence about unsolicited advice remained until that agreement was made. Modeling and gentle shaping are reasonable recourses.

Overview

After debriefing the period following the assessment, the parents’ questions were fielded. They were almost always versions of “What do you think?”

Ultimately, this section of the session helps to develop overviews of: individual problems of state within child, including physical, medical, and/or developmental problems; relational concerns within family, including problematic role issues; historical forecasters, including traumas; problematic environmental, social, academic, and/or extracurricular activity; and residential, legal, and/or financial issues.  

Gently guided by the clinician, the section begins with specifics, evolves into a joint exploration of observations, experiences, and other relevant thoughts, and then begins to hone what will become the initial baseline of problems to be addressed.

Assessment Review

Rather than some kind of semi-formal or otherwise prepared summary of the assessment session, the approach here was a narrative that essentially followed the informal notes taken during the session.The client is summarized and for the most part not directly quoted. The results of evaluative portion, including the depression/anxiety inventory, self-esteem questionnaire, ego-development evaluation, and the socio-moral dilemma response were more directly portrayed, these being test results rather than self disclosure. The artwork of the younger clients were similarly reviewed.

First covered was the ease with which their child engaged by using the 5-tiered format of opening questions, i.e. ‘What can I do for you?’, ‘What brings you here?’,etc. Comments were about their comfort level, where they fit into the norms for their age, and their particular responses. Then field any parent questions.

Similarly, the history of the “problem” from the client’s viewpoint (generally for children age 8 and up) universally drew some kind of comment, be it either affirming, correcting, or elaborating. That would lead to questions or comments on my part.The parent(s) now are more active participants as the “review” moves into discussion mode. Continuing through the notes, any set of problems and events within the family and other problems personal, social, academic, etc., could be encapsulated and presented. 

A body of mutual knowledge about the child is being constructed. The parents are commonly becoming more actively involved through the discussion, sharing their own perspectives and thoughts. The contours of a clinical relationship are emerging. Parental questions, observations, and anecdotes are encouraged, so the process of detailing experiences with their child is interactive, both theirs and mine.They are essentially being acculturated into the collaborative therapy process itself, and accumulating their own perceptions and judgments about the person to whom they turned for help. One’s own comfort helps. 

At the same time, concerns about the presentation of assessment information itself were omnipresent. Thinking about Johari’s Window, the two panes representing what I know that the parent doesn’t, and what they know that I don’t as of yet are still large. The migration of the two knowledge bases to that area representing the knowledge we share is best done on a smooth path, but one that for some can get easily rutted. How privileged information gets conveyed is everything. Making the client somehow vulnerable or leading the parent to question the clinician’s judgement is clearly a problem. 

That the parent could share with the client that which was shared with them is a given not to be overlooked. Whether these particular parents in front of me are susceptible to misunderstanding or poor judgement themselves is still something of an unknown. Ultimately, the clinician has to rely on their own judgement. Being tight with the breadth of information is probably a good governing dictate, but at the same time, passing on relevant and educative information that is instrumental. ‘Protect the process’ is the first rule, if for no other reason than doing so is protecting the client.

Parents leaning forward on the couch is almost always a good sign, and this routinely occurred when the review got to the evaluative and artwork portion. What kids produce is obviously fascinating to the parents, much being positive but some can generate concern. The parents become instrumental in making the interpretations.

The last element of the review was a summary of how the session ended. A question that sometimes arose was whether that particular ending was typical or atypical of the child or   something that they had anticipated or not. The oppositional boy saying thank you at session’s end is an example.

Problem Summation

Then, “So, what questions might you have at this point?” 

If the parents had questions, they sought to clarify something about a particular assessment result or comment, but usually their question amounted to “Where do we go from here?” The underlying thrust of the posed question is a part of the acculturation to the therapy process, in this instance the encouragement to ask.

“Is there anything else you’d like to add?” And field the response.

“Anything else?”, if they in fact added something more, ibid.

The appropriate segue here would be outlining an encompassing, routinized system of problem summary, but that’s not the case. The presentation of the problem formulation was more a reflection of how the clients and parents see the problems, and at least inferentially, what they would like to see get better. The language was not necessarily theirs, but their substances guided the result. If the parents gravitated toward symptom relief and at least inferentially resolution of a diagnosis, which was actually rare, the summary would be so guided. The discussion can be essentially instrumental, targeting what the parents would like to see their child attain in a developmental sense of maturity, including areas such as sociability, confidence, empathy, compliance, industry, the list could go on. If adjustment, normalcy, and achievement were important, then those can be described as goals.  

Somewhat surprisingly even those parents who are more symptomatically oriented seldom asked for a diagnosis, satisfied with the more concrete problem orientation. Presuming that the institutional regimentation of mental health care provision that gained traction in the early 90’s will continue to expand, that question “What’s your diagnosis?” will be heard by practitioners more frequently. When asked, the response was usually “for the time being an adjustment disorder with (one of the options), but we’ll see – I do think you’re in the right place.” The exception would be those kids who have been diagnosed with ADHD since challenging a medical opinion, at least at this point, is folly. The drawback to offering a diagnosis is that the parents may be inclined to ask around, and the chance of losing the case for no good reason rises. As stated though, very few parents ever asked. And as stated, that may not be the case anymore. The one advice is to keep the response simple and and more suggestive than definitive. Clever has drawbacks.

Choice of Format

The predilection in this practice was to begin with the family approach as much as possible. At the same time, the family orientation to child and adolescent therapy spanned most all the format options.

The three basic formats were family, split sessions of roughly equivalent individual time for both client and parent(s), and individual therapy with the client, usually with less frequent parent check-ins. Shifts from one format to another regularly occurred. On occasion, a case could go through all three, from conjoint to split to individual, although these were always cases that were seen for longer periods up time, like a couple of years or more involving fifty sessions or more. Most cases stayed with the family format throughout their time in therapy, but the other formats served their purposes, to wit:

Format Type                   Type 1*          Type 2*              Total #

Conjoint           27 9 36

Conj. to Indiv.               4 1 5

Conj. to Split to Indiv           1 0 1 

Split Session             4  1 5

Split to Indiv.             2 0 2

Individual             3 1  4

Total Type           41           12           53

  • Ending Type 1 were those cases that satisfactorily ended with modest to comprehensive results. 
  • Type 2 covers two categories, including: Those who left therapy early due to administrative imperatives, typically loss of employment and coverage, changes of insurance coverage or companies, or moving away; and those terminating due to lack of progress or wanting a change in therapeutic approach, i.e. moving to a specialist. In the case of the latter, three of the obsessive cases in the family therapy group moved to a specialist. 

Note: Three cases did not progress beyond the fourth session 

To be fair, the distinctions between columns #1 and #2 do lack empirical precision, but they are at least close to a reality. The high number of Type 2’s in the conjoint line of the table – 25% – did come as a surprise. The first question is whether that difference is statistically significant, unknowable with that kind of N. Except for ‘super therapists’, and one can reasonably assume their numbers to be small but they do exist, lost cases are a hazard of the trade. So is making the occasional clinical mistake in case acceptance, choice of format, in execution, or use of basic judgement. Stuff happens, keep an open heart.

The one exception to the practice’s family therapy preference were cases involving 16 – 18+ year-old clients who wanted to be in counseling and whose personal problems according to the client and with the support of parents warranted straight individual work. Those cases went straight to individual work after the summary session with the parents. Mostly the parent came infrequently, as little as maybe twice during a process of months, for five to fifteen minutes to add their perspectives about progress and changes. The clients themselves usually knew of the meeting beforehand, and got a brief summary afterward. These were generally mature young people struggling with early phases of emancipation, losses, traumas, and peer relationships.

The split session format from the outset of therapy was used when prevailing issues required some kind of privacy on the part of either client or parent(s). More than half of the cases involved single mothers, some with and some without the father involved in childcare. For the former, the most common problem presentation was the triad of parenting, the working with the ex, and personal stress, and for the latter the triad of parenting, personal stress, and economic struggles.

Adolescents could insist on being seen alone on a split session basis, the parent wanting to be seen regardless of format. Such was the case for a small few clients who seemed to be suffering an identity crisis. A very small few were instances of early to mid-adolescent boys whose presentations both personally and symptomatically suggested the possibility of an incipient and fearsome anxiety about sexual identity, and who were adamant about being seen alone. These were ticklish situations, where the main clinical feature was the underground nature of the possibility. The teen had said nothing to anyone while living with the fear, was not going to do so in therapy, would not be referred to the “appropriate” resource, and the parents were similarly not going to raise the concern they themselves likely harbored. 

The clinical management of this particular identity crisis may well be changing by now. Circa 2015, the pertinent research quoted in the Seattle area by a local suicide prevention NPO was that suicidal behavior increased fourfold when a young person was brought out early, or when someone comes out late, i.e. in their 40’s or older. How to handle this specific and poignant issue in the office was just not part of continuing education’s commonly presented repertoire, nor advertised workshops, graduate school curriculum, or public presentations. One certainty is that we kept up to date on community standards of practice.

At that time, the clinical management was helping the young person identify those behaviors that needed attention and change, as defined by client and clinician together and be they related to anxiety, depression, and/or self-defeating and self-denigrating patterns. Improvements and resolutions did occur in therapy, just not necessarily toward the presumed source of existential distress. Keeping the door open for returns is a given, and that can act against the impulse to edge into guarded territory, something that would likely scotch any thought of coming back.

Similarly, the process with parents of these young ones was helping them through their own list of presented of problems that similarly did not include “…do you think….?”.

The limited experience in this practice was that this particular casework would continue for several months, at first in the split session format, then a period of individual work once the parents felt sufficiently oriented. The termination was initiated by the clients. Overcoming situational anxiety in social and academic settings appeared to be the improvement that led to finishing. The parting declaration of the last session – these clients did not just disappear – was  “If there’s anything else with which I can be of help, give me a call, and I’d be glad to see you.” At the very least, the young person is offered an unqualified, genuine acceptance that could serve as one tonic for their being and one balm for their soul.

The split session is a necessary accommodation to some circumstances that makes the family session itself unfeasible. However, some of family therapy’s advantages itself are still present. The raison d’etre remains to be the well being of the child or adolescent. The well being of the child is the underlying focus, and, at least from my perspective, the recommendations at the end of the parent session have the child in mind. The therapist continues to learn about the individuals and relationships within the family, continues to monitor the processes of change, including the impacts of the given guidance and recommendations. While the child is the object, the triangle is the force. The triad relationships of parent(s)-child, parent-therapist, and therapist-child-therapist is functioning in some kind of unison, all aimed toward the improvement in the child’s well-being. A good process can have the secondary impact of improving the parent’s relationship. Helping to enhance and sustain a functional triangle can evoke unique strengths.  

Contracting

The last component begins with an agreement about the format, then attends to relevant administrative matters, and for a few cases, finishes with addressing potential complications and hindrances.

For the majority the cases, the format best fitting the client and family was fairly obvious. Most of them were recommendations for a family therapy, and the parents routinely concurred. 

For the older adolescents wanting individual therapy, the only question was how to schedule the parent’s short meetings. What could not occur was a separate weekly or bi-weekly therapy with them. The experience here, somewhat painful, is that the client could develope (unfounded) worries about boundaries and quit.

For about 15 – 20%, conjoint treatment or split sessions were presented to the parents as options. When asking the older children and adolescents at the end of the assessment what their preference of format may be, quite a few would have opted for individual had the choice been solely up to them. Thinking more about family therapy for the particular case, I’d ask them that if the decision when meeting with their parents was for family, how would they feel about that. Most said fine. A few balked, rarely a refusal, but said “OK”. If the case were of mild-moderate severity and the parents had parenting issues with relational tones, and/or this unusual apprehension within the client, that case could go either way, and a discussion led to a decision that could go either way. While not in this cohort, a case going from split to family did occur.

Maybe two or three times a year, the choice of format was deferred, mostly at my suggestion. The dynamics were varied. For example, those parents with oppositional adolescent boys prone to angry outbursts could be leery about a family format, and the boy may very well be a candidate for that approach. Based on experience with that population, the clinical inclination was still toward family. I’d explain the nature of the fourth session, in which vocal adolescents were generally effective contributors, and the parents agreed to bring their child plus other sibs if appropriate and available. We’d see how that went, work out how the next session would be arranged, and go from there until the format question was settled. 

Some parents may have wanted more in the way of assurance that the family format was conducive and not provocative. Some clients were leery of being seen with their parents. Some parents simply wanted a session or to more to evaluate and then decide. More discussion was needed, and that was fine.

To reiterate a point made in the assessment session description, carried into this summary meeting with the parents was the discussion with the client at the end of their assessment session about their format preferences. My role was to represent that point of view.  What the clients preferred, if anything, certainly played a role here.

Scheduling, payment process, cancellation policy, and emergencies were covered during the intake. Just FYI, my particular emergency policy was that the parents could try to reach me through the answering service, but I might not be available. The alternative was to go to the emergency room or call 911. To the best of my knowledge, that did not create problems in and of itself. With maybe three or four exceptions over the year, I did not get emergency calls. I’m convinced that if a service is offered, it will get used.

The last area of focus was on potential complicating factors or hindrances that could pose problems to the process itself. Most of these discussions were about the involved ”ex”, in this instance virtually always contentious fathers. The nature of the parental relationship was explored during the intake session, and a starred note was made for those situations where the post-divorce or separation remained to be contentious. They would have to be addressed, cannot be ignored with the hope they will simply never surface. In most of the divorce families, a functional to good working relationship between the couple had been developed. The concerns were where mutual distrust remained, and the presenting parent’s experience with the ‘ex’  was tainted with issues of implacable anger, obsessiveness, blame, and/or splitting. The results certainly contributed to the youngster’s presence in the office, and the emotional ramifications were part of the baseline. The problem was protecting the process.

About a year into the practice, a particular strategy was developed to use with any biological or parenting ex of the parent seeking help. The approach remained to be effective throughout. I never had a tussle in the midst of the casework, the antagonistic phone call  “I understand you’re seeing my son/daughter, and I want to know what’s going on, and I want get a copy of the records!” More importantly, the procedure offered and encouraged a limited contact for the ex with me to help allay their concerns. Be advised, this was before any widespread use on zoom, which certainly increases the levels of option, and this all precedes the metaverse.

To the parent in the office: “So, what I’d like you to tell your ex is that I’m willing to see him once. It would have to be in the office –  I don’t do this by phone. He would be responsible for payment of that session or the co-pay if the service is covered by insurance. He can ask me about how I see (the child), what I’m doing, or what I’m thinking, and I’d be glad to  to help him understand what’s happening here. Whether I see him or not, your job is to keep him informed as needed. If he does come, I’ll review the gist of the meeting with you one-on-one the next time I see you.” The occasional bemused, instinctive response of  pursed lips, tolling eyes, and slow shake of the head by the parent listening to this did not deter the sobriety of the moment, and they carried through.

3% – 5% of the fathers who received this message responded. On the whole, they did come to share their experiences and learn. For some, the discussions produced helpful perspectives about their child and notions about parenting. None came to challenge, from any stance of objection to their child’s therapy. By the same token, entreaties from them to become involved in one way or another did not occur, none of the fathers asked to be directly included. One mother in this position did so, although that proved short lived. The more hard core objectors who tended to harbor hurts and grudges seemed uninterested to take advantage of the offer to meet.The interpretation of the sum experience is that these were generally fathers who had come to terms with the new family reality, and while several wanted more time with their children, as per the case with many in their position, they were more accepting of the family realities. 

Periodically for most cases, I would occasionally arrange for a few minutes with the mother alone and ask how things are going with the ex, just to monitor. Some reported improvements,  most indicated no particular change. And that small few who were difficult from the outset were more inclined to be yet more irritated, not inclined toward the helping profession. The child is usually getting better to one degree or another, some of the parenting relationships are getting better, but much remains unchanged, and the 2% less hinged can get worse. 

In and of itself, the fact that the child was in therapy seemed to have escalated a couple of cases that can be recalled. The clinical impression the fathers left from afar were that of a threatened personality disorder of the immature group on a splitting mission that was under the legal bar, essentially double binding all three in the mother-child-therapist triad. These were truly difficult situations without a reliable remedy. The therapy plan was: support the dyad; maintain an insightful, reinforcing clinical relationship with the boy with the hope that if their processes were cut short, and they both were, that they would consider returning later;  get as much done as possible in what could be a short period of time; and be available to the mother in the aftermath if she wished. One did and one didn’t.

In terms of working with the ex, the offer of that one orienting session suited the purpose, which was to tamp down paternal resistances to the child’s therapeutic involvement. With the mother keeping the father informed, in some instances as a result of the subtle push of periodically checking with her on how things are going with him, the level of tension is likely to decrease, psychopathy aside. If the father emerges more objectively confident in their parenting skills, the client is bound to be benefitted. As the participating parent gains confidence with the child, they tend to do so vis a vis the ex, as well. Some of the relational work in session lends to effect communication with the ex for the mothers. These developments in turn help the child out of the uncomfortable and anxiety provoking position of taking sides in those cases where the conflicts remain overt. The problem is that remaining tensions become a force that drags on the client’s progress.

In hindsight, the paucity of divorcees and seperatees not involved with the therapy is somewhat surprising. Part of the intake with the involved parent was a quick question about whether the ex knew of the plan to seek help. Most all did. Most of the divorces had settled into a routine where at least some of the dust had settled, and insofar as childcare was concerned, some having visitation, some having every other weekend, some having every other week. These factors did not seem to have any effect on their urge to participate, and that was extremely few. And Seattle’s north Eastside is rife with child-centric communities.

Again almost always operating in that lean forward mode, I frankly did not give the situation that much thought beyond having the involved parent relay the message to the ex about a one time meeting. The impact of a marriage dissolution on children is well documented, where increases in anxiousness, depressed mood, and/or acting out to one degree or another are endemic. I think the data also indicates that the more contentious the marital relationship was prior to separation, particularly during the divorce process itself when the loss becomes extant, and in the aftermath, the greater the disturbance. To deal directly with the parental relationship is to work with both. And that’s a problem.

I view family therapy as a one-household activity. My first mentor and original Satirian family therapist Mary Rygg once said that talking represents 10% of communication. The other 90% in all its permutations is non-verbal, and many of those permutations come to life in the context of family therapy. What is said describes only a portion of meaning. The non-verbal behaviors within the  household that emerge in therapy add so much more about their realities of day-to-day life, and that’s important toward understanding the relationships, and that’s important to treatment. Over time, the real scene at home emerges, and then shapes the therapeutic responses and recommendations. The unit functions better and the child gets better, again to one degree or another and dependent on the non-relational issues brought into treatment, ie. personality, trauma, medical conditions, etc. The foundation is mutual experience, intimacy, the security of four walls, and a trust that undercutting will not occur.

All this was as of 2015, which in this arena differs in two important ways. One is that this one time meeting with the ex could feasibly be done by zoom. Likely a higher percentage of fathers would participate, but whether the is 3% or 20% would be unclear until someone tries. The father’s receptiveness and acceptance of the clinical messaging by will be more difficult to discern, but in this instance the act of reaching out itself and being who you are may is likely to be more important as anything said. Re the other side and to state the obvious, the second difference is that overtly aggressive behavior is far more common now than a mere six years ago, and showing no signs of abatement. The 21st century is not likely to ease up. Hobbs may very well trump Locke. Some predictions are that internecine struggles will be increasing in intensity and, sadly, ferocity. One can only hope that frequency is not included.

Out of that lean forward mode clinicians employ, the use of zoom as an adjunct to the in-person office mode would necessarily occur, if for no other reason than its omnipresence. From that one virtual meeting with the father, what cold arise are periodic, relatively brief three way zoom check-ins with both parents about the client’s progress, share observations, and put forth suggestions. Particularly because of complicated issues involving histories of violated trusts and so on, this would specifically not be a concurrent therapy process. From experience, two concurrent therapy processes run the risk of premature terminations. Referring the divorcees to their own therapy with be the better alternative, but even there, best to be cautious. Protect the process.

Be all that as it may, the metaverse will foster helpful innovation in talk therapy, not in necessarily in clinical terms, if at all, but rather as the expedience it is in times when time itself is a precious commodity for many if not most. The 21sr century will  be….

Etcetera 

Dictation: Make notes as if the client and any or all other family members are looking over your shoulder. Assume the wincing stuff will be filed in your memory. 

Do be careful about unilaterally referring parents out for their own therapy, divorced or not. At their explicit request for a referral is another matter and easy to accommodate. Protect the process.

The split session format does see both child and parent to help both individually.

Two Randoms: Foregoing a no show charge is an option – I often if not usually did so. Call me spineless, it’s OK; Demands to review kept records never happened to me, luckily – unhappy clients are a hazard of the business, and this will happen to an unlucky few clinicians.

Unsolicited Advice:   BE ON TIME – it’s easier for everyone.